Women’s and health professionals’ perceptions, beliefs and barriers to cervical cancer screening uptake in Southern Ethiopia: a qualitative study

Abstract

Cervical cancer remains a public health problem worldwide. Screening for cervical cancer is poorly implemented in resource-limited settings. In Ethiopia, evidence from the community and health professionals regarding implementation of the screening programme is lacking. The objective of this study was to explore women’s and health professionals’ perceptions, beliefs, and barriers in relation to cervical screening in Southern Ethiopia. Five focus group discussions among women and six key informant interviews with health professionals were conducted from June to July 2022 to gather the required data from a total of 42 participants. The participants were purposively selected from a diverse group to ensure varied viewpoints. Data were collected through group discussions and face-to-face interviews using a semi-structured interview guide. The interview sessions were tape-recorded. The data were analysed using a thematic approach. Women demonstrated a low level of awareness and perceived risk. Also, the perceived benefit of screening for cervical cancer during healthy periods was low. Individual and system-level barriers to screening include low awareness, stigma, poor perceptions towards health screening and causes of cervical cancer, low risk perception and competing domestic priorities, shortage of trained human and other resources, human resource turnover, low implementation and lack of close follow-up of screening programmes. In summary, lack of awareness, misconceptions, and poor perceptions were common. Screening implementation and uptake were low due to individual, psychosocial, and system-related barriers. Therefore, behavioural change communication and system-strengthening efforts need to be in place to effectively tackle the observed gaps.

Résumé

Le cancer du col de l’utérus reste un problème de santé publique dans le monde. Son programme de dépistage est mal appliqué dans les environnements à ressources limitées. En Éthiopie, des données recueillies auprès des communautés et des professionnels de santé concernant la mise en œuvre du programme de dépistage font défaut. Par conséquent, l’objectif de cette étude était d’explorer les perceptions, les croyances et les obstacles des femmes et des professionnels de santé relatifs au dépistage du cancer du col de l’utérus dans le Sud de l’Éthiopie. Cinq discussions de groupe avec des femmes et six entretiens d’informateurs clés avec des professionnels de santé ont été réalisés de juin à juillet 2022 pour recueillir les données nécessaires auprès d’un total de 42 participants. Les participants ont été délibérément sélectionnés dans un groupe diversifié pour garantir des points de vue variés. Les données ont été collectées au cours de discussions de groupe et d’entretiens en face à face à l’aide d’un guide d’entretien semi-structuré. Les entretiens ont été enregistrés sur cassette. Les données ont été analysées selon une approche thématique. Les femmes ont fait preuve d’un faible niveau de sensibilisation et une faible perception du risque. De plus, le bénéfice perçu du dépistage du cancer du col de l’utérus pendant les périodes de bonne santé était faible. Il existait différents obstacles contrariant le dépistage au niveau individuel et systémique, notamment une faible sensibilisation, la stigmatisation, une mauvaise perception du dépistage médical et des causes du cancer du col de l’utérus, une faible prise de conscience du risque et des priorités familiales concurrentes, une pénurie de main-d’œuvre qualifiée et d’autres ressources, le roulement du personnel, la faiblesse de la mise en œuvre et un manque de suivi étroit des programmes de dépistage. La sensibilisation insuffisante, les idées fausses et les mauvaises perceptions étaient fréquentes. Le recours au dépistage et sa mise en œuvre étaient médiocres en raison d’obstacles individuels, psychosociaux et systémiques. Par conséquent, des activités de communication pour un changement de comportement et un renforcement du système doivent être mises en place pour s’attaquer efficacement aux lacunes observées.

Resumen

El cáncer cervical continúa siendo un problema de salud pública a nivel mundial. En entornos con recursos limitados, no se ejecutan bien los programas de tamizaje. En Etiopía, se carece de evidencia de la comunidad y de profesionales de salud sobre la ejecución de programas de tamizaje. Por ello, el objetivo de este estudio era examinar las percepciones, creencias y barreras de las mujeres y profesionales de salud relacionadas con el tamizaje de cáncer cervical en Etiopía meridional. Se realizaron entre junio y julio de 2022 cinco discusiones en grupos focales entre mujeres y seis entrevistas con informantes clave entre profesionales de salud, con el fin de reunir los datos necesarios de un total de 42 participantes, quienes fueron seleccionados intencionalmente de un grupo diverso para garantizar una variedad de puntos de vista. Se recolectaron datos por medio de discusiones en grupos y entrevistas presenciales, utilizando una guía de entrevistas semiestructuradas. Se grabaron las sesiones de entrevistas. Se analizaron los datos empleando un enfoque temático. Las mujeres demostraron un bajo nivel de conocimiento y riesgo percibido; además, percibían poco beneficio del tamizaje de cáncer cervical durante períodos saludables. Algunas de las diversas barreras individuales y sistémicas relacionadas con el tamizaje eran: escaso conocimiento, estigma, percepciones negativas del tamizaje y causas de cáncer cervical, percepción de bajo riesgo, prioridades domésticas contrapuestas, escasez de recursos humanos capacitados y de otros recursos, rotación de recursos humanos, poca ejecución y falta de seguimiento a fondo de los programas de tamizaje. Falta de conocimiento, ideas erróneas y percepciones incorrectas eran comunes. Hubo poca aceptación y ejecución del tamizaje debido a barreras individuales, psicosociales y sistémicas. Por ello, es necesario emprender esfuerzos de comunicación para el cambio de comportamiento y de fortalecimiento de sistemas, con el fin de superar eficazmente las brechas observadas.

