- Title
- Improving cervical screening participation in Eswatini
- Creator
- Khumalo, Phinda Goodwill
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2023
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- Despite being highly preventable, cervical cancer is a major public health problem in the Kingdom of Eswatini (formerly named Swaziland) in sub-Saharan Africa. Eswatini has the highest incidence rate of cervical cancer in the world, and cervical cancer is the leading cause of death among Eswatini women aged 15-44. The principal cervical cancer prevention method implemented in Eswatini is an opportunistic screening program using cervical visual inspection with acetic acid as the recommended screening technique. Screening is recommended every two years for human immunodeficiency virus-negative (HIV-negative) women and annually for human immunodeficiency virus-positive (HIV-positive) women. Community health workers and nurses are the driving force behind the opportunistic cervical cancer screening program in Eswatini. The community health workers’ role is to encourage eligible women to visit healthcare clinics for screening. Nurses run healthcare clinics where the majority of screening takes place in Eswatini. Despite the proven benefits of cervical cancer screening, data from two previous studies in Eswatini suggest that only between 5% and 29% of eligible women have ever been screened. Simply considering the history of ever-screening leads to overestimations of screening participation. This thesis extends the findings of past studies by examining adherence to cervical cancer screening recommendations for HIV-negative and HIV-positive women in Eswatini (rather than just considering the history of having ever been screened). It also explores factors that may be associated with cervical cancer screening knowledge and barriers to participation. This thesis-by-publication comprises eight chapters. Chapter one presents the introduction to the thesis, background, overview, and aims. The background provides information about cervical cancer and its risk factors. Cervical-cancer-related incidence and mortality are described from global, regional and national (Eswatini) perspectives. Vaccination against human papillomavirus and cervical cancer screening are described, along with points of difference in cervical cancer prevention between developed and developing countries. The World Health Organization (WHO) cervical screening guidelines and the guidelines adapted for the Eswatini context are described. Cervical cancer screening participation in sub-Saharan Africa and Eswatini, in particular, is described. Further, the Capability, Opportunity, Motivation, Behaviour (COM-B) model is described and used to summarise the literature on factors influencing cervical cancer screening participation within the sub-Saharan African region. Chapter two reports the results of a telephone survey of 172 community health workers in Eswatini, assessing knowledge regarding cervical cancer screening. Factors associated with community health workers’ knowledge are also explored. Knowledge deficits were identified, especially regarding cervical cancer risk factors, the meaning of screening results, and Eswatini cervical cancer screening guidelines. Community health workers aged 46–55 were more likely to have a higher cervical cancer screening knowledge score than those aged 30–45 years. Chapter three reports a cross-sectional survey among 377 women aged 25–59 selected from four primary healthcare clinics in Eswatini. Knowledge (and associated factors) regarding cervical cancer screening were assessed. Sixty-one percent of the participants answered 80% or more knowledge questions correctly. Compared with HIV-positive participants, HIV-negative participants had 0.61 times lower knowledge scores. Participants who travelled more than 30 minutes to the clinic had 0.3 times lower knowledge scores than those who travelled less than 30 minutes. Chapter four presents further results from the telephone survey of 172 community health workers (outlined in chapter 2). The study examined community health workers’ views regarding nine barriers to discussing cervical cancer screening, derived from previous health promotion research, with women eligible for screening. The study also explored factors associated with endorsing a greater number of barriers. Highly endorsed barriers included perceived inability to convince women to undertake screening, insufficient time to discuss screening, lack of confidence in discussing screening with older women, and lack of interest in screening advice on the part of women. Community health workers with at least some secondary school level education endorsed 40% more barriers than those without secondary school level education. Community health workers in Lubombo and Shiselweni endorsed 47% and 35% fewer barriers, respectively, than community health workers in Hhohho. Chapter five reports the results of a qualitative study involving in-depth interviews with 20 nurses recruited from 20 healthcare clinics across Eswatini’s four geographic regions. Barriers and enablers were discussed. The following themes were identified: the need for improved engagement and leadership by the Ministry of Health, process and resource barriers, the need for strengthening organisational support for improving nurses’ skills and performance, and the need for improving equity of access to screening. Chapter six presents additional results from the cross-sectional survey of 377 women aged 25–59, recruited from four primary healthcare clinics in Eswatini, outlined in chapter 3. The study examined adherence to cervical cancer screening recommendations and attitudes toward cervical cancer screening. The study also assessed the extent to which knowledge, attitudes, and sociodemographic factors were associated with adherence to screening recommendations. One hundred and sixty-six women (44%) were classified as adherent to cervical cancer screening recommendations. Participants had higher odds of being classified as non-adherent if they were aged 56 years or older compared with those aged 25–35 years, perceived screening as likely to be painful, had not been advised by a doctor or nurse to screen, had up to secondary or high school education compared with up to primary school education, and were single compared with married. Chapter seven presents a review of trends in sub-Saharan African cervical cancer screening-related research between 2001 and 2020. The study found that no measurement studies (those that involve the development and validation of measurement instruments) were recorded, and the bulk of studies that involved collecting data from a sample of participants (89%) were descriptive studies. Key findings from chapters two to seven are organised using the COM-B model and discussed in chapter eight. Chapter eight also presents an analysis of the strengths and limitations of the thesis, recommendations about future research, and a conclusion summarising the main findings of this thesis. This thesis suggests that adherence to Eswatini cervical cancer screening recommendations participation is low, estimated at 46%. This level of screening participation is still better than the “ever-screened” data from two previous studies suggesting that only 5% and 29% of eligible women had ever been screened. This thesis also highlights several factors associated with poor screening participation in Eswatini. Chapters two and three reported significant knowledge deficits regarding cervical cancer risk factors, the meaning of screening results, and Eswatini cervical cancer screening guidelines among community health workers and women. Chapter four reports that 53% of community health workers perceived that they could not convince eligible women to screen. Chapter five identified structural and screening-delivery system factors influencing nurses’ screening-delivery behaviours. They include the Ministry of Health’s limited leadership and engagement in screening delivery, process and resource barriers, a lack of organisational support for improving nurses’ skills and performance, and issues around equity of access to screening. Chapter seven found that from 2001 to 2020, only 11% of sub-Saharan African data-based publications were intervention studies. To advance cervical cancer elimination in Eswatini, this thesis proposes a comprehensive approach that encompasses tailored interventions targeting both intrinsic and extrinsic barriers to screening participation. Key components of this approach include enhancing health worker training, ensuring equitable access to screening services, and strengthening the overall health system. This can be achieved through increased engagement from the Ministry of Health, providing improved support for nurses, and addressing resource challenges. Additionally, prioritising intervention research is crucial. By addressing these elements, Eswatini can greatly enhance screening participation and make significant progress towards achieving the global objective of cervical cancer elimination.
- Subject
- uterine cervical neoplasms; prevention; screening; Eswatini
- Identifier
- http://hdl.handle.net/1959.13/1496517
- Identifier
- uon:54171
- Rights
- Copyright 2023 Phinda Goodwill Khumalo
- Language
- eng
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