Barriers and facilitators to effective cervical cancer screening in Belize: a qualitative analysis

Cervical cancer is the 3rd leading cause of cancer and 4th leading cause of cancer-related death in women in Latin America and the Caribbean (LAC) countries [1]. While cervical cancer prevention programs have reduced the disease burden in high-income countries, low- and middle-income countries shoulder nearly 87% of global cervical cancer deaths [1]. The high burden of cervical cancer in LAC countries epitomizes the global inequity of this preventable disease [2, 3]. To combat this public health issue, in 2018, the WHO announced an initiative to eliminate cervical cancer, setting country-wide vaccination, screening, and treatment targets to achieve by 2030. Notably, 70% of women should be screened using a high-performance test by age the age of 35 and again by 45 [4].

Belize, a country of just over 400,000 citizens on the eastern coast of Central America, is not exempt from challenges in cervical cancer management [5]. The 2020 estimates of cervical cancer incidence and mortality (19.1 and 14.8 cases per 100,000, respectively) are among the highest in LAC (14.9 and 7.6 cases per 100,000 population) [1]. The burden of cervical cancer in Belize not only strains the healthcare system, but also impacts the overall economy through the indirect productivity losses from women in the workforce, and due to mortality, care of their children by the family and community [6, 7]. Addressing premature loss of life from cervical cancer has ethical and economic appeal.

The Ministry of Health (MOH) in Belize has implemented policies aiming to increase access to cervical cancer prevention and treatment resources. In 2016, Belize launched a national human papillomavirus (HPV) vaccination program for adolescents in collaboration with the Ministry of Education [8, 9]. At the same time, the national cervical cancer prevention effort was strengthened through implementing visual inspection with acetic acid (VIA) screening protocols and resources in the public sector [10]. The efforts to scale cancer prevention and control services have resulted in an estimated 49% screening coverage of women ages 35–49, still shy of Belize’s goal of screening 80% of women. These programs to improve cervical cancer care were bolstered by the opening of Belize’s first medical oncology clinic in the public sector in 2018 [11, 12].

The real-world impact and implementation of expanded services in Belize have not been evaluated explicitly. This study is part of a larger mixed-methods assessment of cervical cancer prevention and control in Belize [10]. In our prior study, we documented limited personnel participating in outreach to rural communities, geographic barriers to accessing services, and stresses on the pathology infrastructure that impact the diagnosis and screening of cervical cancer in Belize. In this qualitative component, we analyzed interview data from key stakeholders (e.g., health care providers, policy-makers, and patient advocates) to identify the barriers and facilitators of cervical cancer screening services to inform future national and local district policy development.

Our study is the first to evaluate the perspectives of key stakeholders in the national cervical cancer screening program in Belize. We found that barriers to accessing cervical cancer screening were found at all levels of the SEM whereas facilitators were only found at the community and national levels. Recent policy changes to provide screening at no cost and set population-based screening goals must still overcome barriers to cervical cancer screening that exists across individual, provider, organizational, community, and national policy levels.

On the individual patient level, the most salient theme that emerged was patients’ fear of cancer diagnosis and low health literacy regarding the natural history of cervical cancer and treatable forms if diagnosed early. Some patients believe that having access to screening is not enough—if there are no sustainable services offered if dysplasia or cancer is detected, patients would rather not get screened. Not only does this demonstrate a significant barrier to encouraging screening utilization, but it also exemplifies an education challenge where women might not understand the role of asymptomatic screening and identification and treatment of dysplasia. Several studies in Tanzania focused on understanding patient perspectives on cervical cancer mirrored findings seen in our study. Women in Tanzania thought that screening was meant for after symptoms occurred, and a cancer diagnosis was taboo [16]. Many patients don’t wish to be screened because they feel that if cancer is detected, “there is not much to be done,” which notably was not an issue in the middle and upper class [17]. This fatalistic attitude most likely stems from a lack of treatment options in LMICs. In 2020, Global Oncology Inc patterned with Belize’s tertiary care facility to form the first medical oncology clinic in the Belizean public sector, which provides chemotherapy and palliative care options to patients with cervical cancer [18]. While Belize still has no access to radiation therapy in country, this step toward adequate tertiary care access will hopefully lead to increased patient engagement in screening.

On the provider level, we found that while Belize has invested considerable resources to provide access to cervical cancer prevention services in each district [10], there remains the need for additional investment in training of personnel. For example, a deficit of trained workers has created limited availability of screening in Belize. Similar issues were seen in other LMICs where “stability of a trained workforce in many regions was compromised due to high turnover and lack of consistency/durability of contracts for health care professionals” [19]. Many studies have suggested that community health workers (CHW) be employed to fill this deficit with the WHO suggesting “task shifting” certain roles to lesser trained professionals [20]. O’Donovan et al. warns against using CHW as a “silver bullet solution” and calls on policy-makers for adequate training for secondary prevention services [21]. Especially because of the subjective nature of VIA, task shifting might introduce unforeseen consequences of a lack of quality control that can lead to overtreating benign findings or missing cases of invasive cancer that require tertiary services. Training of new healthcare providers, dedicated to providing the VIA services locally and in outreach activities, could improve realized access to care as seen in studies conducted in India, Peru, Vietnam, and Bangladesh [22, 23]. Similarly, the staff trained in providing cervical cancer screening reported morale declining from pressure to balance additional roles and responsibilities. Offering VIA is labor intensive, and although the service might benefit the national screening program in theory, those offering the service are overworked and experiencing burnout. Similar organization level barriers were seen in Tanzania and Uganda where providers noted similar issues of inadequate staffing for cervical screening, limited trained staff resulting in task overload, and staff disinterest in doing the work creating many missed opportunities for cervical screening among clients [16, 24]. According to a 2018 study done in Belize, the public cervical cancer screening workforce in Belize consists of 75 primary care nurses and physicians—one per 1,076 screening-eligible women [10]. Additionally, although “all districts have at least one screening facility, 50% perform screening services only once per week with colposcopy and LEEP available in only three and four districts, respectively,” further emphasizing the service gap created by the lack of trained staff in Belize [10].

