Cervical Cancer Control Program Research Articles

Human Papillomavirus Vaccination Coverage Among School Girls in a Demonstration Project - Botswana, 2013.

What is already known on this topic? Human papillomavirus (HPV) infection is common and aggressive in persons infected with human immunodeficiency virus (HIV). With an HIV prevalence of 28% among females aged 15–49, cervical cancer is the leading cause of cancer death among women in Botswana. Before 2013, HPV vaccine had not been used in the public sector in Botswana.What is added by this report? Efforts to expand services for cervical cancer through the Pink Ribbon Red Ribbon initiative focused on HPV-related disease in Botswana. A demonstration project for HPV vaccination was developed by the Ministry of Health for school girls aged ≥9 years in primary schools in one community. A total of 1,967 (79%) of 2,488 eligible girls received 3 doses of vaccine in the immunization effort that was centered in schools.What are the implications for public health practice? Preventing HPV infection in girls is an important component of a national comprehensive cervical cancer control program. HPV vaccination programming is challenging, and demonstration projects can prepare countries for national introduction. The success of the initial HPV vaccination effort in Botswana led to an expanded project in 2014, with implementation of nationwide rollout of the HPV vaccine in 2015. It might be beneficial for future HPV vaccination campaigns to include strategies to reach out-of-school girls.

Underutilization of cervical cancer prevention services in low and middle income countries: a review of contributing factors.

This review aims at identifying barriers to utilization of cervical cancer prevention services in low- and middle-income countries. An electronic search was conducted using the following key words, HPV vaccination, screening, barriers, utilization and low and middle income/developed countries. Using the Garrard (1999) Matrix method approach, a modified matrix was designed and used as a data collection tool and data related to each category listed on the tool were entered into a matrix containing columns reflecting the categories. Constant comparative analysis was used to identify thematic categories. 31 articles published between 2001 and 2014 were yielded from the search. Analysis of the contents of the articles showed that the underutilization of cervical cancer screening services in low and middle-income countries is the result of barriers in accessing and utilizing of the prevention services. Though not mutually exclusive, the barriers were categorized in three categories; individual, community and health system related. Individual barriers include lack of awareness and knowledge about risk factors and prevention of cervical cancer. Age, marital status, diffidence, social economic status, cultural and religious belief of the women also determine the women's' willingness to utilize the services. In some communities there is stigma attached to discussing reproductive health issues and this limits the young women's awareness of cervical cancer and its prevention. Understanding individual, community and health system barriers that hinder women's utilization of cervical cancer prevention services is very crucial in designing effective cervical cancer control programs in low- and middle-income countries.

Racial/Ethnic, Socioeconomic, and Geographic Disparities of Cervical Cancer Advanced-Stage Diagnosis in Texas

BackgroundAdvanced-stage diagnosis is among the primary causes of mortality among cervical cancer patients. With the wide use of Pap smear screening, cervical cancer advanced-stage diagnosis rates have decreased. However, disparities of advanced-stage diagnosis persist among different population groups. A challenging task in cervical cancer disparity reduction is to identify where underserved population groups are. MethodsBased on cervical cancer incidence data between 1995 and 2008, this study investigated advanced-stage cervical cancer disparities in Texas from three social domains: Race/ethnicity, socioeconomic status (SES), and geographic location. Effects of individual and contextual factors, including age, tumor grade, race/ethnicity, as well as contextual SES, spatial access to health care, sociocultural factors, percentage of African Americans, and insurance expenditures, on these disparities were examined using multilevel logistic regressions. FindingsSignificant variations by race/ethnicity and SES were found in cervical cancer advanced-stage diagnosis. We also found a decline in racial/ethnic disparities of advanced cervical cancer diagnosis rate from 1995 to 2008. However, the progress was slower among African Americans than Hispanics. Geographic disparities could be explained by age, race/ethnicity, SES, and the percentage of African Americans in a census tract. ConclusionsOur findings have important implications for developing effective cervical cancer screening and control programs. We identified the location of underserved populations who need the most assistance with cervical cancer screening. Cervical cancer intervention programs should target Hispanics and African Americans, as well as individuals from communities with lower SES in geographic areas where higher advanced-stage diagnosis rates were identified in this study.

Endocrine therapy initiation among Medicaid-insured breast cancer survivors with hormone receptor-positive tumors.

