PATH's Cervical Cancer Prevention Action Planner

PATH and ACCP findings related to precancer screening and treatment

PATH and our Alliance for Cervical Cancer Prevention (ACCP) partners conducted formative research and evaluated programs in Africa, Asia, and Latin America, with the aim of better understanding the types of barriers women face in accessing cervical cancer screening and treatment services and the challenges that health program managers must overcome to provide sustainable, reliable, high-quality services.

Interestingly, while researchers noted differences in different countries, overall the findings were remarkably similar across all countries. For example, it is common for women all over the world to report that they generally would prefer that a female conduct their pelvic examination, or to point out that long distances to travel and long wait times at clinics make it more difficult for them to be screened.

Some key reasons women gave for seeking screening services included:

  • They were concerned about cancer: they feared death or feared that their children would be left without a mother.
  • They worried about discomfort or pain they were experiencing.
  • They were referred for screening by a health care provider or other knowledgeable figure.
  • A screening project or campaign was promoted in their community or they were exposed to effective community outreach.

Factors that improve access and attractiveness of screening and treatment services, as reported by clients and providers, included:

  • Services (screening and treatment) were convenient and low cost, and did not take too much time.
  • Staff was trusted and was friendly; they explained procedures clearly.
  • Test results were available rapidly (same day or within a few days).
  • They had strong family support for the procedure, especially spousal support.
  • They also felt community support. Their communities supported screening and women who sought screening were not stigmatized.

Respondents also reported factors that hinder access to screening and treatment services:

  • The clinic was far from their homes, transportation was difficult, it took too much time to go to the clinic, there were long wait times for services, and/or associated costs were too high.
  • There was lack of capacity to serve all women who came for screening and some were turned away.
  • The clinics lacked space and equipment for VIA or cryotherapy, or they did not have specula, vinegar, or gas.
  • Services were not offered at times or on days when women were free to come.
  • Staffing issues: providers were stretched thin by demand for services, they faced a heavy workload and felt burned out, and there was high staff turnover and loss of trained VIA providers.
  • Because most clinics offering screening did not also have follow-up and treatment available in the clinic, and women had to be referred for treatment to another facility, many women dropped out of the process before receiving treatment. The longer the delay between the screening test and treatment, the greater the drop-out rate.
  • For women receiving Pap services there was a long delay getting results.
  • Sometimes employers did not give permission for the women to miss work and attend the clinic.
  • Sometimes cryotherapy equipment broke down and there were no replacement parts.
  • In some countries only doctors were allowed to perform cryotherapy, not nurses or other trained staff, and access to the doctors was limited.

Lack of information and cultural barriers also play a role in preventing women from being screened:

  • Often in communities, and even among providers, there are low levels of knowledge about screening in general and specifically about the availability/timing of screening and treatment services. However, this situation is changing.
  • Women may not go for screening because they do not perceive themselves to be at risk or do not perceive that there is any benefit. There is the misconception that "cancer is incurable, so what is the point of screening?" Many only seek care when they experience symptoms.
  • One of the most common fears mentioned was that they would be diagnosed with cancer. They feared needing treatment (often assumed to be surgery), feared "losing a part of the womb" and worried about subsequent infertility or inability to perform sexually.
  • Many women had heard rumors about screening that caused them to be afraid. Sometimes they confused screening (which, while it can be uncomfortable, generally is not painful) with surgical treatment of advanced cancer—like a hysterectomy—or with a biopsy. For these reasons, many women said that fear of pain during screening was an important barrier.
  • Many reported that women dislike a speculum exam. Some also had concerns that the procedure might be difficult or might cause, or accelerate, cancer spread.
  • Women were concerned about stigmatization associated with having cancer. Some worried about what people would say if they knew she had gone for screening.
  • Sometimes husbands or family elders objected and would not give permission to go to the clinic. In some cases the subject of the exam was so embarrassing that the woman did not want to discuss it with her husband.
  • Many women prefer to present to a female provider and feel shy or embarrassed exposing their genital region to a male doctor when they are not in pain or giving birth. Men often did not want their wives "viewed" by a male provider.
  • In some places families do not have faith in the quality of public health clinics—some were concerned for example about whether the specula had been properly sterilized and whether "dirty" equipment could spread infection or cause cancer.

Click for sample educational materials for health workers and communities.

Photo: PATH/Eric Becker

Additional resources

Print version: Cervical cancer screening and treatment in low-resource settings (PDF, RHO Cervical Cancer website)

Watch videoScreening and Treatment of Precancerous Lesions video and transcript

Screening and treatment (RHO Cervical Cancer website)

World Health Organization: Comprehensive Cervical Cancer Control: A guide to essential practice (PDF)

Planning and Implementing Cervical Cancer Prevention and Control Programs: A Manual for Managers (PDF)

Evidence-Based, Alternative Cervical Cancer Screening Approaches in Low-Resource Settings

Strategic Plan for Cervical Cancer Prevention and Control in Uganda (PDF)

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