Barriers to Cervical Cancer Screening in Arba Minch Town, Southern Ethiopia: A Qualitative Study

Background: Over the years perception and uptake of cervical cancer screening services has remained poor in developing countries including Ethiopia. Data on barriers of Ethiopian women regarding cervical cancer is lacking. Objective: This study sought to explore barriers to utilization of cervical cancer screening in Arba Minch town, Southern Ethiopia. Methods: A qualitative research study using in-depth interviews was conducted. The in-depth interviews were tape recorded and transcribed verbatim. The transcripts were analyzed into themes. Result: The respondents had low awareness of cervical cancer and were not utilizing the services. There was also a lack of understanding of risk factors for cervical cancer. The major factors identified by the women that influence screening utilization were lack of knowledge about the need for cervical screening, fatalistic attitudes about cervical cancer and other aspects of health, low perceived susceptibility, having many contending issues, financial constraint, and emotional barriers (fear of having a positive result, embarrassment and anticipated shame). Conclusion: This study provides enormous data on the multifaceted reasons why women do not utilize cervical cancer screening. Interventions are required to alleviate the barriers through using simple and cost effective programs that could have a great impact.


Introduction
Cervical cancer is the second most common cancer in women worldwide. Every year more than 270,000 women die from cervical cancer. Yet, because of poor access to screening and treatment services, the vast majority (more than 85%) of deaths occurs in women living in low and middle income countries [1].
Without urgent attention, deaths due to cervical cancer are projected to rise by almost 25% over the next 10 years. Cervical cancer occurs worldwide, but the highest incidence rates are found in Central and South America, East Africa, South and South-East Asia, and the Western Pacific. Over the past three decades, cervical cancer rates have fallen in most of the developed world. In contrast, in many economically developing countries where cervical cancer is not recognized as a public health priority and screening programs are mostly opportunistic, the incidence of cervical cancer remains unchanged, and in several cases continues to increase. Major disparities also exist in the developed world, where rural and poorer women are at greatest risk of invasive cervical cancer [2].
Observed disparities in cervical cancer incidence and mortality are largely accounted for by inequities in cervical cancer screening. In countries with well-organized screening programs, rates of cervical cancer morbidity and mortality have declined significantly. This decline in observed cases of cervical cancer directly corresponds to the adoption of routine cervical cancer screening practices [3][4][5][6].
Cervical cancer can be prevented by identifying pre-cancerous lesions early using repeated Pap smear screening and treating these lesions before they progress to cancer. Prevention, early diagnosis and treatment have been shown to reduce mortality due to cervical cancer [7].
Ethiopia has a population of 29.43 million women ages 15 years and older who are at risk of developing cervical cancer. Current estimates indicate that every year 7095 women are diagnosed with cervical cancer and 4732 die from the disease. Cervical cancer ranks as the 2nd most frequent cancer among women in Ethiopia and the leading cause of cancer related deaths among Ethiopian women [8].
Several barriers to cancer screening have been reported; these include a lack of awareness of the importance of screening, inadequate access to healthcare, aversion to the discomforts of screening, fear of finding cancer and logistic barriers such as having to take time off work for screening. Studies have also revealed that knowledge, attitudes and beliefs about the Pap smear test appeared to be related to actual participation in cervical cancer screening. In fact, women's knowledge and beliefs of the Pap smear test were shown to be the strongest predictors of repeated screening [9][10][11][12].

Journal of Community Medicine & Health Education
Previous studies on barriers to cervical cancer screening identified knowledge about cervical cancer screening, education level, family history of the disease, and costs, as the most significant barriers to getting screened [13][14][15][16][17][18].
Little is known about the factors that hinder women from taking up screening in Ethiopia. Therefore, understanding the factors associated with the under utilization of cervical cancer screening is important in order to increase overall cancer screening rates. This study aims to get a better understanding of the perception and barriers that prevent women in Arba Minch town, Southern Ethiopia from getting cervical cancer screening.

Methods
The study was conducted in Arba Minch town, Southern Ethiopia, from February to March, 2015. A qualitative study was used to explore perception and barriers for cervical cancer screening using in-depth interview.
The theoretical frame work used in this study is the health belief model (HBM). The HBM is a psychosocial model proposed by Rosen stock (1966) in Stanhope and Lancaster for studying and promoting the uptake of health services like screening. This study found that the HBM serves as a useful framework for understanding participant perceptions and behaviors. The model explains preventive behavior. The model assumes that belief and attitudes of people are critical determinants of their health-related actions. It holds that when cues to actions are present, the variations in uptake behavior can be accounted for by beliefs concerning four sets of variables. The HBM includes four main factors that determine the initiation of a particular health behavior: perceived susceptibility to a disease, perceived severity, perceived barriers, perceived benefits, and cues to action [19].
In-depth interviews were conducted with 22 women. These interviews were conducted in Amharic language. A semi-structured interview guide was prepared in English then translated to Amharic language. The instruments were pretested amongst a similar target group before actual study. The interview included questions on demographic characteristics, knowledge, attitudes, perception and beliefs toward cervical cancer and barriers to screening. Purposive and snowball sampling techniques were used to identify participants from the communities in Arba minch town.
Each in-depth interview was conducted by trained facilitator and lasted approximately 60-80 minutes. Detailed hand written notes of each session were taken at the time of the discussion. The in-depth interviews were tape recorded and transcribed verbatim. The transcripts were analyzed into themes. Informed consent was obtained from all participants. The study was granted ethical approval by the research ethics review committee of college of health sciences, Jimma University.

