Introduction: Early cervical cancer screening can prevent up to 80% of cervical cancer related cases and mortalities, despite of this 80% of cervical cancer patients attend health facilities for cervical cancer screening at the point where the disease is untreatable. This study discovered perspectives of women toward utilization of cervical cancer services. Methods: We conducted interviews with women attending Mount Meru Regional Referral Hospital. A case study was used to explore their perspectives on accessibility of cervical cancer screening services. Sample was obtained using saturation principle a total of 27 women aged 25 years and above were purposely and conveniently enrolled for the study. Data were collected from both secondary and primary sources. Primary data obtained using interview guide and documents reviewed documents are Mid-Term Review of HSSP IV and National Cancer Control Strategy. Qualitative data were analyzed thematically. Permission was sought and informed consent obtained from each participant. Results: Women demonstrated their perspectives toward utilization of cervical cancer screening services. Marital status, income status and awareness on cancer severity and benefits of regular screening said to be factors, which determine women utilization of cervical cancer screening services at Mount Meru Regional Referral Hospital. However, the cited factors can facilitate or hinder the utilization. Finding reveals that partners awareness and support has major contribution toward utilization of cervical cancer screening services. Conclusion: Promoting cervical cancer awareness to both men and women is more required to facilitate effective utilization of screening services. Nevertheless, outreach services should be emphasized to increase accessibility of cervical cancer interventions.
Keywords: Cervical cancer; Human papillomavirus, Cervical cancer screening
Cervical cancer can be avoided and adequately cured if early detected, however cervical cancer remains one of the most common cancers which cancer related diseases across the globe . Once a year around 9,772 women diagnosed with cervical cancer and 6,695 women cancer related deaths and most of them are diagnosed at a late stage . Majority of deaths related to cervical cancer occurs to uneducated and young who live in third world countries .
The global burden of cervical cancer is projected to increase rising to 700,000 cases and 400,000 deaths in 2030 .These rises signify a 21% increase in the number of cases and a 27% increase in the number of deaths over just the 12-year period from 2018. Middle and lower income countries will face major increase of deaths and cases due to limited cervical cancer screening services .
World Health Organization had established cost-effective measures for eliminating cervical cancer yet up to date measures have not been widely implemented in middle and lower income countries despite of having high rate of cervical cancer cases and deaths. WHO recommends all countries to be pathway toward elimination of cervical cancer as the public problem by 2030, through implementing cervical cancer intervention as the national program. Recommended measures for cervical cancer interventions are; Primary prevention (Human Papillomavirus Vaccination and Health education) Secondary prevention (screening with High Performance Test and treatment of pre-cancerous) and tertiary (treatment of cervical cancer). Reports shows that lesions cytology based screening and early treatment can prevent up to 80% of cervical cancer mortalities ,Primary and secondary intervention are cost effective compared to treatment of third (III) stage cervical cancer where by the survival rate of women is 32% to 35% .
For effective implementation of these measures government must scale it into national levels and deliver interventions using National platforms, measures for intervention are recommended to be responsive to women’s needs, cultural, social, structural and economic barriers hindering women to access health services considering that health services which are integrated and people centered are fundamental toward effective implementation of cervical cancer services .
In Tanzania Ministry of Health and Social Welfare implemented national cervical cancer control strategy that targets provision of Human Papillomavirus Vaccination, health promotion and screening programs . In 2014 Human Papillomavirus Vaccination program piloted in Kilimanjaro followed by cancer prevention and awareness campaign which launched in 2017 by Cancer Care Center at Kilimanjaro Christian Medical University College (KCMC). The program involved offering primary interventions and rising awareness and skills to health care provider concerning cervical cancer screening and treatment. Campaign involved northern Tanzania (Arusha and Kilimanjaro) covering Hai, Siha, Mwanga, Rombo, Moshi urban, Arusha urban and Moshi rural districts .
Regardless of efforts done by the Government of Tanzania to enhance both primary, secondary and tertiary cervical cancer interventions, it has reported that the coverage of cervical cancer screening services is low in middle and low income countries. The implementation of cytology screening based program has been difficult and where they have implemented the coverage is low . Therefore we conducted qualitative study to explore perspectives of women on utilization of cervical cancer screening services.