Hormone receptor-positive (HR+) cancers account for most breast cancer diagnoses and deaths. Among survivors with HR + breast cancers, endocrine therapy (ET) reduces 5-year risk of recurrence by up to 40%. Observational studies in Medicare- and privately-insured survivors suggest underutilization of ET. We sought to characterize ET use in a low-income Medicaid-insured population in North Carolina. Medicaid claims data were matched to state cancer registry records for survivors aging 18-64 diagnosed with stage 0-II HR + breast cancer from 2003 to 2007, eligible for ET, and enrolled in Medicaid for at least 12 of 15 months post-diagnosis. We used multivariable logistic regression to model receipt of any ET medication during 15 months post-diagnosis controlling for age, race, tumor characteristics, receipt of other treatments, comorbidity, residence, reason for Medicaid eligibility, involvement in the Breast and Cervical Cancer Control Program (BCCCP), and diagnosis year. Of 222 women meeting the inclusion criteria, only 50% filled a prescription for ET. Involvement in the BCCCP and earlier year of diagnoses were associated with significantly higher odds of initiating guideline-recommended ET (adjusted odds ratio [AOR] for the BCCCP 3.76, 95% confidence interval [CI] 1.67-8.48; AOR for 2004 relative to 2007 2.80, 95% CI 1.03-7.62; AOR for 2005 relative to 2007 2.11, 95% CI 0.92-4.85). Results suggest substantial underutilization of ET in this population. Interventions are needed to improve timely receipt of ET and to better support survivors taking ET. Low-income survivors should be counseled on the importance of ET and offered support services to promote initiation and long-term adherence.

Cervical cancer knowledge and screening behaviors among female university graduates of year 2012 attending national graduate orientation program, Bhutan.

BackgroundCervical cancer is the leading female cancer in Bhutan. This study describes the level of cervical cancer knowledge and screening behaviors among female university graduates attending the National Graduate Orientation Program (NGOP), 2012.MethodsA cross-sectional study of female graduates attending NGOP was conducted using self-administered anonymous questionnaire developed through literature reviews and expert discussions to elicit information on demographic characteristics, knowledge, screening behaviors and determinants of cervical cancer. The association of demographic and other important study characteristics with uptake of Pap test was investigated using cross tabulation and Fischer Exact test. Frequencies and percentages were calculated for all the questions.ResultsThe average age of the participants was 23.43 ± SD 2.73. About 92% (n = 513) of the respondents were aged 25 years or less and 7.9% (n = 44) of the respondents were aged 26 or more. The study revealed low cervical cancer knowledge and poor screening behavior among the graduates. The mean knowledge score was 3.571 (SD1.75, Range 0–8). About 6% (n=34) of the respondents reported undergoing Pap test at least once and 94% reported as never having done Pap test. The most commonly cited reasons for not doing Pap test included “never thought I needed one” (57%, n = 320), “embarrassment of being examined by male health professional” and “fear of finding out cancer”. The study revealed evidence of significant association between increasing age, those who are married, knowledge score and those recommended for screening by health professionals with the uptake of Pap test.ConclusionOur study revealed poor knowledge and screening behaviors among female university graduates in Bhutan. This may be suggestive of even poorer awareness and screening practices among young unmarried women who are less educated or with no education. Although our study group is not appropriate for measuring practice of cervical cancer screening in the country, the findings are expected to highlight the shortcomings and trigger development of comprehensive cervical cancer control programs in Bhutan.

Viva Mulher: constructing a cervical cancer control program in Brazil.

Through a number of isolated initiatives that began in the 1960s, Brazil accumulated knowledge and experience that in the late 1990s culminated in the implementation of the first nationwide public health action meant to coordinate health bodies and personnel from the federal, state, and municipal administrative levels to address a chronic degenerative disease. The main goal of this article is to analyze the process of construction of this public policy for cancer control in Brazil--more specifically, organized screening for the control of cervical cancer in the form of the Viva Mulher program. Our analytical approach relies on elements from the history of public policy and from the history of institutions, combining the use of documental sources, scientific literature, and interviews with managers involved in the process under study. Our analysis endeavors to show how and to what extent this national process incorporated the experiences of local projects and responded both to pressure from the social movement and to the country's political environment. It further shows how the new context, shaped by changes in the organization of the Brazilian health system, influenced this process.

