Practice of Opportunistic Cervical Cancer Screening and Health Education Among Health Workers in Ogun State, Nigeria: A Qualitative Study of Barriers and Facilitators

Study Setting

Study Population and Study Design

Sampling

Data Collection

Data Management and Analysis

Ethical Approval

Background Characteristics of Participants

Knowledge of Cervical Cancer

Uhm.. cervical cancer screening is also done to detect if a person has a potential of having a cervical cancer. If a person has ehm.. has been infected by HPV, human, human papilloma virus, and it is done mainly by using acetic acid. Yeah, by using acetic acid. [PHC nurse; Female]

Well cervical cancer screening is, I think is Pap smear. Usually, if patient is symptomatic, or if patient is sexually exposed, you want to do cervical screening, but basically Pap smear. Though we don’t do it in this facility. [Secondary hospital doctor; Male]

Cervical cancer screening, that is uhm…. when you subject your patient to test in the cervix, to detect if there’s any cancerous cells in the cervix, … you know, laboratory tests just to know if there is any growth of cancer cells in the cervix [Secondary hospital nurse; Female]

Ennn.. Cervical cancer.. screening, …. we all know the gold standard is the pap smear. But we don’t do the pap smear here. What we do here basically is the ehmm the clinical ehm inspection examination. [Secondary hospital doctor; Male]

So, the aim of cervical cancer screening is to detect the early pre-malignant phase and the early phase of malignancy regarding cancer of the cervix and that will go a long way to save some of our women. The advantage of the screening is to pick some of these malignancies at a very very early stage where it can either be treated by local surgery, excision, cryotherapy or cold knife coagulation or diathermy or hysterectomy could be done. [Tertiary hospital doctor; Male]

Health Education Practice

We have health talk every antenatal clinic and we make sure to touch every aspect of health that is necessary for a pregnant woman. And we have a schedule which, with which we follow so that we don’t miss anything. And we make sure that everybody that is in attendance listens and participate in the health talk. [PHC Nurse; Female]

Health Education on Cervical Cancer

We concentrate most on breast cancer [Secondary hospital nurse; Female]

Hardly, hardly. Cervical cancer doesn’t usually come up, hardly [Secondary hospital doctor; Male]

During our health talk for antenatal, breast cancer is part of our topics that we are talking about. But for cervical screening, we don’t really stretch much, but when the vaccine came out, this vaccine they gave to us. So, since that time, we’ve included cervical screening into our health talk. [PHC nurse; Female]

Yes, we do, especially during the family planning session. That is when that will normally tell about cervical health education. …. But when we are carrying out some procedure like IUD, we normally tell them. [PHC nurse; Male]

We do it in my facility and just like the initial question, the initial answer that I gave, it’s mostly done during antenatal, post-natal and whenever they come to the family planning clinic we make them to understand, in case they notice any changes maybe in their private part or discharges, that they should come to the hospital and lodge complaints. [Secondary hospital nurse; Female]

Yeah, as I said before, em one of our hallmarks of en postnatal clinic is especially when we are discharging them from the clinic, as we are educating them about family planning, we educate them about cervical cancer screening for them to join the program (car honking) and get screened regularly. [Tertiary hospital doctor; Male]

Cervical cancer education is usually not discussed in antenatal clinic visits but most times, during our gynae clinic visits is when we take time to talk to women about cervical cancer screening. … Even if they come to the clinic for benign cases, we still take our time to send them for pap smear and other cervical cancer screening just as an opportunity to screen them but we don’t discuss cervical cancer in antenatal clinic. [Tertiary hospital doctor; Male]

It depends on where we see cases like that........We don’t routinely do it. Is when we see cases that are related......... We will discuss with them [Secondary hospital doctor; Male]

We we actually emphasize on sexual partners, and then ehm we I can’t even remember a lot of them now. [Secondary hospital doctor; Senior Medical Officer; Female]

We educate on personal hygiene. We advise them to have one partner, not to be moving from one partner to another. We try to explain the mode of transmission to them, how it can be treated….

