Process, resource and/or capacity barriers
Clinic team function.
Participants identified several challenges to positive clinic team function that may have have led to suboptimal cervical cancer screening rates in some clinics. These challenges included a lack of cooperation between MOH- and NGO-employed nurses. Some MOH-employed participants perceived that NGO-employed nurses were unwilling to provide other services (such as immunisation, antenatal care and treating minor ailments), citing that their role was only on screening.
“They always tell you that they have targets (screening targets) to meet. They do not help us push our antenatal care and immunisation lines; why should we bother ourselves with screening?” – P 3.
This led to some MOH-employed nurses being reluctant to perform screening, believing that NGO-employed nurses were primarily responsible for this service.
“Government nurses think screening is for the nurses employed by the partners [NGOs], not them. As such, if the nurse employed by the partner is on leave, there will be no service provision until she returns.” – P 6.
Poor within-clinic linkage of clients to screening services emerged as a clinic team challenge affecting continuity of care. Participants noted that this deficiency led to some clients being unaware of available services and others struggling to locate them within the clinic.
“Because we do not work as a team, our clients are often stranded at the clinic. No one tells them about the service and some fail to locate our screening rooms on screening nurse and end up going back home.” – P 12.
The lack of cooperation between MOH- and NGO-employed nurses was attributed to differences in reporting structures, priorities, and pay. Participants noted a pay discrepancy, with NGO-employed nurses receiving higher salaries than MOH-employed nurses. This pay discrepancy reinforced the reluctance among MOH-employed nurses to conduct screening, as they felt undervalued and unfairly compensated for their work.
“They (MOH-employed nurses) always say since we are paid to do screening, even paid more than they get, we should do all the screening.” – P 6.
“Our priorities and different. Another thing, why would I bother when there is someone employed and paid well to do just screening.” – P 14.
Participants recognised the potential to promote screening among clients attending other clinic services, like child immunisation. However, due to poor processes, this opportunity was seldom utilised. In clinics with separate screening departments, nurses from other departments, such as antenatal care and antiretroviral treatment, rarely introduced screening or referred clients to the screening department.
"Patients slip through without being screened because the responsibility is overlooked. Patients are not always informed to go to the cervical cancer screening room during their visits for other services."– Participant 19.
Some participants suggested that implementing a triage system and guiding clients between clinic departments would ensure that clients are linked to appropriate screening services.
“Of late, we developed a tool that will enable us to screen women on arrival, if they are eligible for cervical cancer screening so that they can know where to go and what services they need to get.” – P 18.
Other participants suggested that service integration could help clients get “all the services they need from one nurse.” – P 19.
“I feel it is better to integrate because it allows us to offer all the services that a client may need. With disintegrated care, it is easy to miss clients. So, it is better to integrate.” – P 20.
Participants suggested that regional coordinators could also help resolve the issues related to reporting structures and priorities by aligning the differences between MOH and NGO-employed nurses.
“Regional coordinators would help organise, coordinate, and guide the program’s implementation. They would be the middleman between us, partners, and the Ministry.” – P 2.
Staff shortages.
Participants reported staff shortages across clinics, which included both temporary and long-term shortages.
“When one staff member is on leave or attending a workshop, this department suffers the most. It is difficult to leave the outpatient department without staff but have them working in the screening department. In most cases, nurses are reassigned from screening to other departments.” – P 1.
“Ideally, a clinic is supposed to have four to five permanent nursing staff. However, with the perennial shortage in the public sector, you find that two to three nurses run a clinic.” – P 10.
Screening was often deprioritised due to long-term staff shortages and competing client health needs, such as infectious diseases, family planning, and immunisation.
“As screening competes with other priorities at the clinic, there is a need to convince nurses that screening is no less important than other services. Programs like expanded program on immunisation, antenatal care and recently, coronavirus are a priority.” – P 2.
All participants reported that staff shortages increased their workload, leading to feelings of fatigue and burnout. Nurses experienced dissatisfaction, lack of motivation, often acted impolitely, and some considered job transfers.
“The work is a lot because we do not even have a pharmacist, so the nurses must dispense medications themselves. I feel like we all suffer from exhaustion. Sometimes we easily get angry at the clients.” P 14.
