TeleDoVIA Meeting the Challenge of Early Detection on

Cervical Cancer: A Pilot Study in Indonesia

Laila Nuranna

1,2

, Gatot Purwoto

1,2

, Annisa Hadisty Sukana

and Alexander A. W. Peter

Department of Obstetric and Gynaecology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

Female Cancer Program, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia

Obstetric and Gynaecology Resident, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

Female Cancer Foundation, Leiden, The Netherlands

Keywords: Cervical Cancer, Telemedicine, Teledovia, VIA.

Abstract: Background: Visual Inspection with Acetic Acid is a screening method for cervical cancer in Indonesia that

is completed with photographs, or DoVIA. This photograph (DoVIA) can be discussed with the expert team

in the media called TeleDoVIA. Objective: To assess the eligibility of TeleDoVIA as a medium for

longdistance communication and medical consultation among medical practitioners who conduct VIA and

oncology consultants. Methods: The sample was medical practitioners who sent cervical photographs to

TeleDoVIA from between January 2019 and August 2019. Based on the inclusion and exclusion criteria, 96

medical practitioners with 191 cervical photographs were obtained. Results: The medical practitioners were

distributed from the westernmost and easternmost parts of Indonesia (Banda Aceh and Fakfak). 70.8% of the

medical practitioners were midwives, 92.7% work in Primary Health Care and were trained after 2016. Nearly

all those involved (98.9%) were satisfied with the explanation given by the expert team on TeleDoVIA.

Approximately 89% of documentations received were sharp pictures. The interpretation of VIA among

medical practitioners compared to the expert team were similar, with an accuracy rate of up to 88.5%.

Conclusion: TeleDoVIA can be considered as an effective communication and consultation medium to

discuss the results of VIA.

1 INTRODUCTION

As a countermeasure against cervical cancer, Visual

Inspection with Acetic Acid (VIA) is a proper

screening method used for secondary prevention. The

high sensitivity of VIA is believed to be able to show

abnormalities of the cervix, including pre-cancer

lesions that can be observed one minute after rubbing

3–5% acetic acid. However, as the name suggests,

diagnosing the result of a VIA examination heavily

relies lot on the visual interpretation of the medical

practitioner. Therefore, to prevent misdiagnosis, the

Ministry of Health established that the executor of

VIA must go through initial training (Kementerian

Kesehatan Republik Indonesia, 2017; Andrijono,

2018).

In the beginning, VIA did not yet have proper

documentation that could be used as authentic proof

and material for communication and consultation

among medical practitioners. As a result, Oncology

Gynaecology consultants at the Faculty of Medicine

at Universitas Indonesia–Cipto Mangunkusumo

Hospital, along with other experts, agreed to

document VIA results as pictures taken with a

cellphone camera. This method was called

Documentation of Visual Inspection with Acetic Acid

(DoVIA) (Nuranna, 2019).

Over time, it was found that cervical photographs

in DoVIA could serve as learning materials.

Obstacles such as time and distance limited medical

practitioners in remote areas from discussing VIA

results with experts in the urban area. Thus, a portal

was made as a consultation and discussion media

open for all VIA practitioners.

The portal was named Telemedicine of DoVIA

(TeleDoVIA Portal), a photography-based consulta-

tion model that exploited the telecommunication

system through Whatsapp Messenger in smartphones,

computers and computer tablets (Nuranna, 2019).

In medicine, the term ‘telemedicine’ was initially

used on 1970. The word was composed of two terms:

tele, which means ‘far’, and medicine, which means

Nuranna, L., Purwoto, G., Sukana, A. and Peter, A.

TeleDoVIA Meeting the Challenge of Early Detection on Cervical Cancer: A Pilot Study in Indonesia.

DOI: 10.5220/0009387200120016

In Proceedings of the 4th Annual International Conference and Exhibition on Indonesian Medical Education and Research Institute (The 4th ICE on IMERI 2019), pages 12-16

ISBN: 978-989-758-433-6

‘to cure’; therefore, telemedicine literally means to

cure the distance. Nowadays, this term has been

widely used in medicine and pharmacy (Sood et al.,

2007).

Based on a study conducted in Botswana that

showed a significant concordance in the diagnosis of

cervical lesions when comparing the diagnosis of the

onsite clinician to the diagnosis of the clinician

evaluating the photos through telemedicine (Quinley

et al., 2011).

Meanwhile, since first introduced in 2017, many

medical practitioners in Indonesia have used the

TeleDoVIA portal as communication and

consultation media, with varying pictures in DoVIA.

However, it was not known how far the portal

benefits the practitioners of VIA. Therefore, a study

is needed to assess the benefits, understanding,

satisfaction and effectiveness of the TeleDoVIA

portal by medical practitioners as a communication

and consultation media for results uploaded in

DoVIA, and to discover the scope of the TeleDoVIA

portal in Indonesia.