Socio-demographic characteristics of women
A total of 22 women participated in the in-depth interview. The women's age ranged from 20-49 years. Most of them 17 (77.3%) were married. About 27.3% of the women had 4-6 children. They are mainly housewives and had primary education (41%). Over half (59.1%) of had never used any family planning method. Of all the women, 36.4% had their first sexual intercourse experience while they were married and the earliest age at first sexual intercourse was 14 years for two of the participants. All women don't have history of smoking cigarette and drinking alcohol. All participants have never had a Pap smear test.

Awareness on cervical cancer and cervical cancer screening
On awareness of cervical cancer, most of the participants stated that they have never heard about cervical cancer. Only a few women said they had heard about it as a terrible disease and one that often result in huge stress and physical suffering. A 25 year old married woman responds as: "I heard from radio that the cancer affects the opening of the womb or …the entire uterus" This statement shows even those that have heard about did not have accurate information about the disease. When they were asked about the source of information mass media (television/radio) was the predominant source. Few respondents also knew someone who has cervical cancer. Most of the respondents did not know any symptom.
When asked about cervical cancer screening, women often had no concept of what the screening was for, what happened to a woman while she was being screened, or why it was important to be screened. Majority of them have not heard about any screening method. Thus, they did not know about any type of screening methods.
Most participants had not heard of the Pap test. They considered it to be the same as a simple vaginal inspection. A 36 years old woman expresses it as: "I just heard that sometimes they look at it with metal equipment" Of those who knew of the existence of the Pap smear, their understanding of the purpose of the test was poor, many of them associated the Pap smear test with the detection of cervical cancer.
Only three of them mentioned the importance of checking regularly; thus, most of the mothers did not realize the importance of regular check-ups for the prevention of cervical cancer.
Respondents were unsure who should be screened. Many believed that the Pap smear is only for married women.

Awareness on cause of cervical cancer
Most participants were unable to clearly explain the cause of cervical cancer. There was no mention of human papilloma virus (HPV) by any participant. They acknowledged their lack of knowledge, but they expressed their interest to know more about cervical cancer.
A series of probe regarding risk factors, main symptoms, treatment options and prevention and early detection measures of cervical cancer were made. Most of the respondents did not know whether there are risk factors for cervical cancer or not and one woman stated that there is no risk factor for cervical cancer.
Even those who said that cervical cancer has a risk factor, they were unable to mention a risk factor correctly. In general, three of them were able to identify at least one risk factor for cervical cancer. Sexually Transmitted Infection and early onset of sexual activity were specific risk factors mentioned by these three women.
Participants commonly believed that a woman only got cervical cancer by the will of God as a punishment, which they mention it as "Yegziabher Kuta". In addition the participants believe that cervical cancer is a result of variety of socio-cultural and other behaviors including unprotected sexual intercourse, use of family planning methods, and contamination during unsafe abortion by inserting a plant called "yebisana kenbet", scientific name called "Croton macrostachys". One woman explained the association of cervical cancer and the plant as: "... 'yebisana kenbet' is used for terminating pregnancy particularly if unwanted, in my opinion irritant nature of it may damages the cervix which finally leads to development of cervical cancer " Others also mentioned being multipara and some of them related it with lack of personal hygiene. A 49 year old woman mentioned as: "….I think personal hygiene is a risk factor for the cancer because we women's need to clean our selves including the genital area especially during menstruation…. if we fail there will be problem" Most of the women perceive themselves as being at low risk of cervical cancer.

