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


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


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

Pocket Colposcope.

Team Leaders

  • Marlee Krieger, Pratt School of Engineering-Biomedical Engineering
  • Nimmi Ramanujam, Pratt School of Engineering-Biomedical Engineering

/graduate Team Members

  • Daniel Harriman, Business Administration-MBA
  • Christopher Lam, Global Health - MS, Biomedical Engineering-PHD

/undergraduate Team Members

  • Valentina Alvarez, GCS in Literature Program (AB), Global Health (AB2)
  • Erin Brown, Biomedical Engineering (BSE)
  • Ryan Fitzgerald, Biology (BS), Global Health (AB2)
  • Michyla Greene
  • Olivia McKinney, Biology (BS)
  • Morgan McKinney
  • Karina Moreno Bueno
  • Diana Zabala, Interdept Biology/PP (BS)
  • Lillian Zhu

/yfaculty/staff Team Members

  • Libby Dotson, Pratt School of Engineering-Biomedical Engineering
  • Megan Huchko, School of Medicine-Obstetrics and Gynecology
  • Elena Roberts, Pratt School of Engineering-Biomedical Engineering

/zcommunity Team Members

  • Gino Venegas, La Liga Contra el Cancer