Efficacy and safety of human papillomavirus vaccine for primary prevention of cervical cancer: A review of evidence from phase III trials and national programs

The Human Papillomavirus (HPV) vaccines have been widely introduced in the national immunization programs in most of the medium and high income countries following endorsement from national and international advisory bodies. HPV vaccine is unique and its introduction is challenging in many ways – it is the first vaccine developed to prevent any cancer, the vaccine is gender specific, it targets adolescent females who are difficult to reach by any health intervention programs. It is not unusual for such a vaccine to face scepticism and reservations not only from lay public but also from professionals in spite of the clinical trial results convincingly and consistently proving their efficacy and safety. Over the last few years millions of doses of the HPV vaccine have been administered round the world and the efficacy and safety data have started coming from the real life programs. A comprehensive cervical cancer control program involving HPV vaccination of the adolescent girls and screening of the adult women has been proved to be the most cost-effective approach to reduce the burden of cervical cancer. The present article discusses the justification of HPV vaccination in the backdrop of natural history of cervical cancer, the mechanism of action of the vaccines, efficacy and safety data from phase III randomized controlled trials as well as from the national immunization programs of various countries.

The high burden of cervical cancer in Fiji, 2004–07

There are few population-based data on the disease burden of cervical cancer from developing countries, especially South Pacific islands. This study aimed to determine the incidence and mortality associated with cervical cancer and the coverage of Papanicolaou (Pap) cervical cytology in 20- to 69-year-old women in Fiji from 2004 to 2007. National data on the incident cases of histologically confirmed cervical cancer and the associated deaths, and on Pap smear results were collected from all pathology laboratories, and cancer and death registries in Fiji from 2004 to 2007. There were 413 incident cases of cervical cancer and 215 related deaths during the study timeframe. The annualised incidence and mortality rates in 20- to 69-year-old Melanesian Fijian women, at 49.7 per 100?000 (95% confidence interval (CI): 43.7-56.4) and 32.3 per 100?000 (95% CI: 26.9-38.4) respectively, were significantly higher than among 20- to 69-year-old Indo-Fijian women at 35.2 per 100?000 (P<0.001, 95% CI: 29.5-41.7) and 19.8 per 100?000 (P=0.002, 95% CI: 15.1-25.5) respectively. Of 330 cases diagnosed between 2004 and 2006, 186 (56%) had died by 31 December 2006. Pap smear coverage for this period was 8.0% (95% CI: 7.9-8.1) of the target population. The incidence and mortality related to cervical cancer in Fiji is high, whereas Pap smear coverage is very low. Greater investment in alternative screening strategies and preventive measures should be integrated into a comprehensive, strategic cervical cancer control program in Fiji.

Should the ideal be the enemy of the good?

In Mattheij et al.1, the authors claim that HPV vaccine is not warranted in India due to supposedly low rates of cervical cancer and poor data. While we agree that the quality of registry data on cancer is far from ideal, that is true for many global health problems (including diabetes, which has no disease registry at all). Fortunately, lack of registries has not prevented governments from tackling pressing health problems. We believe the authors have misinterpreted the Indian registry data. For example, they do not acknowledge that the decline in rates was an urban phenomenon, and that it was not reflected in the one rural registry (Barshi)2. To understand disease burden PATH relied upon the WHO's GLOBOCAN database3, which estimates that India has the highest absolute number of cervical cancer cases in the world. The study sites in Andhra Pradesh and Gujarat were selected in consultation with a national project advisory committee and were based on multiple criteria, not only regional disease incidence; these included immunization coverage, experience with new vaccine introduction, and commitment to adolescent health and cervical cancer prevention4. The authors cite the WHO document on new vaccine introduction5 as requiring that disease burden data and national surveillance be in place before any new vaccine can be used. While these guidelines set out a worthy ideal to strive for, they did not hold up the introduction of polio or measles vaccines, neither of which has the kind of comprehensive surveillance system the authors call for. Finally, the study was not an effort to introduce or rollout HPV vaccine either nationally or in the two Indian states. Its purpose was to generate evidence on feasible, acceptable, and affordable strategies for delivering the vaccines, should the Indian government decide one day that such a service belongs in their cervical cancer control program. Should that day come, the data generated by the HPV vaccine study will prove useful to immunization planners.