We conducted qualitative case study from 10th July 2021 to 30th March 2021 to get an in-depth understanding on perspectives of women toward utilization of cervical cancer screening services. The study involved interviews with women attending Mount Meru Regional Referral Hospital. A total of 27 women aged 25 years and above were purposely and conveniently selected for the study.
Women aged 25 years and above are at high risk of getting cervical cancer and are recommended by World Health Organization for screening.
Data were collected using interview guide and documentary review. Documents reviewed include National Cancer Control Strategy and data from DHSI2. The interview guide was prepared in Kiswahili and pre-tested at Meru District Hospital to non-participant of this study and findings from pilot were not included in study. Data were collected using tape recorder and conveniently transcribed using English language while interviews were conducted in Kiswahili, transcripts were read repeatedly to crosscheck data quality. Transcribed information were coded and analyzed thematically, statements which present the same theme were grouped together, subsequently findings were presented into narration and quotation and the most prominent quotes were nominated to support identified themes.
We sought permission to conduct study from Hospital management, acceptance to conduct the study was granted by the management of Mount Meru Regional Referral Hospital. During data collection we sought both verbal and written consent from participants, participation in the study was completely voluntary and freedom to withdrawal from the study was granted. Participants were given number instead of using their names.
The study intended to explore perspectives of women on utilization of cervical cancer screening services. We found that social demographic factors influences utilization of cervical cancer screening services hence the result reveals that social demographic factors influence uptake of cervical cancer screening services. However participants shared some experience on barriers which hindered effective utilization.
Awareness of cervical cancer
Interviewed participants were asked what influenced them to visit health facility for cervical cancer screening; we found that most of participants demonstrated that awareness on the benefit of regular cervical cancer screening, disease susceptibility and seriousness of the disease facilitated them to attend screening services. Information gained from neighbors, health care providers and Medias mentioned to be basis of awareness on cervical cancer. Participants demonstrated that it is important for them to know health status hence the trend of non- communicable diseases like cancer in the world reported to be high.
Currently there is a growing rate of cervical cancer cases all over the world. I utilize these services in order to understand my general health status, being healthier creates a sense of confidence in you and you hopefully live (Respondent no 1, March 2021).
Study participants validated their knowledge on cervical cancer susceptibility and they perceive cervical cancer as a serious disease;
As I told you I’m HIV positive, I feel am the most susceptible to cancer than any other woman, thus why am here at the hospital. Imagine having HIV/AIDS and cervical cancer at the same time, its pain over pain. When I imagine that I schedule my plans for the test (Respondent no 15, March 2021).
Nevertheless majority of respondent accredited information they gained from Mass Medias, health care providers and other sources contributed their awareness on cervical cancer;
I remember I was listening to radio program that was airing about early cervical cancer screening. In this program women who were cervical cancer survivors said; they were first diagnosed cervical cancer positive they explained how early diagnosis facilitates easy treatment. From there I started attending Mt. Meru hospital for cervical cancer screening (Respondent no 4, March 2021).
Participant’s demographic characteristics and uptake of cervical cancer screening services
Finding of the study revealed that some demographic factors are associated with utilization of cervical cancer screening services. We found that Age, income status and marital status are the most important factors influencing women to visit facility for cancer screening services. Participants said that they attend for screening because reproductive age make them prone to cervical cancer, similarly marital status demonstrated to be reason for respondents to attend screening services, participants said that they get influenced from their life partners we found few women were escorted by their husband;
My husband does persuade me to use these services. We were all unaware of these services at first point until we both attended an outreach project concerning screening for cervical cancer which was organized by a certain religious healthcare facility in our ward. From that moment he encouraged me to take my first test and he keeps on reminding me to go back for another test after every three years. As you can see he escorted me here (Respondent no 6, March 2021).