Some NGO-employed nurses expressed that their workload and burnout experience could be worse than MOH-employed colleagues since there was limited opportunity for job variation. The opportunity for job variation was considered to increase job satisfaction and motivation.
“I am always conducting screening as I work for NGO [de-identified]. Doing the same thing over and over is sometimes exhausting, especially if you have no one to give you a break or at least assist. The sad thing is that I am expected to assist, yet they never assist me.” – Participant 13.
“The workload is a challenge. I sometimes suffer from burnout because I do the same thing every day. I feel like I am not growing professionally.” – Participant 8.
Participants reported that some staff lacked knowledge and skills to effectively deliver cervical cancer screening services. This was particularly evident in some participants lacked confidence in providing screening and treatment services. Some always required a second opinion to interpret screening results and/or assistance in providing treatment for pre-cancerous lesions.
“I am not happy to enter discussions (with clients) about cervical cancer screening, conducting screening and doing cryotherapy without the assistance of nurse X. He is very knowledgeable about cervical cancer screening.” – P 6.
“Some nurses always need a second opinion when judging the client’s diagnosis. Experienced nurses are forced to leave their lines (stop attending to the clients) and come and assist. That contributes to our inefficiency” – P 14.
The lack of skills was also evident in "delivering bad news," as many nurses felt uncomfortable or unprepared to discuss positive screening results with women.
“What becomes a problem is breaking the bad news to the clients once abnormalities are detected.” – P 3.
Some participants suggested that explaining the screening procedure to women before undertaking it could be a potential solution to the challenge of breaking bad news. This approach would enable women to comprehend the risks and benefits of the screening procedure. When patients have a clear understanding of the potential outcomes, risks and treatment options, they are better prepared for any potential bad news and are more likely to accept the results.
“What usually helps me is that I educate every woman before I do the actual screening…on what cervical cancer is, what the screening is, and the possible result. I explain what pre-cancerous means before doing the screening. Then, I tell the client about the possible treatment options for pre-cancerous lesions. So, the minute we get a positive result, the client would understand what is going on.” – Participant 5.
Participants’ lack of knowledge, skills and confidence was attributed to inadequate training on cervical cancer screening.
“We lack in screening knowledge and skills because we are still waiting to be trained. You cannot expect someone not capacitated to disseminate information or do something they are unsure of.” – P 18.
“Nurses are not trained. It is easier for nurses to encourage clients to partake in the screening once they have been trained.” – P 11.
Few nurses reported being formally trained in screening. Participants indicated that the MOH and/or NGOs typically send a single nurse to undergo formal cervical cancer screening training. It was usually expected that this nurse would return to their clinic and train the other nurses on how to undertake cervical screening. However, according to most participants, this seldom occurred, and trained nurses carried out all screening duties for the entire clinic.
“In a facility, one person is usually trained to conduct screening. It becomes their baby, with the others always lacking back. They always want to be reminded about cervical cancer screening; they do not take the initiative. It is so tiring” – P 7.
Participants expressed concerns about the increased responsibility and burden that tended to be imposed on the trained nurses. All trained participants voiced a sense of being overwhelmed by their workload, which was perceived as “unbearable.” – P 19.
“Screening becomes your baby (as a trained nurse), which is overwhelming. When you are not around or sick, no one will provide the service. Clients are deprived of the service.” – P 8.
Participants perceived off-site training as more effective than on-site training because it was longer and offered more practice opportunities. Off-site training typically lasted one to two weeks and included classroom lectures and off-site clerkships. Conversely, on-site training was delivered to staff in a specific clinic over a few hours, by mentors or colleagues who had attended off-site training.
“Off-site training is in-depth and usually conducted by knowledgeable people. There is ample time to learn as they last around seven days…One has an opportunity to see real-life pre-cancerous and cervical cancer cases. All these are not usually included in on-site training.” – P 13.
Shortage of equipment and supplies.
Nearly all participants identified a general shortage of equipment and supplies, including speculums, forceps, gloves, cotton wools and cryotherapy, as a significant barrier to optimising the delivery of screening in their respective clinics.
“We do not have enough speculums; if 20 clients came for screening in one day, we would not be able to screen all of them.” – P 5.
