Findings from this study show that nurses and midwives, who made up 97.7% of our respondents, are the main providers of cervical cancer screening and prevention services in Rwandan HCs. Studies done in similar resource limited settings showed variation in professional backgrounds of cervical cancer screening and prevention service providers. Data from Malawi are similar to Rwanda where the majority of providers are of nursing background at 92.7% (13). Contrary to Rwanda and Malawi, in Kenya there are a variety of different professional backgrounds involved in cervical cancer screening and prevention services. A survey done in Kenya on cervical cancer screening and prevention providers found that 28% were clinicians (nurses or clinical officers), 56% were health educators (community clinical health assistants, community health workers, peer educators, counselors, mentor mothers, and volunteers) and 16% were ancillary staff (pharmacy, laboratory and cleaning staff). Each was involved at different levels of cervical cancer services such as the actual VIA/VILI screening, patient education or filling entry forms (14). Considering the current critical shortage of healthcare professionals in the developing world, this approach in Kenya of training clinicians and non-clinicians in the provision of cervical cancer care services needs to be replicated in other low-resource countries in need of establishing organized and working cervical cancer prevention programs14. In Rwanda, community health workers have contributed significantly to decreased maternal morbidity and mortality through increased adherence to prenatal care follow up and increased health facility deliveries(15). They could be of importance in increasing the uptake of cervical cancer screening services through community sensitization and follow up.
As discussed, the shortage of healthcare staff is still critical in Rwanda as well as other developing countries (16). The findings of this study also demonstrate the scarcity of staff trained in VIA cervical cancer screening at HC in Rwanda. Cervical cancer screening with VIA is the method recommended by WHO to be the most feasible and cost-effective in resource limited settings (2,17,18). We found that only 17.2% of the respondents reported to have received training on VIA screening and were distributed in 6 out of 10 HC included in the study. Although 75.9% of providers reported having at least one staff trained in VIA screening at their respective HC, 2 or fewer respondents at 9 out of the 10 HC studied reported to have received training on VIA cervical cancer screening. These findings are similar to other limited-resource countries where shortages of staff, specifically those trained in cervical cancer screening, are reported. The survey done in Kenya evaluating providers’ perceptions on barriers to cervical cancer screening found that 62% reported inadequate staffing as the primary barrier to cervical cancer service delivery and 60% reported the limited number of trained staff as the primary barrier (14). Similarly, findings in Malawi showed lack of readily available staff to offer cervical cancer screening and prevention services (13). There is a need to train more staff on VIA cervical cancer screening in order to establish a functional cervical cancer screening program.
Despite the necessity to perform a pelvic examination for cervical cancer screening or to evaluate symptoms suspicious for cervical cancer, 38.4% of respondents were not performing pelvic exam because they lacked experience and 27.9% because of lack of time. These findings are concerning considering that a speculum and or pelvic exam is the first evaluation necessary to detect cervical lesions or raise the suspicion of cervical cancer cases to be referred to the trained staff within the same HC or to a higher-level health facility for appropriate evaluation. These findings are supported by data from a study performed at Kigali University Teaching Hospital in Rwanda with patients who attended cervical cancer screening services, where they found that 95% of the patients were referred from a low-level health facility and 33% of them had no prior speculum evaluation despite their symptoms suspicious for cervical cancer(19). For addressing the lack of appropriate pelvic evaluation for patients in need, each HC should be equipped with a cervical cancer screening unit separate from other outpatient services with trained staff assigned to perform routine screening and evaluate those referred from fellow care providers.
The majority of respondents (69%) reported that cervical cancer screening is being offered at their HC. They reported that the basic equipment for screening service, including examination table, light source and speculums, were available (94.3%, 81.6% and 97.7%, respectively). Contrary to these findings, inadequate infrastructures and insufficient basic equipment and supplies are repeatedly reported to be among the challenges to cervical cancer screening in resource limited settings (13,14). Our study was limited in its design as it was based on participants’ responses and not able to assess the type and quality of cervical cancer screening services that are offered at the HCs. Specifically, we did not assess the quality, quantity and functional status of the facilities that were reported as sufficient. We believe an important next step would be to physically assess the quality and quantity of the equipment available for cervical cancer screening programs. There is need to avail enough equipment since lack of material for service provision is demotivating for women who would have presented for screening, and would have a negative effect on uptake of screening services even in sensitized community.
All of the respondents agreed that cervical cancer is a public health problem in Rwanda. Similar to other countries with limited resources such as Nigeria, health care providers in Rwanda also show awareness of cervical cancer as a public health issue, an important step in establishing cervical cancer screening and prevention services(20). However, their knowledge, skills and confidence level on offering cervical cancer prevention and detection services still need improvement. The present study found that 56.3% of participants had an adequate level (≥ 70%) of basic knowledge on cervical cancer presentation and the appropriate next step in evaluating for it. It would be expected that knowledge level of cervical cancer screening and prevention would be associated with professional background, education level, work experience or prior training in VIA cervical cancer screening. However, our study failed to find an association between these variables. These findings could be attributed to an overall lack of training of health care workers about cervical cancer or the lack of routine practice on cervical screening for the small number of providers who have received training on cervical cancer screening in the past. These findings reflect an almost non-existing cervical cancer screening program, putting almost all staff at the same level of knowledge, because even those who were trained or those who have many years of work experience have not been providing cervical cancer screening services.
This study highlights the existing gap in the number of healthcare providers with adequate knowledge and skills to provide cervical cancer screening and prevention services at health centers in Rwanda. As health centers are the first point of contact of the patients with the healthcare system, there is a need to empower them with both human resources and infrastructure if an effective cervical cancer prevention program is to be established. As providers are often overburdened with providing acute care, there is also a need to have a separate unit for cervical cancer screening at each health center to facilitate the provision of routine cervical cancer screening and evaluation of patients with symptoms suspicious for cervical cancer.
Cervical cancer is preventable and treatable with early detection and appropriate management(21). For its elimination, coordinated effort is needed to integrate a functional cervical cancer screening program into our health system and ensure that every woman over 30 years of age is screened and eventually treated for cervical precancerous lesions as we are called to by the WHO(21).