Endocrine therapy use among Medicaid-insured breast cancer survivors with hormone receptor-positive tumors.

6017 Background: Estrogen receptor positive (ER+) and progesterone receptor positive (PR+) cancers account for the majority of breast cancer diagnoses and deaths. Among women with ER+ or PR+ breast cancers, endocrine therapy (ET) is the cornerstone of adjuvant therapy and reduces 5-year risk of recurrence by as much as 40%. Observational studies in Medicare and privately-insured populations suggest that ET is underutilized. We sought to characterize ET use in a low-income Medicaid-insured population in North Carolina. Methods: We used Medicaid claims data matched to NC Central Cancer Registry records for women ages 18-64 diagnosed with in situ, stage I or II breast cancer from 2003-2007. We excluded dual eligibles and included only cases enrolled in Medicaid for at least 12 of the 15 months following the index diagnosis. We defined our outcome as receipt of any ET medication (tamoxifen, letrozole, exemestane, or anastroxole) in prescription claims during the 15-month period post-diagnosis, among women with ER+ or PR+ disease. In multivariate logistic regressions, independent variables included age, race, tumor characteristics, receipt of other breast cancer treatments, co-morbidity, rural/urban residence, reason for Medicaid eligibility, involvement in the Breast and Cervical Cancer Control Program (BCCCP), patient-centered medical home enrollment, and diagnosis year. Results: Of the 269 women who met inclusion/exclusion criteria and were ER+ or PR+, only 45% filled a prescription for ET during the study period. In multivariate analyses, being involved in the CDC-affiliated BCCCP was significantly associated with higher likelihood of receipt of guideline-recommended endocrine therapy (Marginal Effect: 0.299, p&lt;0.01), but other independent variables were not significantly correlated with receipt of ET. Conclusions: Results suggest that ET is substantially underutilized in this low-income, vulnerable population and that intervention efforts to improve ET use may be important. Qualitative research is needed to understand the more nuanced, behavioral reasons for ET underuse, which may be related to symptom burden, cost, and patient-provider communication.

Population-Based Prevalence of Abnormal Cervical Cytology Findings and Local Risk Factors in Ibadan, Nigeria: Implications for Cervical Cancer Control Programs and Human Papilloma Virus Immunization

Objective: To investigate the prevalence of abnormal cervical cytological findings and local risk factors in Ibadan, Nigeria. Study Design: All women aged ≥15 years in each household in Idikan, Ibadan, were invited to participate in a population-based study. Structured questionnaires were administered to all consenting women. Conventional cervical Papanicolaou smears obtained from sexually active women were classified using the 2001 Bethesda system. The diagnoses were correlated with sociodemographic data and risk factors. Results: Of 2,870 women aged ≥15 years estimated to live in Idikan, 1,204 sexually active women consented to pelvic examination and cervical smears. Results were available for 1,104 women (mean age: 39.8 years). Mean ages at menarche, first sexual intercourse and first pregnancy were 16.1, 20.3 and 20.7 years, respectively. Cytological results were categorized into atypical squamous cells of undetermined significance and atypical glandular cells 22 (1.99%); low-grade 43 (3.89%) and high-grade squamous intraepithelial lesions (HSIL) 17 (1.54%); invasive cancer 2 (0.18%) and normal 593 (53.8%) and reactive changes 427 (38.7%). The prevalence of epithelial abnormalities is 7.6%. Significant host-related factors in those with HSIL and invasive cancer included older age (mean 56.2 years), high parity and gravidity, lack of formal education and being divorced (p < 0.05). Conclusions: This study provides prevalence data and local risk factors for abnormal cervical cytology in a Nigerian population, which will be useful for planning future cervical cancer control programs.