Keywords:

• barriers
• beliefs
• cervical cancer screening
• perceptions
• southern Ethiopia

Background

Globally, in 2018, cervical cancer was the fourth most prevalent and the fourth leading cause of cancer death among women. Nearly 84% of all cervical cancer cases and 88% of all deaths due to cervical cancer took place in resource-limited nations.¹ Likewise, it was identified as the second most common and third leading cause of cancer death among women in less developed nations.² Larger proportions of morbidity and mortality due to cervical cancer occurred in sub-Saharan African countries, where Eastern Africa shared the highest mortality rate in 2018.³ All these statistics describe the heavy burden of preventable morbidity and mortality due to cervical cancer that women have been facing in less developed regions of the world.⁴

There has been a substantial reduction in incidence and mortality due to cervical cancer in developed regions. This achievement was attributed to the introduction and utilisation of screening packages for early detection and therapeutic options.⁵ However, in low- and middle-income countries where the implementation of such packages is limited, cervical cancer is still a major public health concern.³ Moreover, one of the main reasons for high cancer mortality in sub-Saharan Africa is poor public knowledge and awareness about cervical cancer.^6–8 Other contextual factors like poverty, financial barriers to treatment, religious and cultural beliefs, and stigma have made cancer control challenging.⁹

The right to sexual and reproductive health is an integral part of the right to health contained in different international documents.¹⁰ Gynaecological cancers, including cervical cancer, are essential components of reproductive health concerns among women. Addressing cervical cancer issues as an essential reproductive health problem through research activities is an important part of achieving women’s reproductive health rights and improving their reproductive health outcomes.

Cervical cancer is one of the commonest gynaecological cancers of women in Ethiopia,¹¹ where nearly 6,300 new cases are diagnosed and about 4,884 women die from cervical cancer each year. This makes cervical cancer the second most common and most deadly cancer among women in the country.¹² These figures might underestimate the real burden of cervical cancer due to low awareness, transport and treatment costs, limited access to screening and treatment services, and poor national registration systems.

In Ethiopia, efforts to address reproductive cancers, including cervical cancer, have been minimal. To fill this gap, the Federal Ministry of Health (FMOH) piloted a screening programme in 2009. Based on the success of the study, the ministry decided to scale up the service further in public health facilities and initiated a national cancer prevention programme in 2013. Accordingly, cancer prevention guidelines and a national cancer prevention plan were subsequently developed in 2015. From then onwards, the screening programme has been made publicly available for eligible women in public health facilities.^13,14

Recent studies have shown that cervical cancer screening utilisation among women in Ethiopia is lower than expected,^15–17 which could be due to different contextual factors. Understanding local perceptions, beliefs and challenges associated with cervical cancer screening would be helpful to fully comprehend the context and deliver important insights towards the design for effective interventions. Therefore, this qualitative study was intended to describe the perceptions, beliefs, and challenges for women and health professionals regarding cervical cancer screening uptake and provision in Southern Ethiopia.

Research methods

Study context and period

This study was conducted in selected districts of Kembata-Tembaro and Hadiya zones which are located in the Southern Nations Nationalities and Peoples’ Regional State, Ethiopia. Cervical cancer screening has been provided in the selected health facilities of the two zones. According to reports of the zonal health departments, there were 41,100 and 81,200 women eligible for cervical cancer screening in Kembata-Tembaro and Hadiya zones respectively in 2020.

Cervical cancer screening programme activities have been integrated into routine health care delivery as an important health service package for the eligible women in this area at selected hospitals and health centres where our research activities were based. The study was conducted from June to July 2022 using a qualitative descriptive study design taking women’s and health professionals’ perspectives into account.

Study participants

The study participants comprised women residing in the study districts and health professionals working in those districts. Accordingly, women aged 30–49 years were eligible for cervical cancer screening according to the national cervical cancer prevention and control guidelines and were considered for focus group discussions (FGDs). Participants also satisfied the criteria of having been engaged in sexual relations, not having been diagnosed with cervical cancer, and provided informed consent. Health professionals working in the health care facilities and district offices with experience, particularly with cervical cancer prevention and control efforts, were included for in-depth interviews. Both participants’ groups were made diverse with respect to socio-demographic characteristics like age, education, and occupation.

