NURSE FIRST

In Botswana, they power groundbreaking studies and serve as leaders in government. The common denominator of these researchers and ministers: They all are nurses.

By Maryalice Yakutchik

It was the signature white uniform, so crisp and professional, that lured Kereng (Molly) Rammipi into nursing—her, along with so many young and idealistic others before and since.

Decades later and fashion aside, nursing holds even greater appeal for Rammipi and confers more responsibility than she ever imagined. She is coordinator of Botswana’s National Cervical Cancer Prevention Programme and co-investigator on a groundbreaking human papillomavirus (HPV) self-collection study conducted by her country’s Ministry of Health and Wellness along with Jhpiego. That investigation—powered by Botswana-based research nurses—assessed the feasibility and acceptability of an innovative way to defeat the No. 1 cancer killer of women in their country. With authority and evidence, Rammipi and her team seek to inform and change national policy as it relates to cervical cancer prevention and control: HPV self-collection is a bold and promising strategy that can save lives now and in the future, preliminary findings show.

For 20 years, cervical cancer has been a public health priority in Botswana, where cytology-based screening (Pap smear) is generally available at the public primary health care level. However, women often don’t get timely Pap test results or never get results at all because, in addition to there being too few cytotechnicians and pathologists to review tests, women have to go in person to health facilities to get results. In response to those bottlenecks, the ministry introduced same-day screening and treatment, using visual inspection with acetic acid (VIA) coupled with immediate treatment. This single visit approach led to some improvement over the past 4 years, but challenges remain.

“We are not reaching enough women,” Rammipi explained. “We felt that introducing HPV self-collection and testing would go a long way in increasing our still-low screening coverage.”

While hunches might inspire important research, Rammipi needed facts and data to prove her thesis.

Something as important as expanding the reach of cervical cancer prevention called for rigorous study, for dedicated and passionate researchers who knew their community and were trusted.

It called for nurses.

“These nurses, they ran the show,” said the study’s principal investigator, Dr. John Varallo, a cervical cancer expert and Jhpiego’s global director for safe surgery. “They were it. We put the protocol together, and they ran with it. They did absolutely everything.”

At the core of the study, five research nurses enrolled 1,022 participants in the Kweneng East District of Botswana. They recruited and determined eligibility as well as counseled and instructed women—verbally, in writing and with pictures—about how to properly collect their own samples, in private, using swabs and vials. The nurses were responsible for making sure the specimens went to a lab to be tested specifically for high-risk HPV types associated with the development of cervical cancer. Finally, they personally contacted each woman to convey results, assisting all who tested HPV-positive to schedule follow-up visual assessments of the cervix and treatment.

“It’s cutting edge,” Varallo said. “This is the first time Jhpiego is doing HPV testing and doing it through self-collection.”

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Research nurse Thebeyame Diswai at the Tamaga Clinic manages samples and supplies for the HPV self-collection study.

Among the nurses who Varallo credited with “leading Jhpiego’s cervical cancer strategy into a new era” is Thebeyame Diswai, who oversaw a study site in Thamaga, situated between three major villages, about 40 kilometers west of Botswana’s capital city, Gaborone.

Diswai targeted his outreach to malls, workplaces, and community and school events. Wherever he could interact with the women and community leaders, he delivered the key points: one about the ease of preventing cervical cancer; another about a new, private HPV testing method that would deliver accurate results quickly.

He explained that HPV testing is more sensitive and reliable in detecting cervical precancer and cancer than other screening methods, such as Pap testing and VIA. He assured the women that no matter whether they were from urban areas or remote villages, they could rely on the accuracy of the results.

“People really welcomed the initiative,” he said.

Because of the nurses’ rapport with community members, the pace of enrollment exceeded all expectations, Varallo said. In fact, not one woman who was offered self-collection for HPV testing declined to participate. In their responses to a survey, 97.2 percent of study participants said the instructions were easy to understand, and 95.1 percent said sample collection was easy. Nearly all (97.3 percent) experienced minimal to no discomfort and said that they would recommend the HPV self-collection method to others.

“Self-collection has the potential to achieve population-level coverage,” Varallo said, adding, “It’s been a struggle to scale up our current screen-and-treat approach of VIA coupled with immediate cryotherapy.”

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Letang Gaofiwe, lab technician, processes self-collected samples for HPV-DNA testing.

Scaling up means reaching more women in more places—and ultimately saving more lives. It’s a lofty goal largely dependent on the listening ability of those on the ground at the front lines of care.

Women were saying they did want to be screened—but would prefer an approach that was simple, noninvasive and private.

“The self-collection method doesn’t deter them from going for screening,” Rammipi said. “We see it as an advantage that most women would prefer to do the self-collection and then submit the samples.”

“My clients liked doing the collection in private for themselves,” added Diswai. “That is what was pulling people in: They felt empowered.”

Another key was the promise of prompt notification and treatment: 75 percent of study participants learned results from a nurse within 3 days; 85 percent of the 343 who tested HPV-positive completed visual assessment and treatment within 3 weeks.

A nurse-led study has other benefits. “We identified other gaps in care and saw how lifestyle impacts the prevalence of certain conditions,” said Diswai. “Research broadens our [nurses’] thinking in terms of innovation.”

And, there’s something else, he suggested: When community-dependent research—the HPV self-collection study, for example—is in the capable hands of nurses, it can yield optimal results.

“Nurses are well grounded in working in communities. They know who to engage and are skilled at how to engage them,” he said.

Research opportunities for nurses are not uncommon in Botswana, Rammipi said, attesting to the professional growth of nurses who are passionate and committed to lifelong learning. She credits “a very active nursing council, one that is in the forefront of advocating for nurses to hold leadership positions in this country.” Her senior position in the health ministry, for example, requires a broad range of skills spanning training, programming and policy development.

She identifies first as a nurse: “But I’m not wearing the white uniform now.”


Maryalice Yakutchik is the communications manager
for Jhpiego.

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