At the organizational and community level, the main theme that emerged centered on the importance of establishing and maintaining dedicated facilities and staff for screening services to increase the local service availability of cervical cancer. Because of the shared spaces, offering screening services needs to be coordinated with the weekly schedule of the clinic, which may limit the possibility of offering service to walk-ins. While most services at the point of care do not need advanced equipment, sustainable delivery of pathology services require regular upkeep of equipment and a reliable supply chain for disposables and reagents. In a 2018 assessment of essential pathology equipment nationwide in Belize, 38.5% were present and functional, 23% were present but nonfunctional, and 38.5% were unavailable. Additionally, 35% of supplies were unavailable at the time of assessment, and 75% were unavailable at least once in the 12 months before assessment [10]. Although many countries such as Costa Rica have seen great decline in cervical cancer incidence and mortality since centralizing their cytology laboratories [25], the same might not be true in Belize. As discussed, Pap smear result delay was found to be an issue at the individual, provider, and organizational levels in Belize. In Zimbabwe, the national Pap smear screening program was stopped due to limitations in manpower and infrastructure. The study suggested that in LMICs, training general healthcare providers has helped in decentralizing VIA screening, further demonstrating how investment in training can improve cervical cancer outcomes in Belize [26]. While the public sector has been working to augment training of staff to deliver cervical cancer screening, several respondents commented on public–private partnerships as a facilitator improving access to services. This perspective is supported by WHO’s Global Strategy to Accelerate the Elimination of Cervical Cancer as a Public Health Problem [20]. Leveraging provision of services in the private sector and even human resources to educate additional healthcare providers to provide screening could improve access and sustainability. While public–private partnerships may benefit populations in urban areas, it is unclear if services will be accessible to the most at-risk population. Only 44% of healthcare workers participating in screening at the health cancer centers are able to conduct outreach events in the local villages [10]. While the presence of this outreach workforce was cited as a facilitator by some respondents, others suggested that additional investment is needed. The same population of women who may have culturally rooted barriers to access at both the individual and community levels are also living in remote villages, thus further complicating improving their access to services. Geographic inaccessibility remains the central barrier to cervical cancer screening in resource poor districts of Peru [27], a finding which was mirrored in the transportation and geographic barriers to screening seen in more rural districts of Belize such as Toledo. Continuing Investment at the organizational and community level by hiring culturally competent staff for outreach who speak the local dialect could address several barriers for this population.

At the national policy level, the themes that emerged centered around stakeholder desire for coordinated implementation of and investment in policies, protocols, and bureaucracy efforts, to effectuate the national screening program. While Belize does have a national cervical cancer screening program and offers no-cost screening for women who access services in the public sector, some stakeholders reported that they wish they were consulted before implementing new screening programs (e.g., VIA). Peters et al. suggests using the participatory action research method where stakeholders perform their own research to inform decision-making as a method to engage stakeholders, which a team in Uganda had great success in doing [28]. Development and implementation of standardized protocols is needed to ensure that advancements in care reach the entire population. This is especially important as the Ministry of Health prioritizes new programs to advance HPV DNA testing as the primary screening modality in Belize in line with updated WHO guidelines [29]. Another limitation to expanding access to cervical cancer screening is that, due to the bureaucracy, screening services might not be equitably distributed across the population.

Our study had a few notable limitations. First, our study used purposive sampling, visiting clinics that the Belize MOH suggested we visit to conduct our interviews, which increased the risk of researcher bias in our data. Our study also used a mix of individual and group interview methods making group think a potential bias where an individual’s perspective may have skewed the opinions of others participating in the interview. However, the size and scope of our study spanning all regions of the country helped to minimize these biases. Lastly, we did not directly interview patients, limiting our characterization of the patient perspective and the individual patient-level barriers to cervical cancer. However, our study’s main strength lies in the vast breadth of patient advocates from every sector and region of the healthcare pipeline who provided key insights into barriers patients face and where they see room for improvement.

Despite no-cost cervical cancer screening in Belize, complex barriers still exist. This study provided important insights about the needs of the scalability and success of the cervical cancer screening program. Addressing overloaded provider responsibilities, funding for staff training and facilities, and protocols for introducing new implementation are potential areas for system strengthening. Careful consideration of these barriers when implementing new strategies to control cervical cancer morbidity and mortality (e.g., HPV DNA testing) will assure the effectiveness and sustainability of these interventions.