Sample size and sampling procedure

Five kebeles, the smallest administrative units, were purposively selected from the two study districts. Based on the selection criteria, women were also purposively identified from the selected kebeles to take part in the FGDs to explore perceptions, beliefs, and barriers to cervical screening among women in their community. Health professionals took part in key informant interviews to capture the perspectives of health care providers and obtain rich and detailed information regarding cervical screening uptake in the study area. To gain a diverse viewpoint, a purposive sample of women with varying background characteristics was employed in the research. The key informants were health extension workers, health professionals and district health authorities who were also purposively selected to include those with different backgrounds and work experience of at least six months in the area of cervical cancer prevention. This is to ensure information richness as the level of training in the field and the extent of engagement in the cervical cancer prevention programme activities could influence the depth of the informants’ perceptions on cervical screening.

Women were primarily selected to take part in the FGDs by the health extension workers employed at community level. The purpose of the study and selection criteria were discussed with health extension workers prior to the data collection to facilitate participant selection. Based on these grounds, health extension workers selected eligible women for FGDs using the health post records and women’s local networks.

The sample size was determined based on the level of information saturation during data collection. Accordingly, five FGDs and six in-depth interviews were carried out to achieve the study objectives. A total of 42 participants (36 women and six health workers) were included in the study to explore their perceptions, beliefs, and barriers in relation to cervical cancer screening.

Data collection tool and procedure

The data collection guide was developed based on the specific objectives of the study for both the FGDs and key informant interviews. A semi-structured interview guide was organised in appropriate sections to facilitate the information gathering process. The required information was gathered by trained public health specialists through face-to-face in-depth interviews and FGDs, using different interview guide for each. A group of three people from both genders were involved in the moderation of each of the FGDs conducted. All the participants participated and responded to the questions during the FGDs.

The in-depth interviews were carried out at district health offices while the FGDs were conducted at health posts. (A health post is a primary health care unit organised at community level and staffed with health extension workers, which serves as an entry point in the Ethiopian health care delivery system.) Both the FGDs and the key informant interview sessions were tape-recorded for further data analysis and appropriate field notes were organised and used during data analysis. The FGDs and the key informants’ interviews explored the perceptions, beliefs, and challenges, from both women’s and health professionals’ perspectives, regarding the cervical cancer screening programme.

Ethical considerations

Ethical approval for the research work was obtained from the Jimma University Ethical Review Board on 16 July 2021. Written permission was obtained from the regional health bureau, zonal health departments, respective districts and kebele administrations. The objectives of the study were explained to each participant and informed consent was obtained to ensure voluntary participation. Participants were assured of the confidentiality of the information they provided.

Data processing and analysis

The tape-recorded data were first transcribed verbatim by public health experts and then translated into English by independent language experts. The congruence of the versions was also cross-checked. The translated data were coded and further analysed by all the researchers, using a thematic approach.¹⁸ Codes were generated by analysing the participants’ statements and then organised under subthemes and themes based on their similarity. The data organisation and analysis process was supported by the use of Excel application software. Data analysis was illustrated using verbatim quotes as appropriate. The findings have been organised under the identified thematic areas.

Results

Participants’ characteristics

We conducted five FGDs comprised of six to eight women who were eligible for cervical cancer screening, and six key informant interviews with health professionals working at various levels of responsibility. A total of 42 participants were included in the study. The age of the FGD participants ranged from 30 to 49 years, whereas key informants’ ages were within the range of 32–50 years. All the women and key informants who were present at the time of data collection agreed to participate in our study. Key informants had a minimum of 12 years of work experience, inclusive of experience in cervical cancer prevention. Generally, all the participants contributed to the interviews sufficiently, i.e. they participated & provided adequate information required to achieving the research objectives (Tables 1 and 2).

Table 1. Socio-demographic profile of focus group discussion participants, Southern Ethiopia