Income status and accessibility of cervical cancer screening services
Study finding revealed that there is association between respondent’s income and the uptake of cervical cancer screening services. Most of participants reported that sometimes they do not attend screening services effectively because they do not afford transportation fare they pay from their area of residence to health facility. Nevertheless participants demonstrated that access to cervical cancer services is limited they are required to move from one place to another place to search for services, considering low economic status and competing life needs sometimes they opt to use income they get to buy basic needs like food for their family than incurring costs to travel for cervical cancer screening services;
I work in a small business that enables me to pay for transportation from home to the hospital. But sometimes I fail to attend the service especially when the economy is not supporting. Some days you even miss money to attend the seminars for cervical cancer when the specialists invite us. The problem is with us who have no permanent businesses (Respondent no 8, March 2021).
Another respondent validated;
“I think women of higher income it’s easier for them because they are too close to doctors compared to us of lower income. Some they have family doctors who advise them frequently on their health status” (Respondent no 9, March 2021)
The current study offers information on the perspectives of women toward effective utilization of cervical cancer screening services among women in Mount Meru Regional Referral Hospital. The study explored finding related to cervical cancer awareness mainly on benefit of regular screening, cervical cancer seriousness as well as susceptibility to cervical cancer. Additionally income and marital status reported to be factor-influencing women to attend cervical cancer screening services.
Participants of this study provided valuable information that could inform Government and other stakeholders on factors which falitate effective utilization of cervical cancer screening services. Most of participants revealed their good understanding about cervical cancer seriousness, susceptibility to cervical cancer and benefit of regular screening. They stated that being in reproductive age make them susceptible to cervical cancer, their perception showed that cervical cancer is the serious disease, which affects women health. This finding was consistent with the finding of AlMuro, et al. on the factors associated with cervical cancer screening uptake: implications for the health of women in Jordan. Study finding indicated that; participants highly perceived that every woman of childbearing age was at risk of cervical cancer and that susceptibility increases with an increasing number of pregnancies . Women perceived that they are at risk of developing cervical cancer in a range of age groups not just in the older age groups and their adherence to cervical cancer screening recommendations was affected by their beliefs about the susceptibility of contracting the disease.
Participants of this study demonstrated that severity of cervical cancer cervical cancer influenced them to attend for screening cervices this finding correspond with study finding of Ebu and Ogah  on the predictors of cervical cancer screening intentions of HIV- positive women in central region of Ghana.
The finding showed that perceived seriousness of cervical cancer was a determinant of cervical cancer screening intentions for HIV-positive women with high seriousness perception may be knowledgeable about the fact that cervical cancer is a deadly disease. This probably indicates that when women are aware of the difficulties they would face when they suffer from cervical cancer they will be influenced to utilize screening services. Perhaps participant’s awareness is due to the fact that many of them receives education about cervical cancer from different sources like media, health care providers and relatives . Literatures suggests that women need information so as they can make informed decision, if women they are not aware about cervical cancer they are likely not to attend cervical cancer screening effectively .
Participants of the current study pointed out marital status as the catalyst toward their attendance on cervical cancer screening services, possibly is due to influence and support from their husband. This finding corresponds with the study conducted by Nwabichie, et al. on the factors affecting uptake of cervical cancer screening among African Women in Klang Valley, Malasia. Finding reveals marital status as significant predictor of Pap smear uptake in the past three years . Married women were found to be two (2) times more likely to have a good uptake (95%) unlike unmarried women (5%). This could be possibly husbands they have the knowledge about cervical cancer and benefits of early screening and treatment.
Literature demonstrates that women whom their husbands are knowledgeable about cervical cancer are more likely to attend cervical cancer screening than women whom their husband they don’t have knowledge on cervical cancer. Moreover it is provided that men need information about cervical cancer so as to make informed decision to encourage their partner to attend screening services. World Health Organization reported that the uptake of cervical cancer screening needs a supportive strength within the community; men should be educated on the importance of regular screening to encourage their spouses on utilization of cervical cancer screening services .
Participant of the current study demonstrated how their income status affected attendance of cervical cancer screening services and seminars conducted by health care providers. Participants proved that despite of free provision of service they face challenge of lacking transport fare because services were provided away from their resident area; participants said that they opt to use money they earn to buy basic needs than paying transportation fare. The Finding is similar to the study by Woldesadik, et al. on the socio-demographic characteristics and associated factors influencing cervical cancer screening among women attending in St. Paul’s teaching and referral hospital, Ethiopia . The finding shows that women who had been earning 111-148 US dollars were more likely to seek for screening than women who earn less than 75 US dollars. Therefore, the failure of women to attend cervical cancer screening services probably attributed to women’s income logically because of conflicting basic needs resulting to cervical cancer screening services become a last option.
