Background
Methods
Ethical approval
Study setting
Research design and study population
Sample selection
Data collection
Measures
Data processing
Analytical approach
Results
Participants’ demographic profile
Demographic Characteristics | % |
---|---|
Mean Age | 42.6 |
Marital Status | |
Single | 34.9 |
Married | 44.6 |
Other | 20.5 |
Education | |
None | 3.2 |
Primary | 11 |
Secondary | 52.8 |
Tertiary | 33 |
Employment | |
None | 40.6 |
Self Employed | 49.8 |
Government | 9.6 |
Income | |
None | 42.8 |
< 50,000 CFA | 38.4 |
> 50,000CFA | 18.8 |
Mean age at sex debut | 17.2 |
Lifetime sex partners | |
1 | 8.7 |
2–4 | 46 |
5–6 | 21 |
7–9 | 8.9 |
10 or more | 11.7 |
Don't Know | 3.7 |
Current oral contraceptive use | 33.9 |
Major themes and sub-themes
Challenges | Opportunities | |
---|---|---|
Micro-level (Individual) Factors | ||
Awareness and knowledge | Older women were more likely to believe myths and misconceptions about cervical cancer | Nearly all women were aware of at least one type of cancer – cervical and breast cancer most commonly |
Risk perceptions and health-seeking behaviors | Limited knowledge of the relationship of HPV and cervical cancer | Younger women were more likely to demonstrate knowledge of risk factors associated with each type of cancer |
Varied perception of risk associated with age, HIV status, adherence to myths and misconceptions and perceived risk of cervical cancer | Nearly all women were aware of increased risk of cancer diagnosis in their community | |
All women had never been screened for cervical cancer | Younger women and those with higher education were more likely to take preventive actions to minimize their exposure to risk | |
Knowing someone diagnosed with cancer strongly influences perception of risk and willingness to initiative preventative behaviors | ||
Those that were aware of the risks of cervical cancer were more likely to encourage others to take preventive measures against cervical cancer | ||
Lack of access to information about cervical cancer screening services | Women did not have access to any source to obtain information about cervical cancer which made it possible for false and negative information about cervical cancer to spread in their communities | Women sought information about cervical cancer from internet sources or private health facilities offering screening and other services related to cervical cancer |
Cost as a deterrent to cervical cancer screening | Absence of publicly funded cervical cancer screening programs | Available at a few private health facilities, but these services are expensive so many women cannot access them |
Difficulties with personal finances due to high unemployment rates in the country places paying for cervical cancer prevention as low on the list of priorities | Women were likely to appear for cervical cancer screening if it was free and transportation costs were reimbursed | |
The cost of transportation to health facilities is an additional financial deterrent | ||
Meso-level (Community Norms and Social Networks) Factors | ||
Social networks and social norms | The type of information about cervical cancer is determined by the amount of cervical cancer knowledge that community has and how much they are attached to myths and misconceptions about cervical cancer | Community education and stigma reduction around cervical cancer is likely to have a high impact because individual’s knowledge and behaviors are shaped by and conform to expectations is set by the level of awareness in their community |
Cultural norms and the role of men | Men do not take much interest in women’s health issues or encourage preventative behaviors as a result of cultural expectations of how men should conduct themselves | Younger women are encouraging men to be proactive in taking concrete action to help prevent their spouses from getting cervical cancer (ie: not having multiple partners, encouraging their wives to participate in regular screening, etc.) |
Men with negative attitudes about cervical cancer believe there is very little to be done to prevent cervical cancer | Men with higher levels of education demonstrated better knowledge of risk factors and was more likely to demonstrate a positive attitude to cervical cancer prevention | |
HIV and health-related social stigma | Ignorance and fear of death contribute to the stigma surrounding cervical cancer | Lots of opportunity for stigma reduction activities in communities |
The belief that cervical cancer is untreatable fuels stigma | ||
Disease associated with women’s reproductive organs contribute to stigma given cultural norms around female sexuality | ||
Macro-level (Structural: Health System and Policy) Factors | ||
Weak health system and lack of infrastructure | Lack of cervical cancer screening facilities in the regional hospital requires travel to large urban centers for screening | Private clinics have made cervical cancer screening |
Limited basic equipment for screening | ||
Shortage of trained health care workers who can keep up with demand | ||
Weak health care system and poor condition of physical health centers | ||
Emphasis on HIV/AIDS within the health system leaving little space for competing health priorities | ||
Shift to private facilities leading to higher costs for patients with limited trust in providers’ skills | ||
Lack of cancer prevention policies | Lack of comprehensive policies that can aid awareness and encourage positive attitudes to cervical cancer screening | |
Cervical cancer screening in in the context of HIV/AIDS care and treatment program | Women not living with HIV or of unknown status did not want to seek screening from services integrated with HIV/AIDS care because of potential HIV-related stigma they may face | Integration of cervical cancer screening within HIV care and treatment programs |
Interest in community-based cervical cancer screening programs which can be accessed in community settings or done in their own homes | ||
Lack of cancer prevention policies | Limited commitment from government and politicians to improve population health | Interest from age-eligible women to be educated on cervical cancer prevention |
Rural–urban disparities in health care infrastructure and supplies |
Micro level (Individual) factors
Awareness and knowledge
Knowledge of the relationship between HPV and cervical cancer was generally poor. For instance, younger and older participants lacked knowledge that persistent infection with HPV, especially types 16 and 18 is strongly linked to cervical cancer. None of the older women reported having ever heard about HPV, and only a few of the younger women recalled hearing about HPV.“…. hmmm vaginal candidiasis, which comes from using unhygienic and unsanitary public restrooms is the reason for many women diagnosed with cervical cancer. In addition, there are lots of women who wear “second hand” clothing, including underwear filled with germs that can cause this problem”. (FGD, Female HIV-negative 36–45 years).
