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Background: Educating medical students to better understand the complexities of cultural competence, the social determinants and environmental determinants of health that are important and integral components of the medical school curriculum. Methods: In 2014, Weill Cornell Medicine (WCM) implemented a new curriculum, the adoption of which provided the means to enhance an existing global health program, informally introduced in 2009, and to address the issues of cultural competency. In this article, we share WCM’s experience in building and expanding its global health curriculum. Results: A hallmark of our program is the successful collaboration between students and faculty to create a multi-disciplinary global health program that incorporates electives, clinical field placement, and collaborative research. Conclusion: Key lessons learned through our experience include the necessity for strong faculty-student collaboration, full support from the administration, and building global partnerships. Our example could be a useful guide for other medical schools seeking to establish a global health education curriculum.

There is a dearth of data regarding diabetes control among patients experiencing homelessness.We retrospectively collected type 2 diabetes-related measurements, sociodemographic, and clinical indicators from medical records of all incoming adults with diabetes (Bivariate analysis showed that patients experiencing homelessness (63% Black; 32% Hispanic) 134/304 (43⋅9%) were more likely than domiciled patients 13/57 (22·8%) to have inadequately managed diabetes (OR 2⋅67, CI 1·38-5·16,Interventions at shelters or shelter-clinics should target subgroups in addition to addressing traditional risk factors to improve diabetes control. mHealth strategies could be considered to improve engagement, care delivery, and medication taking. Ultimately, homelessness itself needs to be addressed.There are no funding sources to declare.

Background Cervical cancer is among the most common preventable cancers with the highest morbidity and mortality. The World Health Organization (WHO) recommends visual inspection of the cervix with acetic acid (VIA) as cervical cancer screening strategy in resource-poor settings. However, there are barriers to the sustainability of VIA programs including declining providers’ VIA competence without mentorship and quality assurances and challenges of integration into primary healthcare. This study seeks to evaluate the impact of smartphone-based strategies in improving reliability, reproducibility, and quality of VIA in humanitarian settings. Methods and findings We implemented smartphone-based VIA that included standard VIA training, adapted refresher, and 6-month mHealth mentorship, sequentially, in the rural Shiselweni region of Eswatini. A remote expert reviewer provided diagnostic and management feedback on patients’ cervical images, which were reviewed weekly by nurses. Program’s outcomes, VIA image agreement rates, and Kappa statistic were compared before, during, and after training. From September 1, 2016 to December 31, 2018, 4,247 patients underwent screening; 247 were reviewed weekly by a VIA diagnostic expert. Of the 247, 128 (49%) were HIV–positive; mean age was 30.80 years (standard deviation [SD]: 7.74 years). Initial VIA positivity of 16% (436/2,637) after standard training gradually increased to 25.1% (293/1,168), dropped to an average of 9.7% (143/1,469) with a lowest of 7% (20/284) after refresher in 2017 (p = 0.001), increased again to an average of 9.6% (240/2,488) with a highest of 17% (17/100) before the start of mentorship, and dropped to an average of 8.3% (134/1,610) in 2018 with an average of 6.3% (37/591) after the start of mentorship (p = 0.019). Overall, 88% were eligible for and 68% received cryotherapy the same day: 10 cases were clinically suspicious for cancer; however, only 5 of those cases were confirmed using punch biopsy. Agreement rates with the expert reviewer for positive and negative cases were 100% (95% confidence interval [CI]: 79.4% to 100%) and 95.7% (95% CI: 92.2% to 97.9%), respectively, with negative predictive value (NPV) (100%), positive predictive value (PPV) (63.5%), and area under the curve of receiver operating characteristics (AUC ROC) (0.978). Kappa statistic was 0.74 (95% CI; 0.58 to 0.89); 0.64 and 0.79 at 3 and 6 months, respectively. In logistic regression, HIV and age were associated with VIA positivity (adjusted Odds Ratio [aOR]: 3.53, 95% CI: 1.10 to 11.29; p = 0.033 and aOR: 1.06, 95% CI: 1.0004 to 1.13; p = 0.048, respectively). We were unable to incorporate a control arm due to logistical constraints in routine humanitarian settings. Conclusions Our findings suggest that smartphone mentorship provided experiential learning to improve nurses’ competencies and VIA reliability and reproducibility, reduced false positive, and introduced peer-to-peer education and quality control services. Local collaboration; extending services to remote populations; decreasing unnecessary burden to screened women, providers, and tertiary centers; and capacity building through low-tech high-yield screening are promising strategies for scale-up of VIA programs., Ramin Asgary and colleagues evaluate a program for improving digital cervicography via telemedicine to serve women in remote settings., Author summary Why was this study done? Visual inspection of the cervix with acetic acid (VIA)-based cervical cancer screening is the World Health Organization (WHO)-recommended screening method for resource-poor settings, and new advanced human papillomavirus (HPV) testing also requires a reliable, good-quality, and functioning VIA or cytology program. Initial VIA training programs for cervical cancer screening are often short term with variable quality, and opportunities for retraining are limited due to cost and logistics, which contribute to a decline in diagnostic skills of screening providers with high false-positive and negative results over time. Cervical imaging, cervicography, as a proven adjunct to VIA, improves screening results and competencies of providers but requires a digital camera and television screen, which poses scalability and sustainability issues. Smartphone-based VIA strategies provide a low-tech option to improve training of nurses in VIA, but their large-scale implementation and the impact on quality in routine program settings have not yet been evaluated. What did the researchers do and find? We developed and implemented an integrated mentorship training of VIA screening and digital cervicography using smartphones through a telemedicine platform to improve provider nurses’ diagnostic and management competencies and skill retention to ensure reproducibility, reliability, and quality of VIA screening services in routine humanitarian settings. Our findings indicate that provider nurses significantly improved in VIA performance and maintained diagnostic competencies with high agreement rates with the expert mentor over time after smartphone-based mentorship training compared to the standard and refresher VIA screening trainings. In resource-poor settings, these achievements could help reduce the unnecessary burden of underdiagnosis or overdiagnosis and treatment and their psychosocial impact to women, providers, and health systems. What do these findings mean? The strategy of using inexpensive and ubiquitous smartphones presents a unique opportunity for task shifting of high-quality cervical cancer screening at the primary care level in many resource-poor or humanitarian settings. Effective collaborations with local entities, local capacity building, maintenance of quality services, decreased burden on health systems, and direct affordable VIA screening services for women in remote areas and in familiar and sustainable settings could lead to important policy implications for VIA screening interventions in humanitarian settings.