We do tell them especially during antenatal clinic that they should not deliver more much children that they can be putting pressure on their uterus and the cervix. [PHC nurse; Female]

Rhm.. we cannot... We don’t normally tell them on the screening, but we tell them on the prevention. Stop using maybe other something like ehm..harmful ingredients to wash. We normally tell them all this thing are harmful. We let them to know that they are harmful, and it can cause a lot of diseases in the future. [Secondary hospital nurse; Female]

Sure we do. We do give them health talks, both on cervical and the breast cancer. We do teach them to prevent using soap and washing their vagina that is not good for them. And then, you know, douching … and change their pad often and often. [Secondary hospital nurse; Female]

Yes, the nurses do. Yes, they do, they discuss with them about signs to see if there is any excessive bleeding. If there is any bleeding, like they should make sure they come to the hospital.[Secondary hospital doctor; Female]

Ok. So when I have one on one encounter with them, I try to tell them... there are some people they will say that their husband want to use saliva as lubricant. I try to discourage that as much as possible, that they should get lubricants like KY jel. It makes it easier. …. They should avoid using saliva as lubricant or any form of oral sex. [PHC nurse; Female]

We don’t really talk about much on cervical cancer, but when we have patients that have infection, we do speak on cervical screening. When last did you do your cervical examination screening? [PHC nurse; Female]

Availability of Facilities for Cervical Cancer Screening

“Well,like I told you, and as you can see, … this facility that is situated in a local area. And, you know, it’s a surbub, it’s in the bush...(laughter)... So, most of the things we do here, we improvise. So, when it comes to major ehm.. in a things like this screening and all that, we do send them to town. Ijebu Ode is our town here. [Secondary hospital doctor; Female]

“There is no facility for it, there is no equipment and no medical personnel that are specialty for it. We don’t have. So that’s why it’s not available here.” [Secondary hospital nurse; Female]

“Okay, cervical cancer screening? Yes. Some years back, we do it here. We’re using acetic acid to check ehm… We..we check down the cervix with acetic acid so as to detect anybody with this papilloma. But for years back, we could not get acetic acid. So we stopped doing the tests here.” [Secondary hospital nurse; Female]

“Yes, it is available. We offer pap smear to our patients at the family planning center. They are nurses there on standby, always Monday to Friday, 8 am to 4 pm so every woman can come in and have their Pap smear taken and the result will be out in no time. Just 10 days results will be out so the the facility is available” [Tertiary hospital doctor; Male]

In fact, we can do it even in the clinic that we are seeing them. We can screen them immediately, and we can even read the results immediately with VIA or put it on the slide, send it to the histology lab. It’s easily accessible, but cost (hmm) cost is the problem. [Tertiary hospital doctor; Male]

I’ve said that we don’t have the test. There is no way we can do the screening here, so, they are being encour...encouraged to go to the state level. [PHC nurse; Female]

Barriers to Cervical Cancer Screening Faced by Patients

Then financial… financial constraint, If they don’t have much money and they wish to do the test, you know they need to source for fund and all of that, then religious beliefs, then the husband too may not give consent too. [Secondary hospital nurse; Female]

Okay, like the transportation problem? You know, from here to... Abeokuta is a bit far, so you have to...you have to...at least before you go there, you have to have some...at least money with you to go there. And most of them, it is this money, financial problems they complain about. That, ah, going there, coming back, it will cost them a lot. So it is transportation and the financial... As for the distance, majorly... And the financial aspect they complain about. [Secondary hospital nurse; Female]

… Some can just feel ashamed and say how can I just go and ask for a thing like that? [Secondary hospital nurse; Female]

Then, most of the time, it is lack of knowledge. Because they don’t really know the significance. Some of them who have this thing and they think it is harmless, that it will go. So it is basically knowledge based, so, by the time they get here and they get educated. They know that, okay, this thing, this is what I’m supposed to do. [Secondary hospital doctor; Male]

So, the barrier they masy encounter is that, if I enter and they said it’s positive, won’t that lead me to another thing? So that is the barrier people are facing, that’s the barrier they are facing. It’s better for me not to go, than to go there and hear, you are positive of this. [PHC nurse; Female]

Barriers Cervical Cancer Screening Faced by Health Workers

“Erm it’s because we don’t have the facility and we don’t have the equipment on ground, so we still need to refer them. Then when we refer them, some will come back. In fact, the majority will not come back. Only a few will come back.” [Secondary hospital doctor; Male]

“Number one, equipment, number two, these manpower, because if we are many, we will train other people most especially the skilled health workers, I mean the nurse.,if I’m not around, you can do this. But manpower, we have no manpower, there is no equipment and all these intensive things they supposed to give us for the work. So the all reagents and all other things they are not giving us.” [PHC nurse; Female]

“Lack of training, either no availability of knowledge about that or inexperience.” [Secondary hospital nurse; Female]

