Pocket Colposcope: Analysis of Bringing Elements of Referral Services to Primary/Community Care (2018-2019)


Invasive cervical cancer affects 500,000 women worldwide each year. Unlike most cancers, it is highly preventable through the screening, diagnosis and treatment of cervical precursor lesions.

Colposcopy with biopsy is the gold standard for diagnosis of precancerous lesions. However, colposcopes are expensive, and require referral to a facility that can house this machine as well as a trained colposcopist who can interpret the images. These factors make colposcopy inaccessible to the many women in low- and middle-income countries who are at greatest risk for developing cervical cancer.

To address this limitation, Duke researchers have developed a device called the Pocket Colposcope. It is more than an order of magnitude less expensive and lighter than commercial colposcopes. The first year of this Bass Connections project in 2016-17 was dedicated to performing a global value chain analysis in order to identify leverage points that can increase the likelihood of adoption of the Pocket Colposcope in Peru. In 2017-18, team members focused on launching a community health provider program to implement the Pocket Colposcope at the primary care setting in Peru.

Project Description

This Bass Connections project seeks to understand the best practices for creating a training program for community-level providers and to develop a training manual based on feedback from community health providers working with La Liga Contra el Cancer. The project team will engage in an in-country field experience in Lima and surrounding areas of Huancayo, Huanuco and Cusco, for a preliminary field testing of training strategies.

The team’s goal is to demonstrate that the Pocket Colposcope is an economically viable solution in the community health setting. Team members will conduct a cost-effectiveness analysis to determine the incremental cost-effectiveness ratio of the team’s approach relative to “screen and treat” with no triage (World Health Organization guidelines) and a high-resource strategy of treating based on biopsy result. They will use micro-costing to estimate several indices comparing costs to desired program outcomes: cost per case of CIN detected; cost per triage visit; and cost per woman treated. The team will also construct a decision model to estimate the health impact of HPV screening, triage and follow-up with appropriate treatment. This model will portray the paths from HPV to detection, the risks of clinical progression and outcomes with and without treatment.

Team members will use the decision-analysis model to assess the incremental cost-effectiveness ratio (ICER) when comparing triage strategies, and calculate the ICER compared to the current standard. They will look at staffing models and efficiency levels obtained through primary provider use of the Pocket Colposcope, and estimate the costs for scaled-up replication.

Anticipated Outcomes

Mid-year report on progress to date and research plan; cost-effectiveness model; final report with recommendations

Student Opportunities

Team leaders seek 5-7 undergraduates and 2-4 graduate/professional students. Specific backgrounds are open; possible fits include engineering, global health, medicine, public policy, business, law, women’s studies and/or Spanish studies. While fluency in Spanish is not required, at least 50% of the team should be Spanish speaking.

The project will facilitate learning through weekly meetings that cover three topic areas: cervical cancer screening and healthcare systems in Peru; best practices in training and the assessment of training of community health providers; and cost-effectiveness analysis.

Team members will gain exposure to developing and implementing technologies, and learn about the intersection between engineering, social sciences and microeconomics. Members will also experience local-global comparisons and connections; team leaders have an ongoing IRB-approved clinical study to test the Pocket Colposcope in patients undergoing cervical cancer screening at Duke University Medical Center, and participants can be involved in this Durham-based research as well as the Peruvian research. We will compare and contrast the two sites during team meetings.

Evaluation of students will be based on presentations and participation in weekly meetings, weekly blog posts, research and data analysis and mid-term and final reports. Students will also be expected to submit an e-portfolio that documents the work they did and a final reflection statement that emphasizes global awareness, civic literacy, critical thinking, problem solving, creativity, life/team and interpersonal skills. An additional evaluation will be performed on preparedness of students for the international trip with respect to learning cultural, social and language skills.


Fall 2018 – Summer 2019  

  • Fall 2018: Overview of cervical cancer prevention and healthcare systems (public and private) in Peru; recap of global value chain analysis and training modules; overview of cervical cancer prevention strategies, tools currently being used as well as novel technologies, methods for cost-effectiveness analysis
  • Spring 2019: Obtain inputs for cost-effectiveness model to compare break-even point for cost-savings for Pocket Colposcope-based cervical cancer prevention vs. traditional approaches; detailed cost-effectiveness model developed to assess effectiveness of Pocket Colposcope in a community setting in Peru; study design for implementation of observational studies
  • Summer 2019: June–July, four weeks of field visits and interviews in Peru; validate findings through direct observations of staff “time and motion” studies in order to distinguish cervical cancer-related activities from other health services delivered by the same personnel; compile cost-effectiveness analysis as well as stakeholder surveys (from 2017-18 team) and global value chain analysis (2016-17 team) into a report for discussion with the Ministries of Health


Independent study credit available for fall and spring semesters; summer funding

See earlier related team, Pocket Colposcope: Increased Distribution and Adoption (2017-2018).


Faculty/Staff Team Members

Megan Huchko, School of Medicine-Obstetrics and Gynecology
Marlee Krieger, Pratt School of Engineering-Biomedical Engineering*
Ernesto Ortiz, Duke Global Health Institute*
Nimmi Ramanujam, Pratt School of Engineering-Biomedical Engineering*

Graduate Team Members

Elena Roberts, Biomedical Sciences

Undergraduate Team Members

Valentina Alvarez
Namratha Atluri, Neuroscience (BS), Global Health (AB2)
Michyla Greene
Morgan McKinney
Olivia McKinney
Karina Moreno Bueno
Diana Zabala, Program II (AB)
Lillian Zhu

Community Team Members

Gino Venegas, La Liga Contra el Cancer

* denotes team leader


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