Cervical Cancer Prevention in Ethiopia: Providers’ Cancer Awareness, Screening Practices, and Perspectives of a New National Screening Program
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PublisherThe University of Arizona.
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AbstractBackground Cervical cancer disproportionately affects low-and-middle income countries and Africa in particular, the region with the highest incidence and mortality in the world. Referred to as a preventable cancer, the World Health Organization has created a global strategy for the elimination of cervical cancer with a target for all countries to vaccinate 90% of girls by age 15, achieve 70% screening coverage of women by the time they reach 35 years, and ensure that 90% of women receive treatment as appropriate for precancer and invasive cancer by the year 2030. Still, cervical screening uptake in much of sub-Saharan Africa (SSA) remains far below the desired 70% coverage. This dissertation aims to describe interventions to increase screening in the region and then narrows in scope to describe health provider cancer knowledge, screening practices, related factors, and perspectives on implementation of a new national screening program in Ethiopia. Methods This mixed method study is comprised of a literature review, a qualitative aim, and a quantitative aim. A systematized scoping review of interventions to increase cervical screening uptake in SSA was conducted from April to October 2019 by searching four electronic databases (PubMed, Embase, Web of Science, CINAHL) and employing a two-step review process. Data were extracted from included studies for a number of variables such as population, intervention, control, screening method, screening uptake, and secondary outcomes. The Integrated Behavioral Model was used to describe how interventions were supposed to work and effectiveness of approaches. Primary data was collected in Ethiopia from May to August 2019 through key informant interviews and questionnaires. Cancer experts, including screening program managers and cancer focal persons, were interviewed to explore barriers and facilitators to implementing cervical cancer screening using visual inspection with acetic acid. An open coding process identified emergent themes and again, the Integrated Behavioral Model was used as an analytical framework to understand how specific barriers and facilitators might impact screening behavior. Finally, a questionnaire with a locally translated and validated version of the Cervical Cancer Awareness Measure was administered to various cadres of health providers working in public health facilities and programs to measure their cervical cancer awareness and to describe screening practices. Linear mixed models were used to explore associations between cancer awareness scores and other variables of interest. Results The review identified 19 studies for inclusion from seven countries with studies set in urban and rural communities and interventions using a variety of approaches to improve cervical cancer screening. The most common approach was educational interventions (57.9%) which acted on a woman’s knowledge or skills to be able to change screening behavior; this type of intervention was largely ineffective. Two interventions used incentivization and had a moderate effect on screening behavior. The most effective interventions were those that used innovative service delivery solutions, acting on environmental barriers to reduce screening burden and improve uptake. Willingness to screen was high even prior to intervention. Six of the studies (31.6%) reported significant changes to screening uptake and achieved 60% coverage. Interviews with cancer experts in Ethiopia (n=18), such as screening program professionals and cancer focal persons, revealed a hopeful outlook on the ability to greatly impact women’s health outcome through screening. Common barriers to screening implementation included low awareness in the community and among health providers, lack of space and materials to establish screening services, and variable support from leadership within facilities and from local, regional, and national health administrators. For more established screening centers, partnerships, strong referral systems, and demand creation were desired for program sustainability over time. Participants described a need for professional networks to share experiences, advance cancer prevention efforts, engage in advocacy work, and support the ministry of health with training and monitoring and evaluation efforts. Health providers (n=771) at government funded health facilities and programs (n=8) scored, on average, 13.8 out of 22 points on the Cervical Cancer Awareness Measure (CCAM), which was reliable (Chronbach’s =0.86) and valid for use in Ethiopia after being translated to Amharic and Afan Oromo languages. At least 75% of providers knew that HPV infection, having multiple sexual partners, and smoking were risks for cervical cancer and that symptoms included pain or discomfort during sex, bleeding during or after sex, and foul-smelling vaginal discharge. Sex, survey language, education, cadre of health worker, previous cancer training, and site were statistically significantly related to increases in CCAM scores. Physicians, on average, scored 4.4 points higher than health extension workers (p<0.0001). Approximately 35% of providers never asked their female patients about cervical screening history and only 7.8% of women providers had been screened themselves. Attitudes were not significantly related to screening practice, however, providers did exhibit high self-efficacy, agreeing that they could improve their patients’ health by offering screening. Conclusions A commonly cited barrier to screening uptake, both in the existing literature on cancer prevention strategies used in SSA and from the perspectives of cancer experts in this study, is low cancer awareness. However, interventions from the literature review that acted on a woman’s knowledge were not particularly effective at increasing screening behavior. Among the health providers in this study, most were able to identify several risk factors for and symptoms of cervical cancer. Providers who had previously been trained about cervical cancer were more likely to ask their patients about screening history, demonstrating importance of provider training not only for increasing awareness but for also increasing opportunistic screening behavior. Still, other behavioral constructs, particularly environmental constraints, are important to developing effective interventions to increase screening uptake. In various SSA contexts, interventions that recognized environmental barriers to screening, such as cost and transportation/distance to facility, and acted on those factors were most effective at increasing screening. In Ethiopia, cancer experts also described environmental factors, such as lack of supplies and space, as major barriers to implementing screening. In the Integrated Behavioral Model, a person’s intent to perform a behavior is the immediate precursor to the actual behavior and is considered the most important factor acting on the behavior. For cervical screening, both from the patient and provider perspective, intent to screen was not necessarily the most important factor determining screening behavior as environmental factors still presented significant challenges even when willingness or intent was high.As Ethiopia transitions to the next iteration of a national cancer control strategy, successes and challenges from the first iteration are timely and point to specific areas for improvement moving forward. Significant scaling-up and decentralization will increase screening accessibility in Ethiopia, particularly in smaller, rural health centers where environmental factors may play an even greater role. Future research is needed on community-based screening practices, including HPV testing, to determine its feasibility for widespread use.
Degree ProgramGraduate College
Degree GrantorUniversity of Arizona
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