Cervical cancer disproportionately affects low-resource settings. Papanicolaou, human papillomavirus (HPV), and visual inspection of cervix with acetic acid (VIA) testing, each with different characteristics, will reduce cervical cancer burden. We conducted a critical literature review using PubMed, Cochrane, WHO, and grey literature from 1994 to 2020. We examined efficacy, harms, and comparative effectiveness of screening methods by age, human immunodeficiency virus, provider characteristics, and assessed implementation challenges in low-resource settings. Comprehensive data on utility and efficacy of screening tests indicates that each screening has strengths and shortcomings but all confer acceptable performance. HPV and VIA appear more promising. Primary HPV test-and-treat, self-testing, and co-testing have been studied but data on triage plans, cost, support system, implementation and sustainability is unclear in low-resource settings. HPV testing could help target subgroups of older or higher risk women. VIA offers local capacity-building and scalability. Quality VIA technique after HPV testing is still required to guide post-screening treatments. VIA competencies decline gradually with current standard trainings. Stationary cervicography improves VIA quality but isn't scalable. Affordable smartphones eliminate this barrier, enhance training through mentorship, and advance continuing education and peer-to-peer training. Smartphone-based VIA facilitates cervical image storage for patient education, health promotion, record-keeping, follow-up care, remote expert support, and quality control to improve VIA reliability and reproducibility and reduce mis-diagnoses and burden to health systems. Rather than ranking screening methods using test characteristics alone in study or higher-resource settings, we advocate for scalable strategies that maximize reliability and access and reduce cost and human resources.

OBJECTIVE The purpose of this study was to determine Peruvian women's attitudes toward novel reimbursement incentives used to improve adherence to obtaining cervical cytology test results. MATERIALS AND METHODS Women presenting for cervical cancer screening in Peru completed a 34-item Investigational Review Board-approved questionnaire. The questionnaire determined their attitudes toward various reimbursement incentives to improve adherence to obtaining cervical cytology results. Descriptive statistics, generalized linear models, and Kruskal-Wallis tests were used in the analyses. RESULTS Completed questionnaires were available for 997 women. Most women (51%) would be more likely to return for their Pap result if an incentive was provided, 79% (759/956) agreed that they would pay for the Pap test, and 51% (402/859) would be willing to pay 10 Soles or less. Quechua-speaking women considered follow-up more difficult (p < .0001) but were less likely to return for their Pap results (p < .0001), pay for the Pap test (p < .0001), and afford paying more than 5 Soles (p < .0001) than women who spoke Spanish or both languages. More women who earn 1000 Soles/year or less would likely return if incentivized (p < .0001), felt the incentive would help them remember to return (p = .0047), and would be willing to pay whether there was a rebate (p = .010) as compared with women earning more money. CONCLUSIONS A reimbursement incentive program designed to improve follow-up of cervical cytology test results was acceptable to most Peruvian women. Such a behavioral-modifying program may improve patient follow-up after cervical cytology testing. Implementation may reduce the morbidity and mortality of cervical cancer in remote regions of the country.