Perceived benefits of cervical cancer screening
To explore familiarity with the concept of screening as a preventive method, participants were asked if they agreed that cervical cancer screening would be appropriate for a woman who was apparently healthy or free of symptoms. Nearly half of women perceived screening as a necessary procedure among women who did not have clinical symptoms. They believe that cervical cancer like other cancers will get worse if not detected and treated early.
The majority of participants believed that modern medicine cannot cure cervical cancer; they believed that traditional healers can be effective in treating the cancer.
A 37 years old woman said: "…this disease is less likely to be cured once developed, no need of screening as I heard from other people that almost all die once they develop the cervical cancer"

Perceived barriers to cervical cancer screening
Most of them felt that they did not believe that they were susceptible to cervical cancer, and that this might affect whether a woman felt it necessary to be screened When probed, two women said that they had never been sexual active and so thought that they did not need to attend for screening, and seven cited other reasons, including lack of understanding of the need to attend screening, hearing others' negative stories about the test, and embarrassment.
Fear of the test was cited as an obstacle to some women, even if they appreciated the need for screening, perceived as a painful instrument.
Cancer was not only described as being rare, but also as stigmatized. Few women remarked that cancer evoked secrecy; in some cases being associated with other stigmatized illnesses. Fear of certain death from cancer lead women to avoid the service.
A few women talked about potential shame if diagnosed with cervical cancer as a barrier to attending screening among others. A 36 years old woman mentioned: "…even if the women develop the disease, they kept secret saying their disease other than cervical cancer" In addition, various factors including cultural, socio-economic, and beliefs about the disease and the health care system were found to affect the treatment seeking behavior for cervical cancer. Some of them mentioned it as: "….I think that the service is not available here in our community" "…I don`t have information about the availability of the service" "…I am too busy working in the house and fields to go to the hospital for that service …time shortage" Some participants had the desire to visit health facilities as soon as the symptoms and signs appeared however they perceive there are barriers to access the facilities. The barriers included; long distance to the facility and means of transportation to reach the health facility.
Some participants felt that the cost of treatment may be unaffordable as mentioned by the following statement: "…I heard that the cost of screening and treatment is unaffordable and all patients are referred outside of Ethiopia… I don't want to utilize screening service for cervical cancer, if I screened the condition affects me more than the disease…" "….I heard that any cancer service is costly and are referred outside Ethiopia" Several women described fear of cancer or worry about the results of the test as something that had put them off attending screening: "… I have seen somebody die of cancer it's not nice, so it's not easy for me to hear the result of the screening" In addition to being embarrassed, all the women also described the examination may be very uncomfortable. While the procedure, by its nature, is uncomfortable, the discomfort is often worsened by the way it is done.
"Personally I still find it embarrassing exposing my body to people I don't know… so still now I have difficulty to take of my clothes and show my private parts" One woman said this was a barrier for her personally: "I don't want anybody else to look at my own body or touch my own body, which could be one of the reasons that are putting me away for screening" The limited knowledge was also associated with traditional beliefs among women. The fact that screening involves looking for disease in the absence of symptoms was seen as a reason not to be screened by one of the woman: "It's not urgent because you don't have any symptoms" "… Why I need to be using the service while I am health"

Discussion
This study explores the perceptions and barriers for cervical cancer screening. Most participants were not aware of risk factors and symptoms of cervical cancer and believed that cervical cancer could be prevented.
screening uptake could be channeled through this mass media, which is also supported by other findings [20,21].
Furthermore, a considerable proportion of participants held beliefs that cervical cancer is always fatal in spite of medical treatment, while others were unaware that cervical cancer is curable when diagnosed in an early stage. There is therefore need for targeted innovative interventions which is locally acceptable to increase awareness about cervical cancer treatment.
This study revealed the importance of beliefs in determining the perception of risk of cervical cancer within this participants, with most believing that God's will was the most important factor in determining whether a person developed cervical cancer. Studies conducted also shows cultural beliefs, myths and stigmas about cancers are present. Cultural beliefs have reduced Pap smear uptake and hampered healthseeking for cervical cancer [22][23][24].
Despite their fatalistic beliefs, this study revealed that the participants also thought that other factors might play a role in determining a woman's risk of cervical cancer. Although there was no mention of HPV, some thought that infections posed a risk of cervical cancer.
Though they did not know what screening bring about but the women believe that screening is good as it will help those that have problem to know early. Poor knowledge of cervical cancer among women has been reported in various studies also [25][26][27].
Women were not using the services as they did not know about the services or where to obtain such services. The major factors identified by the women in the study are lack of awareness about the screening; some people think that such services are for people who are married. Also, the facts that when people are healthy they don't bother about preventive services as they have other competing problems.
The perception of one's susceptibility to cervical cancer can affect screening behavior. Many women expressed a lack of personal susceptibility to cervical cancer and therefore believed it was unnecessary for them to have a Pap smear test done. Additional barriers identified includes: embarrassment, perceived pain from penetration, low perceptions of risk, and not prioritizing screening which is also observed in other studies [28][29][30].
Some of the women also raised the potential for feelings of shame, if diagnosed with cervical cancer, as a barrier to screening for others in their community. Anticipated shame and stigma has been suggested as a barrier to cervical screening in other studies [31][32][33].

Conclusion
This study has shown that the awareness of cervical cancer screening was very low among women. The finding revealed that there are complex factors that prevented women from utilizing the cervical cancer screening. Therefore, there is a need for community-based innovative and culturally sensitive interventions to improve awareness and understanding of cervical cancer which will enable women to utilize the service.