Participant’s code	Age	Occupation	Years of education completed	Marital status	Residential kebele
FGDP1	39	Household roles	12	Married	Abonsa
FGDP2	38	Household roles	10	Married	Abonsa
FGDP3	46	Household roles	8	Married	Abonsa
FGDP4	30	Household roles	4	Married	Abonsa
FGDP5	36	Household roles	5	Married	Abonsa
FGDP6	30	Household roles	8	Married	Abonsa
FGDP7	31	DA worker	10 + 3	Married	Abonsa
FGDP8	30	Household roles	8	Married	Abonsa
FGDP9	30	Household roles	3	Married	Teza Agara
FGDP10	35	Household roles	10	Married	Teza Agara
FGDP11	35	Household roles	6	Married	Teza Agara
FGDP12	30	Household roles	9	Married	Teza Agara
FGDP13	32	Household roles	5	Married	Teza Agara
FGDP14	35	Household roles	8	Married	Teza Agara
FGDP15	30	Household roles	10	Married	Zato Shodera
FGDP16	49	Household roles	3	Married	Zato Shodera
FGDP17	30	Household roles	7	Married	Zato Shodera
FGDP18	30	Household roles	9	Married	Zato Shodera
FGDP19	45	Household roles	9	Widowed	Zato Shodera
FGDP20	30	Household roles	12	Married	Zato Shodera
FGDP21	45	Household roles	5	Married	Zato Shodera
FGDP22	32	Household roles	5	Married	Benara
FGDP23	33	Household roles	7	Married	Benara
FGDP24	32	Household roles	10	Married	Benara
FGDP25	32	Household roles	5	Married	Benara
FGDP26	32	Household roles	9	Married	Benara
FGDP27	36	Household roles	9	Married	Benara
FGDP28	31	Household roles	4	Married	Benara
FGDP29	30	Household roles	10	Married	Benara
FGDP30	49	Household roles	12	Married	Ambicho Gode
FGDP31	47	Household roles	8	Married	Ambicho Gode
FGDP32	35	Household roles	11	Married	Ambicho Gode
FGDP33	30	Household roles	10	Married	Ambicho Gode
FGDP34	36	Household roles	12	Married	Ambicho Gode
FGDP35	30	Household roles	10	Married	Ambicho Gode
FGDP36	30	Household roles	6	Married	Ambicho Gode

Note: “+” indicates the number of years training was attended after general high school education.

Table 2. Socio-demographic characteristics of key informants, Southern Ethiopia

Key informant’s code	Age	Sex	Education level	Responsibility	Marital status	Years of work Experience
KI1	45	Female	10 + 3	HEP activities	Married	15 years
KI2	50	Male	12 + 3	MCH activities	Married	12 years
KI3	27	Female	10 + 3	HEP activities	Married	15 years
KI4	32	Male	12 + 4	MCH officer	Married	17 years
KI5	35	Female	12 + 5	MCH activities	Married	12 years
KI6	34	Male	12 + 4	MCH officer	Married	14 years

Note: “+” indicates the number of years training was attended after general high school education.

Emergent themes

We organised our research findings under four thematic areas. The themes include cancer perception and awareness, perceived causes of cervical cancer disease, perceived preventive mechanisms, and barriers to cervical cancer screening. Health professionals’ perspectives towards cervical cancer screening have been organised into a distinct section. The themes progressively emerged from the codes and subthemes.

Theme 1: Cancer perceptions and awareness

The FGD participants perceived cancer disease in general and cervical cancer in particular in different ways. The majority of the participants perceived cancer as a non-curable disease that ultimately leads to the death of the patient. When participants were asked to mention the types of cancer they have known, they identified cancer of breast, blood, bone, uterus, lung, throat, mouth, and leg. Most of the participants mentioned breast and uterine cancer types. Cervical cancer was spontaneously mentioned by only two of the discussants. Participants opined that women are especially vulnerable to cancer when compared to other community members. Cancer is known as “nekersa” in Amharic, “miqicha” in Hadiysa, and “banicha” in Kembatisa languages.

Women usually keep cancers of reproductive organs, including cervical cancer, undisclosed for protracted periods of time. They believe cancer to be the most dangerous of all the disease types, although a few women mentioned that it remains treatable and curable when identified early. Awareness about cervical cancer is non-existent among women in the study settings. Most of the study participants reported that they had not heard of cervical cancer before and did not mention it during the interview. Almost all women perceive the symptoms of cervical cancer as uterine cancer and don’t differentiate between them. For this reason, we made repeated explanations about reproductive structures and cervical cancer symptoms in order to facilitate women’s participation in the discussions.

Opinions that would favourably contribute to cancer prevention efforts were recognised amongst the study participants, as a few of the FGD participants opined that cancer disease is curable if it is known and treated early. A 32-year-old woman (FGDP24) said that, “ … if the disease is recognized before it advances and severely hurts the individual, it can be cured by medical treatment. If it becomes serious, it may not be curable”.

In the majority of cases, women with cervical cancer disease keep it confidential, restrict their social networks and lag behind the social responsibility they are expected to have in the community due to stigma associated with the disease. A 38-year-old woman (FGDP2) stated that,

“ … People in the community see a woman with cervical cancer in different eyes, as it causes a foul smell; … People discriminate against her. Since there exists a foul smell, she may not play a social role with others. She isolates herself”.