Ehm The challenges we usually encounter is most time, most time when patient, patients that actually need screening. Most times when they get to you. Most time it’s usually late, most times, it’s usually late. Somebody will tell you that my menses stopped five years ago, I just saw it from January, I’ve been seeing blood, I’ve been seeing blood. So by the time you do your your vagina or your speculum examination, you already see florid clinical signs that most times you really just need that pap smear to confirm. [Secondary hospital doctor; Male]

Em but in eh cervical cancer screening (car honks), okay, once patient asks about the cost and you tell them it’s 15,000, they’ll tell you, okay, doctor, I have heard. And we lose them to follow-up (hmm). We don’t see them. Even if you call them on phone, they won’t pick up. [Tertiary hospital doctor; Male]

Facilitators of Cervical Cancer Screening

We don’t want to lose our patients; we want them to be safe at all times.... Because we don’t want to lose them,.. because we know the prevention is usually...it’s always better than cure. [Secondary hospital nurse; Female]

Because I don’t have a choice. When they come for family planning, I have to check them. In some cervix you see erosion lesion that will even not allow you to insert IUCD. Usually, I don’t insert IUD when there is erosion. I rather send them for screening. [Secondary hospital nurse; Female]

Like I said, most time when the presenting complain is related, so that encourages not only health education, then the screening itself. If the complaint is related, then we are motivated to screen. [Secondary hospital doctor; Male]

Challenges of Health Education on Cervical Cancer

We don’t have any challenge in offering health education. Because, someone who cannot speak English, you speak to them in their mother tongue. [Secondary hospital doctor; Male]

In this environment, gender differences are there. Right? The, the females feel freer with their female counterparts, they open up more to the female counterparts than you a male. Despite the fact that you are a doctor and will help them out. [Secondary hospital doctor; Male]

It is still shortage of manpower, because for two nurses to be manning the ward and still come back to give health education. Then the time,… because for you to give a quality health education, you need to have enough time…. When the work load is too much, you won’t be free with your patients [Secondary hospital nurse; Female]

Sometimes we have people that do not understand the lingua franca, English or Yoruba. So you need a translator, in short we have a whole lot of them, because this community is mixed, we have Fulani’s, we have people from Cotonou, we have Igedes, we have a lot of people, so most of the things I might want to tell them get lost in translation. [Secondary hospital doctor; Male]

They all want to go back to their workplace. Nobody is ready to listen. They feel we are talking too much like they don’t really see… They don’t really attach importance to health education perse. They are always in a hurry to go back to their workplace... And also the health workers sometimes. Let me say we don’t really prepare ahead for their questions. [PHC nurse; Female]

Facilitators of Cervical Cancer Health Education

I think it is based on what we are hearing nowadays of people dying of cervical cancer, of cancer of different types, so we always want to guide our patients you know, against having such. [Secondary hospital nurse; Female]

In all sincerity the motivation comes from the clients, when you have a client who you are sure is interested, then you really want to help the client. But when the patient is interested in something else, then when you’re not overburden, then you can help, but when you have so much to do, you get discouraged. [Secondary hospital doctor; Male]

Ehm It depends on most time, the educational level or the status of the patient matters, you understand. If you are explaining to a pepper seller that there is a disease called cancer, they will not understand. They will not relate as well, compared to somebody that is more enlightened, that is probably exposed, and has heard things like that. Educational status makes your job easy, which means you do less counselling. [Secondary hospital doctor; Male]

You know, we need to update our knowledge. If we have the latest information about these services, we’ll be able to provide it and let our people know that this is the latest information.

You know, the medicine is changing every time. [PHC nurse; Male]

There is nothing stop me from giving education. My own is I will tell them. I will give the advice... Some people, they are ready to listen to you, while some people they will tell you they will never have it and which we don’t pray so. [PHC CHEW; Female]

Practice of cervical cancer screening

We don’t really perform it here as being a primary healthcare center. We refer to higher clinic for further investigation. [PHC nurse; Female]

About the cervical cancer screening, it is a good program, but in a local area, we don’t usually have the facility to carry out the cervical cancer screening. I could remember one time that there was a time that we have cervical cancer screening outreach at Ajegunle during a former governor for breast and cancer of the cervix. [PHC nurse; Male]

Okay, little experience I had about that, but I know that during cervical screening, there is this testing lotion that is being used, that the cervix will be infiltrated with it, and there could be discoloration of the cervix, there could be patches on the cervix, and the likes. Although I have not been able to set my hand on it to screen, to do cervical screening, but I have seen it being done. [PHC nurse; Female]

