Views on integration
Women appreciated the convenience of sexual reproductive health services being integrated with HIV services, reporting that it allowed them to access multiple services, cervical cancer screening included, under one roof on a single visit, thereby saving time and travel expenses. They also appreciated that services were offered free of charge.
“When I came for (HIV) testing I was also offered family planning, and then when I went for family planning that is when I was told that we also test for cancer…You can have all the services here on one day, so it saves time”( IDI 28-year-old woman, screened for cervical cancer)
Service integration appeared to facilitate the acquisition of knowledge on cervical cancer screening, among clinic attendees, including the fact that services were offered for free. Women reported getting information on cervical cancer screening from health workers at multiple service points within the clinic thereby facilitating uptake even among women who were not initially seeking the service. Posters on cervical cancer screening hung at the clinics prompted women to enquire and book for service. The efficiency of health workers’ information-giving sessions was commended by women during on site discussions among themselves:
“The health workers are so good in the way they counsel us before screening…the way they teach you is so understandable and makes you want to go out and tell others in the community” (Participant observation, words of a middle-aged woman).
In-depth interviews revealed that knowledge on cervical cancer screening also spread through informal discussions women held in the waiting areas at the clinics.
“We were just discussing stories as women, sitting in the shade (waiting area) and that is when I heard that here they screen for cervical cancer.”(IDI 27-year-old woman took up cervical cancer screening).
It was evident that discussions on cervical cancer screening also happened in communities and that these discussions encouraged some women to attend for screening.
“…she told me that as women you should have your uterus checked so that you can be diagnosed early, if you delay look at me I had my uterus removed (IDI 40 -year-old woman, took up cervical cancer screening).
Of note, discussions among women in the waiting area were also a source of misinformation: they were sometimes laden with myths and misconceptions about cervical cancer screening, causing uncertainty, mistrust, and fear of the screening process. During participant observations women were heard giving exaggerated information of the pain and discomfort that was experienced during screening. In these discussions, many women who had just screened likened the pain they experienced during screening to that of labour pain. The speculum was described as a formidable ‘metal dipstick as long as one’s arm’:
“Ah I am dreading this (screening); I will faint before that metal is inserted” (elderly woman, participant observation)
Knowledge and awareness on cervical cancer screening at the integrated services sites improved from phases 1 to 3. Findings from participant observations suggested less pronounced misconceptions about cervical cancer screening in the last quarter of phase 1 through to phases 2 and 3 as more women screened and shared more positive experiences at the clinic waiting areas and presumably in the community. However, knowledge and awareness on cervical cancer screening remained somewhat limited at the public-private-partnership site across all phases as cervical cancer screening services were not offered on site until phase 3 when PSI-Z started offering services once a week on an outreach basis. Though the media particularly radio and television were frequently cited as sources of information on cervical cancer screening, the radio was often perceived as limited in catching the attention of the target audience.
Increased knowledge is associated with uptake of cervical cancer screening.
We observed that good knowledge about cervical cancer screening was associated with uptake of cervical cancer screening across all phases. Uptake figures showed an upward trend from phase one to three (Fig. 1).
Knowledge on cervical cancer was associated with positive views on screening. Knowledge about cervical cancer was acquired at the integrated clinics and through the media, peers, and community discussions. It was evident that women who had been screened portrayed deeper knowledge about cervical cancer compared to women who had not been screened as they gave accurate descriptions of the importance of screening and the procedures involved. It follows that this good knowledge was enhanced by having gone through the procedure, but there was evidence that many women who took up cervical cancer screening had good prior knowledge which informed their decisions to take up cervical cancer screening.
On the other hand, we found that women who had not taken up screening had poor knowledge, with poor understanding of the importance/value of screening, with evidence of several myths and misinformation. For example, there was the view that screening was not necessary for young women as cervical cancer only affected older women; and for some women the absence of symptoms meant one was not at risk, which in their view made it unnecessary to take up screening.
“I am still young; I don’t think I have any chances of getting cancer… it affects our mothers who are grown up.” (IDI 28-year-old married woman; did not take up cervical cancer screening).
A recurrent theme was the fact that cervical cancer screening was viewed as a complex surgical operation that carried a lot of risks, suggesting that the decision to take up cervical cancer screening was a big one. Linked to this was the perception that the cervix is very fragile and should not be tampered with – with fear that ‘tampering’ would cause post-screening complications or even cervical cancer itself.
“…we discussed with others, and they said being checked causes you to have cancer… when you go for the second time to be checked you will find out that you now have cancer…” (IDI 25-year-old woman, did not take up cervical cancer screening)