Patient perspectives on delays in cervical cancer screening and follow-up care in Botswana: a mixed methods study

Abstract

Background Delays in screening and timely diagnosis contribute significantly to global disparities in cervical cancer mortality in Botswana and other low- and middle-income countries, particularly those with high rates of HIV. Little is known about the modifiable factors shaping these delays from the perspectives of women themselves and how these perspectives may differ between those living with and without HIV. Methods From March–May 2019, we conducted a concurrent, mixed methods study of women receiving treatment for cervical cancer at a multidisciplinary oncology clinic in Botswana. Enrolled participants completed a one-time, concurrent semi-structured interview and structured questionnaire assessing patient characteristics, screening and HIV-related beliefs and knowledge, and barriers and facilitators to screening and follow-up care. Qualitative data were analyzed using directed content analysis guided by the Model of Pathways to Treatment and triangulated with quantitative questionnaire data to identify areas of convergence and divergence. Fisher’s exact tests were used to explore associations between questionnaire data (e.g., screening knowledge) and HIV status. Results Forty-two women enrolled in the study, 64% of whom were living with HIV and 26% were diagnosed with stage III cervical cancer. Median age was 45 years (IQR 54–67) in those living with HIV and 64 years (IQR 42–53) in those living without. Overall screening rates before symptomatic disease were low (24%). Median time from most proximal screen to diagnosis was 52 median days (IQR 15–176), with no significant differences by HIV status. General screening knowledge was higher among those living with HIV versus those without (100% vs 73%; p < 0.05), but knowledge about HPV and other risk factors was low in both groups. Similar to questionnaire results, qualitative results indicate limited awareness of the need to be screened prior to symptoms as a central barrier to timely screening. Some participants also noted that delays in the receipt of screening results and fear also contributed to treatment delays. However, many participants also described myriad sources of social and tangible support that helped them to overcome some of these challenges. Conclusion Interventions focused on increasing routine screening and supporting timely awareness and access to care are needed to reduce global disparities in cervical cancer.

Cervical cancer screening uptake, associated barriers and facilitators: a systematic review and meta-analysis

“…From the eight studies which were eligible for the systematic review, only seven were included in the meta-analysis, where data from five studies were disaggregated (see Additional file 2). The five studies were [20,12,19,16,18]. Since proportions of women who have ever gone for cervical cancer screening were reported separately by subgroups, we considered the groups separately to avoid any masking of the group differences if there were any.…”

“…In an attempt to explore why there is evidence of high heterogeneity, we assessed publication bias through a funnel plot (Figure 3), which showed that there were 11 outliers ([16]-1, [16]-2, [17], [18]-2, [20]-5, [18]-1, [20]-6, [20]-3, [15], [20]-1). These studies were suspected to be the source of variation in the effect measures across the 17 studies.To account for this variation, a sensitivity analysis was performed on the 11 studies (see Additional file 3).…”

“…The majority of studies reported low level of knowledge and awareness as the leading barrier to cervical cancer screening utilization [17,18,20,15,19,12,12]. The second leading factor reported by participants from the included studies was misconceptions regarding cervical cancer screening [19,12,14].…”

“…The health system-related factors comprised equipment shortages, long queues, inconsistencies in appointment systems, failure to explain abnormal results, and poor access to the availability of results. A leading factor reported from the studies was delays in receipts of screening results and in some cases no delivery of results [18,12,14]. Other factors included poor service delivery from health facilities, personnel and equipment shortages as well as negative staff attitudes [18,12,14].…”

“…Despite this, there is still an identified low participation in cervical cancer screening and low follow-up of screening in Botswana [11,15]. In an attempt to get the underlying reasons for this, several researchers have recently studied barriers to cervical cancer screening as well as factors associated with a late-stage diagnosis of the disease in Botswana [16,15,17,18,19], where they have observed among others, negative results on the first visit, having health insurance and a regular health care provider, laziness for women who have never gone for screening, distance, public transport issues, work commitments, personal fears, and misconceptions, inconsistent appointment systems, long queues, equipment shortages, poor explanation, and planning skills by service providers, wealth status, and delays in receipt of screening results as contributing factors.…”