Most time we send them for pap smear elsewhere, because it is not all the time we do have acetic acid to do VIA. [Secondary hospital nurse; Female]

Some years back, we do it here. We’re using acetic acid to check ehm... We..we check down the cervix with acetic acid so as to detect anybody with this papilloma. But for years back, we could not get acetic acid. So we stopped doing the tests here. [Secondary hospital nurse; Female]

I think I mentioned that earlier. The cervical cancer screening is mainly done at the heart to heart clinic. There is screening mainly for the HIV, people living with HIV, but for general population, I’m not aware that it’s being done. There is no program for that at the moment. [Secondary hospital doctor; Male]

We are aware that there are other types of screening, They is liquid based cytology. We don’t, have it. We are a resource poor country, so we don’t do liquid based cytology. We cannot do HPV analysis, so we just do the conventional pap smear. Then some women will go beyond pap smear and we do colposcopy for them Because we have col..col.. colposcopy machine. During the colposcopy, we can do the VILI and the VIA, visual inspection under acetic acid or under Lugos i..iodine We do that you know, also for indicated patients. Patients who have the abnormalties on pap smear we go further to do the colposcopy for them. So those are the methods that that we use, Pap smear routinely, then colposcopy as indicated. [Tertiary hospital doctor; Male]

We do it routinely, especially for our infertility patient or patient with any gynaecological problem is a must. [Secondary hospital nurse; Female]

We all know the gold standard is the pap smear. But we don’t do the pap smear here. What we do here basically is the ehmm the clinical ehm inspection examination using a speculum. That usually happens when you want to kind of ehm when you are recommending ehm IUCDs for women during family planning. Once the nurse sees some characteristics that are not normal, they call us the doctor we examine, ask for samples to be taken. Though the samples are not taken here, we have to refer them to centers where they are will be taken, but that’s basically what we do here. [Secondary hospital doctor; Female]

Recommendations for Cervical Cancer Screening and Health Education

If it’s actually incorporated as a routine… the counselling… into ANC. You won’t forget. You will know—I’ve not done this. [Secondary hospital doctor; Female]

And also there should be a kind of renumeration also for health workers in order to do all of these things. Because when you’re being renumerated, apart from you having that eagerness or willing to do the job, but because there is renumeration and you are being appreciated, it’s not even about paying huge money, but be appreciated, either by word or even in cash, you know, that will also help to facilitate and will help the health worker even to perform well. [Secondary hospital nurse; Female]

So if we have more centers, we have more screening centers, that’s where the government comes in. That is, the government should be proactive about having centres in different local government. if they can do these things, can be put in place, for instance now, if you in Imeko and you don’t have to travel 2 hours away before you can have the pap smear test done. If you have the Pap smear center in the Imeko, or at most, you have two, at least each local government will have one, or we are one in two local governments, it makes it easier. For instance now, rather than going to Abeokuta from Imeko, patient can go to Ayetoro. It is one hour from each other. That way, it reduces the cost. [Secondary hospital doctor; Male]

Well, I think if we have the facilities, the equipment, the necessary things to get it done so that when you counsel them and they agree, you get them screened immediately, that will motivate them and that will also encourage them to want to do it. And maybe even if a costs will be attached to it, it will be so that he cost will be so minimal that they can afford…. It so affordable by them, like, for example, if you said, okay, you counsel somebody on cervical cancer screening and said for you to do it, it’s just 500 Naira or even not up to that and the person is already aware of the benefits attached to it, why I need to get it done and where to get it done is right in front of her, she will [PHC nurse; Female]

ehhh, the health workers themselves should also be trained. Because what you don’t have, you cannot give [Secondary hospital doctor; Male]

But as... assuming we have female personnel, they will feel free. At least they do come for delivery and they are free. Because they know nurses here they are mostly female. We don’t even have male, so they are free. So if the same thing applies to this screening... They may want to submit themself for the test ? [Secondary hospital nurse; Female]

There should be community-based awareness programme. Why I said this is that, many of the people in this environment will not come to the hospital to register. They prefer going to “alagbos”for their antenatal care. So if you say until when they get to the hospital you will give them information, what about those that are outside there. So public awareness, community awareness is important. [Secondary hospital doctor; Male]

Through giving them health information. And giving them free screening. [Tertiary hospital nurse; Female]

Yes, I think cervical cancer screening should be made to be a part of the postnatal clinic because that’s where you have an exposure to larger number of women population. [Tertiary hospital doctor; Male]

Strengths and Weaknesses of the Study