2 METHOD

This study uses the descriptive method. The unit of

analysis was the medical practitioners who provided

VIA and the documentation of VIA in the form of

cervical photographs and consulted through

TeleDoVIA. The result of the analysis was provided

in the form of frequency distribution tables showing

each variable: practitioners’ working area, age of

medical practitioners, year of training, profession,

type of healthcare facility, understanding and

satisfaction of medical practitioners, reason for

consultation, number of cervical photographs sent,

accuracy of diagnosis, sharpness of cervical

photographs and consultants’ response duration. The

sample for this study was all medical practitioners

who utilized TeleDoVIA from January to August

2019.

Based on the inclusion and exclusion criteria,

information from 96 medical practitioners located all

around Indonesia and 191 cervical photographs were

obtained.

3 RESULTS

TeleDoVIA makes use of the Whatsapp Messenger

feature in cell-phone, an application that is widely

used by Indonesians. Internet connectivity is widely

available in Indonesia, thus optimizing consultation

and discussion media to assist VIA practitioners.

The TeleDoVIA team consisted of Oncology–

Gynaecology consultants and a few Obstetricians

working at Cipto Mangunkusumo Hospital gathered

in a Consultant Group using Whatsapp Messenger.

Each consultant had their own schedule to provide a

response to cervical photographs and questions asked

by medical practitioners. TeleDoVIA was managed

by an administrator. Through phone numbers spread

on screening events, newly trained VIA practitioners

could easily consult with experts. Every cervical

photographs and question would be forwarded by the

administrator to the Consultant Group and

immediately answered by the scheduled consultant.

Table 1: Working Area of VIA Practitioners who Utilize

TeleDoVIA.

Category Frequency Percentage (%)

Banda Aceh 1 1.0

Padang 1 1.0

Pekan baru 1 1.0

Batam 1 1.0

West Tanjung Jabung 1 1.0

East Belitung 1 1.0

Kalianda 1 1.0

Tangerang 1 1.0

West Jakarta 7 7.3

Central Jakarta 24 25.0

South Jakarta 9 9.4

East Jakarta 16 16.7

North Jakarta 8 8.3

Bekasi 7 7.3

Banjarnegara 1 1.0

Makassar 2 2.1

Mataram 1 1.0

Pontianak 1 1.0

Banjar Baru 1 1.0

Banjarmasin 1 1.0

Ambon 9 9.4

Fakfak 1 1.0

Total 96 100.0

Based on Table 1, medical practitioners

benefitting from TeleDoVIA were located around

Indonesia, spread from the west in Banda Aceh City

(Aceh Province) to the east in Fakfak (West Papua

Province). Most medical practitioners using

TeleDoVIA worked in Central Jakarta (25%).

Indonesia is an archipelago state consisting of

18,210 islands over an area of 7 million km

. The

complex physiographic condition causes each

territory to have different accessibility that is

restricted by time and distance. Medical practitioners

TeleDoVIA Meeting the Challenge of Early Detection on Cervical Cancer: A Pilot Study in Indonesia

working in remote areas had limited access and

ability to directly discuss cases with experts (Bintarto

and Hadisumarno, 1979).

Currently, TeleDoVIA has been utilized by

medical practitioners from Banda Aceh City (Aceh

Province) on the west to the east at Fakfak (West

Papua Province). With the development of 905 ‘Desa

Dering’, internet access is available in even the most

remote areas (Masa, 2017).

Whatsapp Messenger enabled TeleDoVIA to

display original cervical photographs. TeleDoVIA

also helped to assist newly trained medical

practitioners. With TeleDoVIA, the discussion could

be conducted without time and distance restrictions;

thus, consultants did not need to come to practitioners

working area. Through the TeleDoVIA portal,

medical practitioners could easily send DoVIA and

questions through Whatsapp Messenger to discuss

cases with consultants. All telecommunication

devices used were commonly used devices in

telemedicine (Masa, 2017).

Table 2 shows that the majority of medical

practitioners who were more than 40 years of age

trained after 2016. Almost all practitioners were

satisfied with TeleDoVIA consultations and

understood the explanations given by the consultants

(98.9%). Seventy-five percent of medical

practitioners consulted fewer than three times in eight

months. The majority of medical practitioners (76%)

consulted through TeleDoVIA because they wanted

to confirm VIA interpretation.

Information and photography technology used in

DoVIA and TeleDoVIA was easily implemented by

all medical practitioners, regardless of age and

profession. This was proven by the high percentage

of midwives utilizing TeleDoVIA (70.8%).

Additionally, medical practitioners who were more

than 40 years of age could also upgrade their

knowledge and insight through communication and

discussion with consultants through the TeleDoVIA

portal (Jamil, Khairan and Fuad, 2015).