Risk perceptions and health-seeking behaviors
Despite the consensus that most women were susceptible to cervical cancer, some participants did not consider themselves to be at risk. Those in this category agreed with statements expressed by a participant who said: “I take care of myself and I am sure I don’t have anything that will bring me cancer”. We also found that knowing someone who was diagnosed with cancer strongly influences the perception of risk and willingness to initiate preventive behaviors.“Like cervical cancer, I’ve heard that allowing antiseptic soap to penetrate the vagina during a bath can cause cervical cancer, therefore, I make sure I do not use antiseptic soap to wash my vagina when taking a bath”. (FGD, Female HIV-negative = > 46 years).
Lack of access to information about cervical cancer screening services
“…the limited or complete lack of access to reliable and trusted sources of health information represented a major hurdle for those who know the dangers of cervical cancer, but do not know how to access reliable and trusted information to enable them to take appropriate preventive actions. In an environment rife with myths, misconceptions and mixed messages from the internet, obtaining relevant information about the importance of cervical cancer prevention is critical for women’s preventive behaviors.” (FGD, HIV-negative 25–35 years).
Cost as a deterrent to cervical cancer screening
In women and men’s FGDs, participants agreed that the economic situation in the country, with high unemployment rates, meant that families struggling to meet their basic needs for daily survival were unlikely to consider paying for cervical cancer prevention given their limited budget,even in situations where they know it can be fatal. Indeed, many women participants reported that they were screening for cervical cancer for the first time only because the service was free (as part of the study). Despite not having to pay for screening, many participants still reported that transportation costs from their homes to the screening center was a major expense that only a few can accommodate within very tight budgets. Most of the women who showed up for screening did so only because they knew they would be reimbursed for their transportation costs. The words of a female respondent captured participants’ feelings about how cost constituted a barrier to accessing screening:“cost is perhaps the biggest challenge to obtaining cervical cancer screening, not only in the communities but for low-income women everywhere”. Without money, it is impossible to obtain health services even in government run hospitals” (FGD, WLHIV 36–45 years).
Another respondent emphasized this point when she said:“It would have been impossible for me [and many of us] to show up for the free screening if not that we knew we would be given transport money for coming. I know that if the service was not free, many women will not be able to come, therefore we are grateful to this hospital for this free service and even paying the cost of transportation to come.” (FGD, Female HIV-negative 36–45 years).
“When they asked me if I want to join the study, I told them I was not interested because I was not sure how much it will cost and I do not have the money to pay for something like this. It was when they told me that I do not have to pay that I agreed to join. How and where would I get the money if I have to pay?” (FGD, Female HIV-negative 25–35 years).
Meso-level (community norms and social networks) factors
Social networks and social norms
Cultural norms and the role of men
Older women shared the view that most men were constrained in terms of what they can do, and that men’s lack of interest in the health of their spouses resulted from cultural expectations and/or notions of how men should conduct themselves. As one participant reported:“it should start by not having multiple sexual partners, which increases the risk of passing on a sexually transmitted infection”. (FGD, Female HIV-negative 25–35 years).
Men’s attitudes toward cancer prevention were shaped both by these cultural norms as well as their level of education and knowledge of risk factors for cancer. Generally, male participants with negative attitudes about cancer were those most likely to believe in myths and misconceptions about cancer. Similar to the women who held myths about cancer, some men believed that cervical cancer, for instance, was most likely to be diagnosed among women who took hygiene for granted, used second-hand clothes, had unsanitary toilet habits or were simply promiscuous. Men with such views believed nothing can be done to prevent cervical cancer. A male participant suggested that the way to prevent a diagnosis of cervical cancer is for “women to avoid second-hand clothing, unsanitary conditions and not sleep around”. Men with higher levels of education demonstrated better knowledge of the risk factors and positive attitudes for cervical cancer prevention, including actively encouraging spouses to be aware of the risk and getting screened for cervical cancer. One male participant reported that”.“a man who takes too much interest in women’s health runs the risk of being labeled by society and many men want to avoid such perceptions”. (FGD, WLHIV 36–45 years).
“preventing cervical cancer is a responsibility both men and women should share equally; it should begin with preventing sexually transmitted infections, avoiding risk factors and obtaining screening when possible”. (FGD, Male Partners of HIV-negative Women).
HIV and health-related social stigma
“…women’s bodies are subject to all manner of sociocultural regulations and norms that men’s bodies are excluded from. Thus, any condition that affects women, especially their reproductive organ will be stigmatized even if they are not to blame.” (FGD, Female HIV-negative, 25–35 years).
Macro-level (structural, health system and policy) factors
Weak health system and lack of infrastructure
“Private clinics are expensive and want to make as much money instead of providing appropriate care. I know of people who started going to a private clinic to receive care but came back to the Mile 1 [the Regional Hospital] because of poor treatment” (FGD Female HIV-negative, 36–45 years).