Lack of awareness regarding cervical cancer and its screening was a commonly perceived gap among women in the study settings. The majority of the study participants had not heard about cervical cancer before the time of the interview and declared the interview to be their first encounter. A 35-year-old woman (FGDP11) stated that, “ …  I heard of cervical cancer as of today. It was the first time that I heard about cervical cancer i.e. I haven’t heard it before. … I came to know about cervical cancer as of today.” This was also affirmed by health workers in the study area. A 50-year-old male health professional (KI2) said that “ … cervical cancer is a very recent disease condition which is being recognized currently and not well known so far”.

Theme 2: Perceived causes of cervical cancer

Women in this study perceived different socio-cultural, reproductive, sexual, hygienic, and spiritual factors as causes of cervical cancer. These include not keeping genital hygiene, touching genitalia with unclean hands, having many closer birth experiences, frequent sexual practices, multiple sexual partnerships, genital cutting, unhygienic home delivery, sitting on unclean ground and exposure to vapour from the ground during sunny hours, and “evil eyes”. A few women also associated the occurrence of cervical cancer with birthing, menstruation, sexual experiences, and the exposure of reproductive organs, including cervical cancer, to germs.

As mentioned by a few women, exposure to disease-causing germs was perceived to be the cause of cervical cancer as it takes advantage of weak cervical structures caused by many birth experiences. A 38-year-old woman (FGDP2) stated that, “ … when the germ gets access to the cervix it causes cervical cancer; … when there are too many births the cervix becomes loose and light. This predisposes to germs and finally leads to cervical cancer”.

Some women related cervical cancer with the experiences of menstruation, childbirth and sexual activity. Also, some associated that having multiple sexual partnerships or repeated sexual practice with a single partner may lead to cervical cancer. A 32-year-old woman (FGDP13) said that

“ … women are at the age of reproduction and many other things. They practice sexual contact with males i.e. with their husbands. Therefore, cervical cancer affects women with such life experiences. They are at the age of childbirth and menstrual cycles”

A 36-year-old woman (FGDP27) also mentioned that “ … One cause of cervical cancer could be sexual practice with many partners. Also, having sex with one partner more frequently can lead to cervical cancer”.

Some women perceived that exposure of genitalia to dirty things followed by poor hygienic practices causes cervical cancer. The perceptions of poor hygiene after toilet use and the practice of touching the vagina with unclean hands were also evident as causes of cervical cancer. A 49-year-old woman (FGDP16) stated that, “ … cervical cancer develops due to poor washing and unhygienic practices. It is caused by sitting on dirty ground and not washing the genitalia properly” and a 30-year-old woman (FGDP33) indicated that “ … After toilet use, touching the vagina with unclean hands leads to infection. The infection causes cervical cancer”.

Moreover, unhygienic birthing conditions associated with home delivery were perceived to be among the causes of cervical cancer. A 30-year-old woman (FGDP17) said that “ … when women give birth at home, dirty things may predispose to cervical cancer. … During home delivery when hygiene is not kept properly, this may cause such problems in my understanding”.

Theme 3: Perceived mechanisms of prevention

Women identified a range of perceived cervical cancer prevention mechanisms related to hygiene, particularly washing the vagina and underwear pants; health care services like use of family planning, regular medical checkups and vaccination; and sexual behaviour that includes avoidance of multiple sexual partnerships.

Women cited that limiting the number of births through the use of family planning prevents cervical cancer by averting women’s exposure to many birthing experiences. A 35-year-old woman (FGDP11) said that

“ … we have to use contraception and keep ourselves. … We will be hurt if we birth too many children. So we need to use family planning methods in order not to be hurt ourselves and not to be affected by cervical cancer”.

The practice of personal hygiene, especially of washing genitalia and keeping underwear clean, was among the identified mechanisms to prevent cervical cancer. A 30-year-old woman (FGDP9) stated that “ … it is better to keep the body by cleaning and washing. Once we wash our underwear, the disease may not happen. Lack of cleanliness predisposes to cervical cancer disease”.

Women also identified the use of health care services like vaccination and regular medical checkups as a recommended means of cervical cancer prevention before the disease advances. A 30-year-old woman (FGDP20) said that “ … it is possible to prevent cervical cancer … through vaccination. That is, it is possible to prevent it when we get vaccinated all the time and get examined on every body part”. In addition, a 32-year-old woman (FGDP26) stated that “ … receiving medical follow-up and checkup from the health facilities is the main thing to prevent cervical cancer. In doing so, we can prevent it before it advances”.

Theme 4: Perceived barriers to cervical screening

Health screening practices were non-existent among the study participants. However, women in the study area mainly seek care from modern medical facilities for cancer at its advanced stages. Women with cancer diseases also make treatment-seeking visits to traditional healers to receive herbal medication.

The majority of women in the study area were not using cervical cancer screening, mainly due to lack of information regarding cervical cancer and screening. Other perceived barriers to screening include fear of stigma and discrimination, low perception of the importance of screening, being ashamed of exposing private body parts, competing household priorities, low level of perceived risk, transportation costs related to the screening service, and the need for husbands’ approval to get the service.