Abstract PL01-02: Human papillomavirus in the etiology and prevention of genital cancers

Abstract PL01-02: Human papillomavirus in the etiology and prevention of genital cancers

Cancer of the cervix in unscreened West African women

Background: Cancer of the cervix remains an important health problem amongst women worldwide. Widespread comprehensive cervical cancer control programs have resulted in a marked reduction in the incidence and mortality in most developed countries. Developing countries bear over 80% of the global burden, with only 5% of the global resources for the control of cancer. Majority of the cases in these countries present late and are incurable at the time of diagnosis. Aim: To review the presentation and histopathological types of cervical cancer cases seen in Aminu Kano Teaching Hospital Kano, over a sixteen-year period (1995– 2010). Materials and Methods: Case records of histopathologically diagnosed cases of cancer of the cervix were retrieved. Demographic data, stage of the tumor at presentation, and histopathologic type were extracted. The results were analyzed using descriptive statistics. Results: Six hundred and sixty gynecological cancers were seen during the study period, with cancer of the cervix accounting for 58.5% (386/660) cases. Among these cases with cancer of the cervix 71.1% (275/386) were grand multiparous and majority 89.7 % 346/386 presented with advanced disease. Squamous cell carcinoma (SCC) accounted for 86.3% (333/386) of the cancers, adenocarcinoma contributed 12.4%,(48/386) and others contributed 1.3% (5/386). Conclusion: Cancer of the cervix is the commonest gynecological cancer at Aminu Kano Teaching Hospital, Kano, Nigeria. SCC is the commonest histological type.

Risk factors for high‐risk human papillomavirus infection in unscreened Malian women

To investigate the epidemiology of human papillomavirus (HPV) infection in Malian women, for whom cervical cancer is the most common cancer and the second most common cause of cancer-related mortality. Pilot study of 202 women aged 15-65 to determine the prevalence rate of high-risk HPV infection among unscreened Malian women. Information on risk factors was collected through a standardized, structured interview and clinical examination. High-risk (HR) HPV DNA was detected using signal amplification methods (hybrid capture II). High-risk HPV DNA was detected in 12% of unscreened women, while visual inspection after application of acetic acid and Lugol's iodine (VIA/VILI) identified suspicious abnormalities in 2.5% of unscreened women. Histopathological evaluation of VIA/VILI-positive biopsies revealed no evidence of cervical intraepithelial neoplasia or cervical cancer. The majority of infections occurred among women in the 15-24 year old range. Compared to women who were married or widowed, single women were 3.5 times more likely to be infected with HR HPV. The prevalence of infection with cancer causing types of HPV in this study was 12%. These prevalence estimates are consistent with what has been reported previously for other West African countries.

Prevalence of human papillomavirus infection among female sex workers in Bulgaria

The present study estimates the prevalence and risk factors of human papillomavirus (HPV) infection among female sex workers (FSWs) in Bulgaria. HPV DNA was detected by polymerase chain reaction (PCR) in 43.4% of FSWs. HPV16 was the most common type, found in 17.0% of samples, followed by HPV31 (9.4%). Age and smoking were associated with a significantly greater risk of being infected. The results of this study indicate that FSWs in Bulgaria are at increased risk for cervical cancer and represent an important source of HPV infection for the general population in the country. They should be considered as a priority group in cervical cancer control programmes.

Human papillomavirus (HPV) type distribution in cervical carcinoma, low-grade, and high-grade squamous intraepithelial lesions in Venezuelan women

Objective Cervical cancer is an important cause of mortality among women in developing countries, especially in the Latin America and Caribbean (LAC) region. Infection with high-risk (HR) human papillomavirus (HPV) has been identified as the primary cause of cervical cancer. The aim of this study was to determine the frequency of HR-HPV genotypes in low-grade and high-grade squamous intraepithelial lesions (LSIL, HSIL) and cervical carcinoma (CC) among Venezuelan women. Materials and methods Subjects with histopathological diagnosis of LSIL, HSIL, and CC (LSIL = 200; HSIL = 100; CC = 150) were enrolled in the study after obtaining informed consent. Biopsy samples of these subjects were analyzed to determine the lesion type. HPV detection and typing was done using polymerase chain reaction (PCR) and reverse hybridization. HPV type specific prevalence was determined in subjects with single and multiple infections. Results HPV DNA was detected in 68%, 95%, and 98.7% of LSIL, HSIL, and CC cases, respectively. HR-HPV and low-risk oncogenic HPV (LR-HPV) was observed in 66.9%/11.8% of LSIL cases, 87.3%/3.2% of HSIL cases, and 91.2%/0.7% of CC cases. HPV types -16/-18 (65%) were the most common high-risk HPV types observed, followed by types -52, -33, -45, and -31. Conclusion Cervical cancer burden in Venezuelan women is substantial. HPV types -16/-18 were the most common types prevalent among Venezuelan women followed by types -52, -33, -45, and − 31 (prevalence, ~ 90.1%). The results of this study provide baseline information on the HPV type distribution, which may facilitate the development of a cervical cancer prevention and control program in Venezuela.