Conversely, participants perceived it is easier to people with high income to have closeness with health care providers compared to people with lower income. This is probably due to classes in the society where by people with high income they are provided services differently with people with low-income level . Government need to change this perception to enhance equity on access of cervical cancer services.
Most participants of current study demonstrated determinants of their uptake of cervical cancer screening services, most prominent factors were marital status, awareness on cancer severity and benefits of regular screening as well as income status. This entails that men need to be provided enough information about cervical cancer so as to influence their partners, daughters and other relatives to attend screening services, adequate provision of cervical cancer training to health care providers and other community health care workers so as they can provide comprehensive health promotion and advice to clients [11,12]. Majority of participants pointed out low level of income as the major hindrances toward effective utilization of cervical cancer services. Participants said that sometimes they lack transportation fare to attend seminar and clinics. The finding call upon Government efforts to increase outreach services so as to accelerate geographical equity due to the fact that some women unable to reach cervical cancer services due to geographical constraints. This study limited its self and more focused to women other studies may aim to investigate the contribution of men toward cervical cancer screening in the society.
We thank Management of Mount Meru Regional Referral Hospital for granting us permission to conduct study. Also we appreciate all participants of this study for their willingness to provide information that enabled development of this manuscript. Additionally we acknowledge reviewer for their tirelessly guidance toward improvement of this manuscript.
HM provided technical support, critically reviewed the drafted manuscript and extensively contributed to the development of the manuscript. MMM conducted interpretation and drafted the manuscript. YM developed idea, developed data collection tools, collected data, conducted transcription and analysis MA reviewed the study design, transcripts, data collection and analysis tools and provided technical support. All authors read, commented, revised and approved the final manuscript.
- World Health Organization (2020) Global Strategy to accelerate the elimination of Cervical Cancer as a public health problem. Geneva.
- Mugassa AM, Frumence G (2020) Factors influencing the uptake of cervical cancer screening services in Tanzania: A health system perspective from national and district levels. Nurs Open 7: 345-354.
- Global Cancer Observatory (2018) Estimated Cancer Incidence, Mortality and Prevalence in 2018. Geneva: International Agency for Research on Cancer, WHO.
- Henke A, Kluge U, Borde T, Mchome B, Serventi F, et al. (2021) Tanzanian women´s knowledge about Cervical Cancer and HPV and their prevalence of positive VIA cervical screening results. Data from a Prevention and Awareness Campaign in Northern Tanzania, 2017 Glob Health Action 14: 1852780.
- Al-Amro SQ, Gharaibeh MK, Oweis AI (2020) Factors Associated with Cervical Cancer Screening Uptake: Implications for the Health of Women in Jordan. Infect Dis Obstet Gynecol 2020: 9690473.
- Ebu NI, Ogah JK (2018) Predictors of cervical cancer screening intention of HIV- positive women in the central region of Ghana. BMC Women’s Health 18: 43.
- World Health Organization (2013) Comprehensive Cervical Prevention and Control: A healthier future for girls and women.
- Nwabichie CC, Manaf RA, Ismail SB (2018) Factors Affecting Uptake of Cervical Cancer Screening Among African Women in Klang Valley, Asian Pac J Cancer Prev 19: 825-831.
- Woldetsadik AB, Amhare AF, Bitew ST, Pei L, Lei J, et al. (2020) Socio-demographic characteristics and associated factors influencing cervical cancer screening among women attending in St. Paul’s Teaching and Referral Hospital, Ethiopia. BMC Womens Health 20:
- Merino-Ventosa M, Urbanos-Garrido RM (2018) Changes in incomerelated inequalities in cervical cancer screening during the Spanish economic crisis: a decomposition analysis. Int J Equity Health 17: 84.
- World Health Organization (2018) Tanzania rolls out vaccination against cervical cancer.
- World Health Organization (2002) Cervical screening in developing countries: Report of a WHO consultation.