The perceived importance of screening during disease-free periods was nil among women and they did not recognise any need to go to a health facility for screening purposes unless explicit disease symptoms are observed. A 32-year-old woman (FGDP26) said that “ … the reason why women are not receiving screening is that women do not see any disease symptoms in themselves. I think women are not receiving the screening service due to the absence of symptoms related to cervical cancer disease”.

Stigma and discrimination associated with cervical cancer was a prevailing condition among women which prevented them from getting screened for cervical cancer. A 38-year-old woman (FGDP2) reported that

“ … they (women) may be ashamed of stigma and discrimination and don’t get the courage to go for cervical screening. They feel that it becomes publicly known once a woman is screened positive and starts treatment. Due to fear of bad rumors related to cervical cancer, she may not go for screening”.

Women’s busy work schedule at home with competing domestic priorities followed by lack of attention to their health needs, was a perceived barrier to screening. In the majority of the cases, women prioritise family concerns in favour of their health needs, which is further aggravated by poor husbands’ attention to the health needs of their wives. A 35-year-old woman (FGDP32) stated that

“ … women most of the time are concerned about and occupied in fulfilling different things important to their family needs. They do not recognize their health needs. On the other hand, husbands do not pay attention to the health conditions of their wives due to lack of knowledge”.

The low level of perceived risk of cervical cancer observed among the study participants was another important barrier to screening for cervical cancer. A 30-year-old woman (FGDP20) stated that “ … women feel that they are not at risk and will not be affected by cervical cancer. As a result, they do not go for screening”.

In most cases, women are ashamed of exposing their private body parts and refuse to get screened for cervical cancer, particularly when the health professional that provides screening is male. A 47-year-old woman (FGDP31) stated that “ … as far as my understanding, women are afraid of exposing their private body parts to others. They are most of the time afraid of this”. A 45-year-old health extension worker also indicated that “ … when the screening service provider is male, women are not comfortable enough to receive the service … They are afraid of exposing their body parts to male health workers”.

Women’s financial constraints negatively affected the screening uptake as most women cannot afford transportation and other costs associated with screening services. The need for husbands’ approval and associated financial requests to get the service hindered the uptake of screening as well. A 36-year-old woman (FGDP27) said that “ … I think women may postpone the screening due to financial problems i.e. they may not have money that will be paid in charge of examination and screening”. In addition, a 49-year-old woman (FGDP30) stated that “ … there may be a problem with husbands. Husbands, when asked for money, might complain about the financial expenses associated with the screening”.

Health professionals’ perspectives

The summary of findings from key informants’ interviews has been organised to distinctly demonstrate health professionals’ perspectives in our study. Health professionals working in the study area perceived a range of barriers to the cervical cancer screening programme, including low health workers’ awareness, weak programme implementation, lack of resources and supplies, service interruptions, inadequate training and turnover of human resources, poor client handling, and lack of close follow-up of the screening programme.

Inadequate attention from health authorities, demonstrated by poor follow-up of the screening programme, undesirably affected its implementation status in the study area. Maternal and child health expert (KI6) said that “ … There is inadequate support and monitoring of the program. … We are not working as seriously as required in terms of close follow-up of the screening program. The support and monitoring is not adequate. It is not problem solving”. In some areas, the perceived workload at the health post level further impaired its execution. A 45-year-old health extension worker (KI1) stated that “ … there are urgent and routine health related activities to be carried out in the health post. Due to such work load and time shortages, I am not making adequate home visits to inform and encourage women for cervical screening”.

Health care providers’ non-receptive and unwelcoming attitude towards client handling mechanisms at health facility level was noticed to affect women’s use of screening services. Maternal and child health expert (KI4) said that “ … What deters women from showing interest in going to health facilities is the unwelcoming approach of health care providers. Lack of professional ethics and client respect can obstruct women’s cervical screening uptake”.

Shortage of supplies and resources needed for screening in screening centres played a considerable role in hindering the provision and uptake of cervical screening in a sustained manner. Maternal and child health expert (KI4) said that “ … Sustained provision of screening supplies and logistics from higher levels of the health system is vital. The government needs to give attention in this regard”.

In the study area, there existed an obstacle to screening service provision and utilisation related to shortage of trained human power, staff turnover and inadequate service coverage. Maternal and child health expert (KI4) said that

“ … There are only two health professionals who received training on cervical screening from one health center in the entire district. So this is not adequate. When there is a turnover, there should be an adequate pool of trained health professionals to sustain the service. Moreover, there are no trained health professionals in other health facilities in the district.”.

Furthermore, service irregularities associated with professionals’ absence and off-duty from the screening units made its utilisation further challenging. A 27-year-old health extension worker (KI3) said that

“ … the absence of professionals from the screening units when women go for screening may sometimes create a problem. There was an occasion when women were told to come back again. Since women came at the expense of transportation and time, it may be difficult for them to come back again for the service”.