Based on this study, it was found that almost all

medical practitioners utilizing TeleDoVIA were

newly trained practitioners who wanted to confirm

their diagnosis. As newly trained practitioners, they

were sometimes doubtful about their interpretation of

VIA results. It should be noted that the VIA

examination iss subjective; thus, the experience had a

great deal to do with increasing the accuracy of VIA

interpretation. Guidance and assistance were needed,

for example, through the TeleDoVIA portal.

TeleDoVIA could act as long-ranged assistance for

medical practitioners by consultants (Bigoni et al.,

2014).

VIA screening method training for medical

practitioners obliged newly trained practitioners to

screen a minimum of 50 patients to be reported to the

trainers afterwards, as noted in the logbook as a

condition to be able to participate in Objective

Structured Clinical Examination (OSCE) as

evaluation model, albeit it in an informal manner.

This was intended to increase the familiarity of the

practitioners towards varying cervical appearances in

VIA.

However, the evaluation model by means of

OSCE was limited by time and financing. Through

this study, it was concluded that TeleDoVIA could be

an alternative as assistance by newly trained

practitioners and a refreshing course for senior

practitioners. Most practitioners (98.9%) were

satisfied with the TeleDoVIA portal. The same

percentage of practitioners claimed that they fully

understood the explanation given by the consultants.

Table 2: Characteristics of VIA Practitioners.

Category Frequency Percentage (%)

Age

≤ 30 years old 25 26

31 - 40 years old 40 41.7

41 - 50 years old 21 21.9

> 50 years old 10 10.4

Year of Training

< 2017 18 18.8

≥ 2017 78 81.3

Profession

Midwife 68 70.8

Doctor 28 29.2

Type of Healthcare

Facilities

Private Clinics 7 7.3

Community Health

Centre

89 92.7

Understanding

Understood 95 98.9

Not Understood 1 1.1

Satisfaction

Satistied 95 98.9

Not Satisfied 1 1.0

Reason for

Consultation

Case Discussion 23 24.0

Confirmation of

Diagnosis

73 76.0

Number of

Photographs Sent

< 3 Photographs 72 75.0

3 - 5 Photographs 20 20.8

> 5 Photographs 4 4.2

Total 96 100.0

The 4th ICE on IMERI 2019 - The annual International Conference and Exhibition on Indonesian Medical Education and Research Institute

Table 3: VIA Results Documentations.

Category

Frequency

Percentage

(%)

Diagnosis

Correct 169 88.5

Incorrect 22 11.5

Sharpness of

Photographs

Sharp 170 89.0

Not sharp 21 11.0

Duration of

Consultant

Response

1 - 6 hours 106 55.5

7 - 12 hours 14 7.3

13 - 18 hours 17 8.9

19 - 24 hours

54 28.3

Total

191 100.0

Out of 191 documentations obtained in

TeleDoVIA, the majority of the cervical photographs

were sharp and clear (89%). The interpretation made

by the practitioners and consultants showed an

accuracy of up to 88.5%. Photographs and questions

were mostly answered in less than six hours’ time

(55.5%).

The response time for DoVIA sent by the

practitioners ranged from one minute to 24 hours.

Therefore, TeleDoVIA was deemed effective as a

medium for communication and consultation of

medical practitioners in secluded areas. This also

solved the discrepancy of the distance between

practitioners (Hardati, P., 2016).

Some studies show that DoVIA has become an

important method to control the quality of an

examination. Therefore, standardization for

photography procedures using smartphones is

needed, including but not limited to shooting angle,

distance from the cervix and the number of pictures

taken. In this case, DoVIA has specific photography

techniques. This material had been a part of VIA

screening method training, which requires that every

practitioner must be able to take DoVIA photographs

with their own cellphones. This showed in the results

of DoVIA sent in the portal, with 89% out of all

pictures being categorized as appropriately sharp

photographs. Therefore precancer lesions or white

plaque could be clearly seen (Bray et al., 2018).

Quality of DoVIA was an important part of

diagnosis and reference for consultants. This was in

line with previous studies that stated that photographs

of the cervix were crucial for accurate cervical lesion

diagnosis. This was supported by an expert opinion

that stated that quality assurance for VIA was

important and documentation of VIA results could be

an important supporting procedure.

(Goldie et al.,

2005; Quinley et al., 2011).

4 CONCLUSIONS

This study proved the benefits of TeleDoVIA, which

was in line with the function of telemedicine according

to the World Health Organization. The TeleDoVIA

portal was effective as a consultation and discussion

medium for medical practitioners, especially those

who work in rural areas and are unable to directly

consult with a Gynaecology– Oncology expert. The

TeleDoVIA portal also acted as a form of assistance for

newly trained medical practitioners when doing VIA.

ACKNOWLEDGEMENTS

We would like to show our gratitude to Dr Tofan and

all the staff of the Division of Oncology–

Gynaecology as the expert team on the TeleDoVIA

portal. We are also immensely grateful to the ethical

reviewer of the Faculty of Medicine Universitas

Indonesia, who reviewed the proposal for this study

so we could collect this data without any ethical

issues.

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