“We do not have equipment for cryotherapy, which a nurse can conduct (cryotherapy). Additionally, there is a shortage of pap smear equipment typically used to screen post-menopausal women..” – P 20.
The shortage of equipment not only limited service provision but also served as a significant barrier to implementing certain interventions, such as service integration, which some participants suggested as a way to optimise screening.
“It (service integration) can be difficult for the nurses because we cannot spread equipment across all the consultation rooms; we will not have enough.” – P 20.
Participants reported that equipment shortages were often due to maintenance and hygiene issues. For example, when equipment broke down, it was not repaired promptly. Subpar hygiene practices, such as delayed washing and failure to dry washed instruments, led to equipment becoming rusty and unusable.
“We have cryotherapy equipment. The challenge is that it is not functional. A whole year has elapsed, and the equipment has not been fixed.” – P 4.
“There was an instance when I opened a pack of sterilised instruments and found that the instruments were rusty and unusable. So, our major challenge at this clinic relates to instruments.” – P 9.
Systems to support service delivery.
Participants working in clinics without NGO support reported that they lacked electronic and paper-based record-keeping systems. This meant that they had to rely on notebooks to track screened and scheduled clients, which led to challenges in scheduling and monitoring those due for screening. The lack of scheduling capabilities resulted in long waiting times when multiple clients arrived simultaneously for screening. Poor record-keeping also left nurses unaware of the number of women needing screening in their clinics.
“We do not have an appointment system, paper-based or electronic. We end up using notebooks, which often get lost. As a result, we cannot track whether women keep their screening dates.” – P 9.
“Clients come for screening without being appointed. They are not to blame; we do not have registers to appoint them so that we can regulate their numbers. This becomes a problem when they all show up at the same time. They overwhelm us and complain that we make them wait for extended periods.” – P 1.
Client-related barriers to equity of access to screening hinder nurses' efforts to provide cervical cancer screening services.
Participants believed that equity of access was vital for ensuring that all women, regardless of socio-economic status or background, would receive timely screening when needed. However, existing barriers to equity of access made it challenging for nurses to offer screening to a broader population.
“Because of certain issues, not all woman a fair chance to participate in screening and safeguard their health and well-being.” – P 4.
“If patients cannot easily access the clinic due to a lack of bus-fare, nurses may not be able to reach a significant portion of the target population for screening.” – P 11.
Barriers to the availability of screening.
Participants reported that the MOH relied on NGOs to drive cervical cancer screening. However, as most NGOs focused on HIV-related programs, they provided support primarily to clinics in areas with high HIV prevalence. This resulted in a lack of adequate resources and attention in regions with lower HIV prevalence, which hindered nurses’ ability to reach and provide equitable screening services to all women.
“Clinics are supported with extra nurses depending on the number of HIV patients they see and how big the catchment area is.” – P 15.
In some NGO-supported clinics, cervical cancer screening was not available to HIV-negative clients. Nurses’ performance in these clinics was evaluated solely on their ability to meet screening targets for HIV-positive clients.
“We do not screen HIV-negative women because we get appraised based on the total number of HIV-positive women we screen per month. My employer aims to get more HIV-positive women screened, so they are not interested in knowing how many HIV-negative women were tested in a month.” – P 8.
Many participants indicated that clinics with higher rates of precancerous lesions were prioritised and provided with cryotherapy equipment and supplies. As a result, participants from clinics with lower rates of precancerous cell cases had to refer their clients to other clinics and regional hospitals.
“Facilities that offer treatment were prioritised according to their positivity rate. Clinics with high positivity rates were provided with cryotherapy equipment.” – P 10.
Another factor that determined the availability of screening services was the remoteness of the clinic catchment area. Participants reported that most clinics in remote areas did not have treatment services. As a result, women needing cryotherapy or other advanced treatment modalities had to travel to other clinics or regional hospitals.
“Clients in remote areas are less privileged. They do not have clinics. Even when they have a clinic, it offers screening without cryotherapy.” P14.
Participants reported that each of the four regions of Eswatini was supported by a different NGO, and in some cases, two NGOs. Each NGO had its own model of care, leading to a lack of uniformity in cervical cancer screening and treatment approaches across the country. As a consequence, there were disparities in the availability of screening and treatment services among clinics in Eswatini.