Discussion

Our study demonstrated a low level of community awareness about cervical cancer and its screening. Despite such gaps, women identified a wide range of individual, socio-cultural and psychosocial factors as barriers to cervical cancer screening uptake. Such factors include stigma and discrimination, low perception of the importance of screening, being ashamed of exposing private body parts, competing household priorities, low risk perception, transportation and service-related costs, the need for a husband’s approval to get the service and women’s low attention to their health needs. System-related barriers recognised by health professionals include poor implementation of the screening programme, lack of screening resources and supplies, interruption of the screening services, lack of support and follow-up, shortage and turnover of trained human power, and poor client handling practices.

Women identified a range of perceived causes of cervical cancer which include infection of the cervix, poor hygiene of the genitalia, touching genitalia with unclean hands, multiple sexual partnerships, repeated and closer births, sitting on dirty ground, and “evil eyes”. They also mentioned various mechanisms to prevent cervical cancer: hygienic practice, regular medical checkups, avoiding multiple sexual partnerships, vaccination, and use of family planning. Participants perceived that cervical cancer is preventable when identified and treated early.

Our findings showed that there are misperceptions about cervical cancer in that it is not recognised in its scientific form. Other studies conducted in Ethiopia reported similar findings.^19,20 The misperceptions associated with cervical cancer could have arisen due to inadequate knowledge about cervical cancer and cervical structure in the women’s reproductive system. Traditionally, the vagina and uterus are known by the same term “mahitsen” in the local context. Furthermore, women didn’t differentiate the cervix and uterus as distinct organs, but rather perceived them as one. These misperceptions might have made the identification of diseases that originate from reproductive structures in their actual form more difficult for women. The gaps could have also influenced women to have confused cervical cancer with uterine cancer during the interview.

There is a low level of risk perception for cervical cancer among the women participants in our study. Our finding is supported by evidence from other studies conducted in different parts of the country.^20–22 Studies conducted in Nigeria,²³ Ghana,²⁴ Iran,²⁵ Ecuador,²⁶ and the UK²⁷ also reported low cervical cancer risk perception among women. However, in a study conducted among Saudi women, the majority of the participants had a high risk perception regarding cervical cancer,²⁸ which is different from our findings. This is because, unlike our study, it involved women residing in urban areas where access to cervical cancer information could be better when compared to our study participants, which could have brought the observed differences in risk perception.

In the Ethiopian context, the Ministry of Health has been committed to expanding cervical screening centres to primary care unit level to improve service accessibility.²⁹ Consequently, screening centres have been established at primary health care unit level, especially at primary hospitals and health centres. Nevertheless, cervical cancer screening uptake among eligible women, including health professionals, was identified to be low in the study area. Similarly, different studies have shown low levels of cervical screening uptake among women in Ethiopia.^30–33 In addition, like our study findings, evidence shows that low awareness about cervical cancer and screening has been documented as a barrier to cervical screening uptake among women in other parts of Ethiopia^{22, 34} and other African countries.^35–38

The demonstration of preventive health behaviour in symptom-free periods among women was non-existent in the study area, as evidenced by women’s low perception of the importance of cervical screening in disease-free periods. As a result of the community’s perceptions, women made health facility visits only for medical consultations whenever there were observable disease symptoms, which had negatively influenced cervical screening uptake among women. This finding is supported by other studies done in Ethiopia,^{20, 21, 39} the UK,²⁷ and Nepal,⁴⁰ where the absence of cervical cancer symptoms was a perceived barrier to screening uptake.

This study revealed that the awareness level regarding cervical cancer and its screening among the study participants was low. This finding is in agreement with study findings conducted in Ethiopia^20,31,41 and other African countries such as Cameroon,⁴² Sudan,⁴³ Uganda,³⁸ and Malawi.⁴⁴ It is also supported by a systematic review of studies from LMICs⁴⁵ and a study conducted among ethnic minorities in the UK.²⁷ Furthermore, the observed poor implementation of public awareness and programmatic activities about cervical cancer at community and health system levels could have contributed to the low level of awareness among women in our study. This could have in turn hampered the uptake of a screening programme by the target women.

Cervical cancer preventive and awareness creation activities were not well implemented in the Ethiopian health care system, as cervical cancer prevention and control had not been given adequate emphasis.¹³ Such implementation gaps evidenced by inadequate awareness about the nature of the disease in Ethiopia could have restricted women from receiving appropriate information regarding cervical cancer. For these reasons, there were misperceptions regarding cervical cancer among women in this study, which in turn put screening and early detection of pre-cancerous lesions below expectations. The demonstration of such misperceptions about cervical cancer among women is consistent with the findings of a study conducted 10 years back in some parts of the country.¹⁹ Likewise, a systematic review of evidence from LMICs⁴⁵ and a study from Malawi⁴⁴ show that community misperceptions about cervical cancer were barriers to its screening.

