Five FGDs were conducted with 30 women (14 urban and 16 rural). In terms of the reasons for visiting the sites, 15 came specifically for cervical cancer screening, while the others came for other reasons (2 women working in the cleaning company, 2 women working as accountants, 6 women were accompanying their patients, 5 were there for other health reasons). The mean age was 39 years.
Qualitative data were classified into 3 different themes: knowledge about cervical cancer, barriers to the use or adoption of screening services, and motivation to use screening services. Each theme had subthemes as summarized in Table 1.
Knowledge about cervical cancer
Existence of cervical cancer
The existence of cervical cancer was reported in all FGD. Women in the FDG showed awareness of risk factors, symptoms, and treatment options by the following expressions:
‘’Cervical cancer can mostly affect women in childbearing age…., or those who start having sex at an earlier age, among symptoms I know that someone may have persistent menses’’ (#4, urban, age 45)
‘’Cervical cancer may be caused by becoming pregnant at an earlier age or by having too many babies, ‘’ (#1, urban, age 36)
‘’my friend had cervical cancer and told me that it is the most painful disease.’’ (#12, urban, age 33)
Examples of lack of knowledge about cervical cancer were expressed in statements such as:
‘’ I did not know that cervical cancer is related to having sexual intercourse, … I was thinking that it could be a disease like the most common disease’’ (#2, urban, age 40).
Lack of knowledge can also be detected in such questions as:
Does cervical cancer have signs/symptoms that we can recognize and go for screening? (#29, rural, age 37)
Existence of cervical cancer prevention and screening
Women understood how cervical cancer is screened. Some women also knew how cervical cancer could be prevented by using HPV vaccines, use of condoms, and limitation of the number of sex partners
‘’you can do prevention by not involving in prostitution, or by going for consultation as earlier as possible’’ (#21, rural, age 46)
‘’you can use condoms when having sexual intercourse,’’ (#7, urban, age 34)
‘’I knew, through radio and television broadcast, that screening for cervical cancer is being done but I did not know where to go for screening.’’ (#9, urban, age 39)
Barriers to cervical cancer screening:
The major barriers identified include the following:
1. Fear of pain, especially during speculum insertion and removal:
‘’I thought about going to screening many times, but I always had fear of pain, … even in the past time I went to a screening area where the campaign for cervical cancer screening was being done but because of fear of the pain I did not yet participate in screening’’ (#13, urban, age 40)
‘’I always had fear of pain even though today I came for screening, I come with reluctance because of fear for pain’’ (#6, urban, age 38)
“I thought about going for screening but once I heard that it is painful, I decided not to go (#19, rural, age 36)
‘’I know nothing about cervical cancer screening but those who went for it told me that the procedure is painful’’. (#2, urban, age 40)
Concerning fear for the pain two women suggested that:
‘’I can suggest the use of anaesthesia during screening because the procedure is painful, even though I do not know if it is possible to use anaesthesia’’ (#10, urban, age 39)
‘’I am afraid that the procedure is painful and I am asking myself if there is no other way of screening for cervical cancer, for example by using imaging tool or ultrasound’’ (#17 rural, age 46)
2. Privacy concerns especially discomfort with exposure of private parts during the procedure:
‘’Let’s consider a not yet married female (a girl) with no prior experience of giving childbirth, she is very concerned with her privacy, she may have shyness, … There is no other way of doing screening without exposing private part of the body?’’ (#26, rural, age 58)
Another woman asked about alternative procedures that would not require exposure.
‘’Can you use other technics for screening like ultrasound or by testing through blood?’’ (#6, urban, age 38)
3. Financial issues which prevented them from screening, such as the lack of health insurance, unaffordable consultation fees, and other medical expenses.
‘’I had a desire for screening but because of lack of health insurance, I waited until I got it’’ (#11, urban, age 41)
4. Other barriers include the long-distance from the testing site, lack of services nearby, inadequate information about the location of screening services, and other administrative problems such as not having enough testing materials and confusion about screening eligibility
‘’When I reached the screening service, they told me that the screening tools were not available and they advised me to come back at another time’’ (#23, rural, age 35)
‘’ I had a desire for cervical cancer screening for a long time but I could not know where I can get screening services’’ (#9, urban, age 39)
“I came for cervical cancer screening in past time but nurses told me that they can not do screening for me because I was less than 30 years old. Now as I have reached 30 years, I am back at the health center and am happy that now they will do a screening for me!”(#22, rural, age 30)
Another woman was afraid that she might be too old because she was 59 years old, but was reassured by the nurse that she was eligible to be screened.