“Some clinics offer cryotherapy within the facility. My clinic refers clients to other facilities because we do not have cryotherapy. Our partner did not support us with treatment equipment.” – P 20.
Barriers to the accessibility of screening
Limited human resources negatively affected accessibility, as screening services were "rationed" (P 14) due to this constraint. Many clinics were only open on specific days to offer screening services, leading to reduced availability throughout the week.
“We offer screening on Fridays. If a woman comes on a Tuesday, for example, we turn them back.” – P 19.
Participants also perceived that long wait times at regional hospitals were a barrier to clients attending referral appointments.
“They must join long queues when they get there (regional hospitals), which frustrates them. They miss buses to take them home.” – P 2.
“They expect to be attended first. Unfortunately, that is not always the case. Also, they complain that they do not get same-day treatment. Instead, they are booked to be treated on another day. They will tell you: I do not have money to return for my appointment, so I’m not going.” – P 7.
Participants expressed concern about clients' reluctance to be screened by male and younger nurses, which created additional barriers to screening accessibility.
“We leave screening to our female colleagues. Women generally do not want to be screened by us. It gets complicated when an older woman walks in. They do not want to be screened by younger nurses, female or male. They feel embarrassed. Maybe it is because of our culture.” – P 11.
Barriers to affordability of screening
While cervical cancer screening was free across public clinics in Eswatini, participants reported barriers such as the cost of bus fare to access further investigation and treatment services in regional hospitals.
“Many times, they won’t go because they have no bus fare to travel to the next level of the health system.” – P 3.
“Most people in this community are poor. They don’t have money. So, if I mention that they must go to Siteki (a referral hospital), they just go back home. It is a problem for them. Sometimes it depresses us. We end up paying for their bus fare.” – P 9.
Barriers to acceptability of screening
Most participants pointed out that a significant number of Eswatini women showed a lack of interest in screening. This lack of interest stemmed from a lack of awareness regarding the importance of screening. Negative past screening experiences and perceptions further contributed to the lack of interest. For instance, some women feared potential stigmatisation if they were seen going to the HIV treatment unit, where screening is typically offered. This fear was particularly pronounced among HIV-negative clients.
“Sometimes you tell women about screening, and they just show no interest.” – P 2.
“Daily, before we start refilling their medication, we teach HIV-positive women about cervical cancer…. We cannot reach HIV-negative women. I am sure they do not know they should screen for cervical cancer. They are clueless about cervical cancer and screening.” – P 14.
“The provision of screening services within antiretroviral treatment departments may discourage some HIV-negative women from getting screened.” – P 6.
Additionally, participants noted that some clients attributed long waiting times to nurses' perceived laziness and poor work ethic. These negative perceptions were thought to contribute to poor nurse-client relationships and discourage clients from seeking screening services.
“We lose many clients because of the long queues and waiting times. Unfortunately, they think we just sit in the consultation rooms and be busy on our phones. It is a pity that we end up being labelled as lazy and not having a caring heart.” – P 20.
Participants observed that nurses provided minimal screening-related health education, limited to one-on-one conversations with clients seeking primary healthcare at the clinic.
“We do not conduct enough health talks; women do not get to hear about screening every time they come to the clinic. We do not have the time for it. It is hectic here” – P 12.
Participants recognised the necessity for increased health education to effectively communicate the importance of screening. They identified insufficient or inconsistent outreach campaigns and limited access to, or distribution of, educational materials as contributing factors to the lack of knowledge and negative perceptions surrounding screening.
“Healthcare workers are not teaching patients in communities about the importance of cervical cancer screening. That is why they feel like it is unimportant.” – P 15.
“Another thing would be to have enough information, education and communication material to give to the clients so that they can read on their own.” – P 17.
Most participants considered current community-based health education strategies ineffective, particularly because the most utilised form was through radio dissemination and other methods primarily focused on urban areas.
“The Eswatini Ministry of Health must not focus on teaching on the radio. No one listens to the radio these days. People only listen to the news; it is not helping anyone.” – P 9.
“…I am saying this because most of the campaigns are being done in towns, not in the communities, yet there are people in the communities.” – P 17.