HPV prophylactic vaccination: The first years and what to expect from now

New prophylactic HPV vaccines have the power to prevent many HPV infections, thus reducing the burden of HPV-associated diseases. Two vaccines composed of HPV L1 proteins self assembled into virus-like particles (VLPs) have been developed: one containing VLPS of HPV types 6, 11, 16 and 18, while the other vaccine is composed of HPV 16 and 18 VLPs. Large phase II and III clinical trials to assess prophylactic efficacy have been conducted in which both HPV infection endpoints and disease endpoints were evaluated, particularly high-grade cervical intraepithelial neoplasia – CIN2 or CIN3 – as well as vulvar and vaginal intraepithelial neoplasias – VIN or VaIN – and genital warts for the quadrivalent vaccine. Very high efficacy rates were observed in different populations that included young women between 16 and 26years of age, and older (up to 55). More recently, the quadrivalent vaccine has been shown to be efficacious in men to prevent genital and anal infection and disease caused by the types included in the vaccine. Based on demonstrated clinical efficacy and favorable safety profile, HPV prophylactic vaccine are being introduced worldwide aiming the reduction of the morbidity and mortality of tumors caused by HPV. From 2006 when first approved in the USA, hundreds of countries have licensed the HPV vaccines, a significant proportion of which are offering the vaccine to young women in national immunization programs supported by the government. The ultimate goal is to implement worldwide cervical cancer control programs to include HPV vaccination and screening with cytology and HPV DNA testing, particularly in less-developed countries where it is most needed.

Avaliação do programa de controle do câncer de colo uterino: percepção de portadoras de papilomavirus

The purpose of this research was to evaluate features of quality of services offered to woman with Human Papillomavirus from the basic health services in the city of Tubarão, through National Uterine Cervical Cancer Control Program of Ministry of Health. It is a qualitative approach case-study which used observation and semi-structured interviews with 16 selected women so as to get to know their profile, perceptions and satisfaction towards the attention provided to them, evaluated in accordance with the Program. The results showed organizational failures towards the follow-up of these women, as well as inconsistencies towards the adoption of diagnostic conducts and therapeutics and incorrect information about exams sequence and results. There was also lack of organization to help the women whose exams showed colposcopic changes, and those who needed follow-up. These factors may work as barriers to join the program and compromise its quality. The results of the evaluation are hopefully expected to extend the perspective of improvement towards the quality of the programs, and support the development of strategies to better conduct control policies of sexually transmitted diseases by providing subsidies in order to adapt the program to towns.

Human Papilloma Virus Vaccines: Implications for use in developing world

Cervical cancer may be substantially prevented by human papillomavirus (HPV) vaccination. The two most common oncogenic HPV types causing 70% of all cervical cancers are represented in the vaccines by synthetic virus-like particles to the L1 protein of HPV 16 and 18. The virus-like particles and adjuvant systems promote long-term antibody response. Invasive cervical cancer (ICC) is the second most common cancer among women worldwide. Approximately 85% of the disease burden is seen in women in developing nations. India with its highest share of global burden of cervical cancer has to implement a population based cervical cancer control program to reduce the number of deaths. Development of effective vaccines against human papillomavirus, the necessary cause of cervical cancer, has introduced a fresh lease of life to the cervical cancer control strategies. Vaccination programs targeted to a large age range of women will achieve cervical cancer reductions several decades from now.

Breast Cancer and Cervical Cancer Control Program Enrollees Inform the Kin Keeper Curriculum

The purpose of this study is to present the methodology of developing the Kin Keeper Cancer Prevention Curriculum Guide and Workbook through participatory engagement of women from underserved communities. It was developed to cross train community health workers (CHWs) from public health programs to deliver cancer education. Data collection included review of existing educational materials, a 10-minute telephone survey of 146 women enrolled in a Breast and Cervical Cancer Control Program and a pair of pre-post training assessments of 31 African American, Latina, and Arab CHWs. The enrollees adequately informed the curriculum and the CHWs increased their scores by 7% (14%) in breast (cervical) cancer literacy; P-values <0.01. The methodology was validated; the curriculum was well-informed and CHWs were effectively cross trained using the curriculum.