None of the women expressed religious beliefs or familial reasons as barriers to attending cancer screening services. However, one female insisted that she would not attend cervical cancer screening because she was a widow:
‘’Because I do not have a husband … and as are the males who bring cancer to the females… and I had my way, I do abstinence, therefore, I think that there is no reason that I have to go for screening, but in case I have signs/symptoms I will go for consultation’’ (#30, rural, age 46.)
Motivators for use of cervical cancer screening services
Government and healthcare providers’ role
The current study found that the main motivator cited for using screening services was from government promotion through different channels including mobile phones, radios and television broadcasts, and local leaders. Individual health care providers also helped.
‘’Even today I received an SMS (short message service) advertising for cervical cancer screening’’ (24, rural, age 42)
‘’When we come for antenatal care or the health of our children, nurses sensitize us about cervical cancer screening,’’ (#7, urban, age 34)
Friends and family members or familial history of cancer
Women whose family members or relatives or friends had previously been screened for cervical cancer or had a history of cancer were motivated to seek screening services.
‘’I come because I had my grand sister who had cervical cancer’’ (# 25, rural, age 42)
‘’My friend had many times advised me to go for cervical cancer screening.’’(#10, urban, age 39)
‘’My daughter has cervical cancer before she did not know that it was cancer and she was seriously ill weighing like 20 kg but after we consult different hospitals, she received treatment and she is doing well with about more than 50 kg, she is now healthy’’. (# 26., rural, age 58)
‘’After my mother died of cervical cancer, I thought about cervical cancer screening but I did not yet come because I did not have insurance.’’(#18, rural, age 36)
Personal reason: early treatment and quick recovery
A few women reported that they decided to go for cervical cancer screening on their own without any external motivators. They thought that they were increasing the recovery chances if the results were positive.
‘’When you go for screening, if you have illness they will treat you as earlier as possible and you will be cured. And if they find that you do not have cancer, they will teach you more about how to do prevention’’ (# 5, urban, age 46)
Cervical cancer screening in Rwanda: insight from the key informant.
We identified one senior officer from the non-communicable diseases division of Rwanda biomedical center of the Ministry of health who served as a key informant. His views are summarized below
The current situation on cervical cancer screening
‘’The statistics show that we still have a low number of people who come for cervical cancer screening. But the screening service is also at its earliest stage. We have now done training of health care providers in half of the health centers countrywide. In 2013 we did a screening campaign in 5 out of 30 districts and we did a screening of 10,000 people using HPV testing kits. In 2014 we changed our approach to using visual inspection of the cervix with acetic acid (VIA) because of a financial barrier. As VIA needs further training, we did a training until 2018.
Since 2020, besides VIA we are also using HPV DNA test for which we started with 3 districts. If a test is positive, we do VIA and if positive we do treatment with thermo-ablation. The most challenge is the low rate of training of health personnel because you can not avail devices without trained people to use them. And we need to train people to be able to do the basic treatment (thermo-ablation) of VIA positive cases at health center level’’.
Barriers to reaching the goal
Among the major barriers mentioned by the key informant were the issues of lab consumables and reagents as screening services are not covered by health insurance companies.
‘’We are also facing the issue of consumables/reagents because screening services are not reimbursed by health insurance companies in our country. But we are doing our best to work together with insurance companies and explain to them why it is better to invest in screening services: they have to think about the price of screening which is around 1000-1500RWF (1 to 1.5 USD) and the price that they will pay in future if someone is having cervical cancer because she has not been screened. The major message is that insurance companies must not think about the premium of the client within one year of insurance but within 30 years later on’’.
Key factors for more success
When queried about key factors to make screening program successful, two main important ideas were raised:
‘’We need collaboration from lower level to high level…., Cervical cancer screening campaign approach looks more productive/ effective than routine screening because for routine screening women are procrastinating due to their daily work. Campaign periods target a lot of people but we use HPV DNA test which cost 8–15 USD for one female and this cost is high as we target about 1.5 million for the entire country to reach the World health organization (WHO)’s target of cervical cancer elimination by 2030’’.
We investigated how the number of women attending /seeking cervical cancer screening services can be increased and if there is no problem with the referral system and we found that women have the will to attend these services but the problem could be found elsewhere as it is stated below:
‘’The problem is not limited to females only because they are eager to come for screening especially during community outreach strategies and females transmit the message to their neighbours/ friends. Therefore, there is a need to avail services at their nearest health facilities and involve community health workers (CHW) and media to increase the awareness of cancer existence, prevention, and screening program. We must also increase the number of trained health care providers, number of community outreach activities because, during this period, females attend the screening services with a reduction of cost and do all possible to attend the screening.