Date Published: October 24, 2018
Publisher: Public Library of Science
Author(s): Tjedza G. Matenge, Bob Mash, Geofrey Musinguzi.
Low and middle-income countries have a greater share of the cervical cancer burden, but lower screening coverage, compared to high-income countries. Moreover, screening uptake and disease outcomes are generally worse in rural areas as well as in the HIV positive population. Efforts directed at increasing the screening rates are important in order to decrease cancer-related morbidity and mortality. This study aimed to explore the barriers to women with HIV accessing cervical cancer screening in Kgatleng district, Botswana.
A phenomenological qualitative study utilising semi-structured interviews with fourteen HIV positive women, selected by purposive sampling. The interviews were transcribed verbatim and the 5-steps of the framework method, assisted by Atlas-ti software, was used for qualitative data analysis.
Contextual factors included distance, public transport issues and work commitments. Health system factors highlighted unavailability of results, inconsistent appointment systems, long queues and equipment shortages and poor patient-centred communication skills, particularly skills in explanation and planning. Patient factors identified were lack of knowledge of cervical cancer, benefits of screening, effectiveness of treatment, as well as personal fears and misconceptions.
Cervical cancer screening was poorly accessed due to a weak primary care system, insufficient health promotion and information as well as poor communication skills. These issues could be partly addressed by considering alternative technology and one-stop models of testing and treating.
Cervical cancer is a global public health issue, affecting not only women, but also their families, communities and social institutions. It is the second leading cause of cancer-related mortality among women globally, although it is also one of the most preventable cancers due to its slow progression, identifiable cytological precursors and effective treatment.[1,2] Even though the disease is preventable, more than half a million women worldwide develop invasive cervical cancer each year. Low and middle income countries bear a disproportionate share (83%) of the global cervical cancer burden, but only manage an average screening coverage of 19%, compared to 63% in high income countries. Screening uptake and disease outcomes are generally worse in rural areas compared with urban areas because the population is substantially poorer and access to health services is more difficult. The burden of disease from cervical cancer also falls more on older women who are post-childbearing and who are important to both family stability and the broader economy.
Ethical approval was obtained from the University of Stellenbosch Health Research Ethics Committee (S15/01/006) as well as from the Ministry of Health of Botswana (HPDME 13/18/1 X (2).
A total of 14 women were interviewed and their characteristics are described in Table 1. Overall, eight women had accessed screening and six had not, three were aged 21–29 years, five were aged 30–39 years and six were aged 40 years or more. All were from Oodi village, apart from one woman who was a farm worker from Kgaphamadi Gaborone North farms.
A wide range of factors delaying women from undergoing cervical cancer screening are summarised in Fig 1.
There is a significant deficit in knowledge of the benefits of cervical cancer screening amongst women living with HIV in Kgatleng district, Botswana. Although the participants heard that screening was important, they did not understand why and could not link it to prevention of cervical cancer. Participants had low levels of confidence with regard to the quality of the service due to poor patient-centeredness, inadequate appointment systems, unavailability of equipment and results. Moreover, there were many fears and misunderstandings regarding the screening process and interpretation of results.