Uncomfortable community beliefs and perceptions regarding cervical cancer disease had negatively contributed to the uptake of cervical screening among women. Accordingly, stigma and discrimination associated with cervical cancer disease in the study setting was a barrier to the uptake of the available screening services among women. Other studies in Ethiopia,^21,22 Kenya,³⁶ Nepal,⁴⁰ the Caribbean,⁴⁶ and among Somali and Pakistani immigrants in Norway,⁴⁷ demonstrated stigma as a perceived barrier to cervical cancer screening and care. Moreover, women in the study area are usually labelled as having violated normal sexual practices or been promiscuous when they are known to have been screened for cervical cancer, and become ashamed of screening, as supported by a study from India.⁴⁸ This psychosocial condition could have exerted emotional influence and discouraged women’s efforts to use cervical screening.

Important health system-related deterrents were identified as barriers to cervical screening uptake and delivery efforts, including transport costs associated with the service, unfriendly client handling, interruption of the service due to shortage of supplies and resources, and attrition of trained human power. These findings are in line with the findings from other studies in Ethiopia.³⁴ Studies from Uganda implicitly reported organisational and health system challenges as a barrier to cervical screening.^37,38 Financial constraint is also among the perceived barriers to screening as supported by findings from Arba Minch, Ethiopia,²² Kenya,^36,49 Cameroon,⁴² and Uganda.^37,38 In Malawi, lack of equipment and supplies and supportive supervision hindered the use of cervical screening.⁴⁴ Studies demonstrate that health facility readiness in providing sustained screening services is found to be low in Ethiopia,⁵⁰ which could have hampered the provision of effective screening services. As identified in our study, poorly resourced health systems in LMICs hindered screening uptake.⁴⁵

Strengths and limitations of the study

The main strength of our study was the use of a qualitative method to capture the perceptions, beliefs, and barriers to cervical cancer screening. This ensured the perspectives of both women as service users and health professionals as service providers to ensure insights from both supply and demand sides of the screening programme. However, our study has some limitations. It did not have a large sample size for women eligible for screening and health care providers, and covered a limited geographical scope in the region, which might have limited its generalisability. However, our sampling aim was not to recruit a large enough sample to ensure representativeness but rather, as a qualitative study, to recruit a sample sufficient to reach to a level of data saturation.

Member checking, where participants are given an opportunity to review findings and provide feedback, was not performed since participant names and contact information were not recorded and there was no way to follow-up with the interviewees at a later time when data analysis was complete. Finally, we noted that interview quality varied significantly in our study, which might have compromised the richness of the data. The skill of moderation in some FGDs and key informant interviews was not sufficiently deep which might have led to capturing less detailed information. Furthermore, even though we protected participants’ anonymity to ensure free discussion, taking tape recordings might have created apprehensions and hindered, to some extent, the provision of information in detail and required richness.

Conclusion and recommendations

This qualitative study identified low levels of awareness and cervical screening uptake among women participants. The low level of cervical screening can be attributed to a wide range of important individual, socio-cultural and belief-related factors that operate in the community. These barriers include a low awareness level, poor perceptions of health screening, stigma, and discrimination, misconceptions about the causes and prevention of cervical cancer, low level of perceived risk, fear of exposing private body parts, and competing domestic priorities. Health professionals also revealed system-related barriers to cervical screening, which embrace low cervical cancer awareness among health professionals, poor implementation of the screening programme, and lack of close follow-up and monitoring, lack of resources and supplies, service interruptions, shortage and turnover of trained human power, and poor client handling practices.

In general, the study explored and brought various issues relevant to the prevention and control of cervical cancer to light and provided important insights and understanding of the implementation context at the community and health system levels. The utilisation and provision of cervical screening services require the fulfilment of multiple factors in the community and health system as a whole. Cervical cancer being an important aspect of women’s reproductive health concerns, screening uptake deserves due attention as a matter of their rights. Therefore, the cervical cancer screening programme must address those factors and barriers that negatively influence screening uptake and its provision through appropriate behavioural change and communication strategies, and close monitoring of the screening programme by all concerned parties at different levels of the health system.

Authors’ contributions

SYA, MAW and TB designed the study. SYA drafted the manuscript. MAW and TB critically revised the manuscript. All authors read and approved the final version of the manuscript.

Acknowledgements

We would like to acknowledge Jimma University for granting ethical approval and funding for the conduct of this research activity. We also extend our heartfelt thanks to research participants for their voluntary participation and data collectors for their invaluable role in the research process.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplemental data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/26410397.2023.2258477.

Additional information

Funding

This work was supported by Jimma University.