The influence of gender roles and traditional healing on cervical screening adherence amongst women in a Cape Town peri-urban settlement

Abstract

Background: Cervical cancer is the third most common gynaecologic malignancy worldwide and is the second most common cancer among South African women. Although entirely preventable, cervical cancer is responsible for the death of approximately 3 027, 53% of those diagnosed, South Africa women annually. A variety of factors influence women’s cervical screening adherence.

Methods: A focus group discussion was conducted with female residents in Khayelitsha. Data from the focus group discussion was analysed using thematic analysis whereby emergent themes and subthemes were identified and reported.

Results: The study confirmed previous findings around screening barriers amongst women residing in other Cape Town peri-urban settlements. New information regarding the influence of gender inequalities and traditional healers on screening adherence also emerged.

Conclusion: The incorporation of men into cervical screening intervention programmes and the integration of traditional healers meaningfully into the health care system appear to be vital in improving adherence to screening.

Keywords:

• adherence
• barriers
• behaviour change
• cervical cancer
• cervical screening
• Pap smears
• South Africa
• traditional healing

Invasive cervical carcinoma is the third most common gynaecologic malignancy and is the fourth leading cause of death in women worldwide.¹ Despite its high prevalence, the slow growing nature of the cancer renders it almost entirely preventable if detected at an early stage.^2,3 An extreme disparity of annual mortality and new diagnoses exists between developed and developing countries (comprising 85% of global cases).¹ This dichotomy is caused by differences in the implementation of, and adherence to, cervical screening programmes, as well as other psychosocial factors such as poverty, HIV/AIDS, and gender inequality.¹ In South Africa, epidemiological studies demonstrate significant screening, diagnostic and mortality biases among different ethnic groups. Black women are most likely to die of this disease.²

Currently disadvantaged black South African women face a multitude of the known barriers to screening including, poor knowledge, low socio-economic status (SES), unemployment, poor health care accessibility, lack of health insurance, language barriers, and opposing cultural beliefs (Figure 1).³ This myriad of complications is often reflected in fatalistic attitudes and beliefs regarding cervical screening with consequent low adherence to treatment on receipt of an abnormal Pap smear result.^2,4

Figure 1: Barriers to cervical screening

Few published studies have explored factors relating to cervical screening adherence amongst South African women. An urgent need to comprehensively determine screening barriers specific to currently disadvantaged South African women exists in order to end continued unnecessary suffering and death.

This study aimed to: further explore factors affecting currently disadvantaged women’s cervical screening adherence, add to the existing qualitative data, and expand upon a previous study by two of the authors.³

The University of Cape Town’s Psychology Ethics Committee approved the study. Community health trainers working with a Khayelitsha¹-based NGO assisted the researchers in recruiting black low SES Xhosa women residing in Khayelitsha as participants. Fifteen women, aged 25–51 years old, took part in the study.

A focus group discussion, co-facilitated by two researchers and an established isiXhosa-speaking community health trainer, was held at a Khayelitsha community health centre. In recognition of previous methodological limitations,³ emphasis was placed on pre-focus group rapport building and the inclusion of an isiXhosa-speaking facilitator. Consent was obtained and the discussion was recorded. To ensure privacy, names and identifying details were omitted from transcriptions and notes; and participants were requested to respect confidentiality. The data generated was analysed using thematic analysis with an emphasis on researcher collaboration and agreement. Throughout the study, the authors were mindful of their subjective social and cultural positions, distinguishing their potential impact on the study.

Seven themes emerged from the data. Five, namely: Stigma, Fear, Time, Age, and Health Education re-emphasised those identified in the previous research study.³ Two further sub-themes, Gender and Traditional Healing, also emerged.

Gender (Figure 1) highlighted the construction of gender and the subordinate position of poor black women in the family and society.⁴ Men’s lack of acceptance of cervical screening, the association of cervical cancer, hysterectomy and the potential loss of womanhood and female sexuality,^2,4,5 and suspicion of promiscuity negatively impacts on screening adherence.⁵ Promiscuity relates to the sub-themes of stigma and health education, but emerged with the sub-theme of gender as it links to the frequent stigmatisation of black South African women as the carriers of sexually transmitted diseases (STIs) (particularly HIV).⁵ Although the biggest STI risk factor for some women is sexual intercourse with their partners, STIs (particularly HIV) are associated with promiscuity and are stigmatised.^4,5 Emotional and financial support from a partner is a key factor in adherence.^5,6 Therefore, involvement of sexual partners is crucial for cervical screening and treatment adherence.⁶

Traditional Healing (Figure 1) as a theme denoted a preference for seeking treatment from traditional healers. Marginalised and underserved populations tend to connect more powerfully with social institutions that provide them with a sense of belonging.⁶ Up to 80% of South Africa’s population consult traditional healers prior to primary health care consultations,⁷ as cervical cancer is often framed in terms of sociocultural beliefs rather than biomedically.² Allopathic health care, often fraught with economic, practical and other issues (Figure 1), is only sought out when traditional or home-based methods fail.^4,5 Traditional healers’ explanations and treatments of medical complaints also tend to resonate more powerfully with individuals’ belief systems.^4,7 Consequently, stronger links need to be created with traditional healers in order to truly build a working relationship which maximises all patients’ health care outcomes. Although, traditional healers are recognised via the Traditional Health Practitioners Act, Act 35 of 2004 as registered members of the South African medical fraternity, the integration of alternative practitioners in the health care system is still fragmented.

Facilitation of regular adherence to cervical screening demands careful consideration of all the barriers to the implementation and maintenance of this health behaviour. Such information is vital for enhancing the development of effective screening programmes for urbanised, resource-poor communities.

Authors’ contributions

DL (University of Cape Town) was the project supervisor and leader, responsible for project design, data collection, data analysis, write up of the initial draft and critical review of final draft for important intellectual content, and preparation of the paper for submission for publication. AJvV (University of Cape Town) was responsible for write-up of the initial draft and preparation of the paper for submission for publication. CDA (University of Cape Town) was responsible for data collection, data analysis and contributed to the write-up of the initial draft.

Notes

1. Khayelitsha is a large peri-urban settlement on Cape Town’s outskirts.