Table 2 Barriers and facilitators to cervical cancer screening implementation, using the Integrated Behavioral Model (IBM)
IBM construct | Barriers | Facilitators and strategies to overcome barriers |
|---|---|---|
Attitudes | Patient attitudes: “Why go to the hospital if I am healthy?” contributes to low patient flow/demand of services Patient attitudes: Low awareness and misconceptions Gender and religion were cited as factors that shape patient attitudes about screening Provider attitudes: “Why screen if we don’t have the cryotherapy machine?” prevents facilities from offering screening until the material arrives Provider attitude: “What happens if she has cervical cancer? We are afraid to screen because then we have to treat.” Lack of treatment options, long time from diagnosis to treatment, and poor prognosis are demotivating factors | Mass media awareness raising campaigns can promote preventive care seeking Providers feel that they are able to overcome misconceptions with proper counselling Have female health workers available to screen and consider gender and religion when counselling Strong referral networks can be used to screen at one facility and conduct cryotherapy at another Provider experience: Seeing women suffer from advanced cervical cancer was a strong motivating factor Provider perspective: Knowing that cervical cancer is preventable was a strong motivating factor to offer screening |
Experiential (feelings about behavior) | ||
Instrumental (behavioral beliefs) | ||
Norms | Lack of monitoring and evaluation (M&E) made providers feel like there was low accountability to actually screen after receiving training Providers expressed that cervical screening was a service they offered in their “extra time” without additional incentive, not their primary job function The success of a screening clinic is highly dependent on the motivation of one or a few individuals Sometimes male partners were engaged in a woman’s medical decision-making, concern over male partner approval was especially relevant for cryotherapy as sex is prohibited for some time after | Government support for the issue at the national level created positive expectations to offer screening which could be enhanced by M&E Administration that prioritizes the service can offer incentives and assign workers to the screening clinic to ensure adequate coverage Providers with high motivation to offer screening should be selected to receive the training Male partners can be strategically engaged to improve screening norms Screened women can offer peer support and education for other women |
Injunctive (others’ expectations) | ||
Descriptive (others’ behaviors) | ||
Personal agency | Environmental constraints such as lack of materials and space were major limiting factors Perspective: Things happen at the “good will of the Ministry of Health” Policy can be influenced by personal and political motives, not evidence-based Poor coordination between facilities and local, regional, and federal government can hinder progress Other job duties make it difficult to prioritize cervical screening, providers too busy with acute care duties | Some providers overcame environmental constraints by borrowing materials from other units or facilities or paid for supplies out-of-pocket Consistent funding, training, oversight, and policy are needed for steady growth of services Providers wanted to be consulted by the Ministry and have a greater voice in policy-making Creation of professional organizations, task forces, and committees can create space for more diverse voices, representation, and collective action Building strong patient rapport allowed providers to overcome low community awareness |
Perceived control | ||
Self-efficacy | ||
Knowledge and skills to perform screening | Some cadres of health workers may be more or less equipped to offer cervical screening Training varied greatly from a two-day orientation to a three-week intensive skill-based training with a practical attachment at a hospital Confidence to perform screening decreased over long periods of time between training and initiation of screening services | Midwives were viewed as especially proficient, emergency surgeons were not preferred Training should be standardized Refresher training should be made available: |
Salience of behavior and Habit | Changing political landscapes can disrupt progress Declining patient flow over time was a demotivating factor | When the former First Lady championed the cause, attention was garnered for cervical cancer with some lasting effects Steady patient flow, through collaboration with Health Extension Workers and community-based education, motivated screening clinics to continue providing the service |
Environmental constraints | Human resources High turn-over of providers and Medical Directors Screening centers are understaffed Space and infrastructure Inadequate space or no room available to screen Inadequate privacy or cleanliness in available space Materials No cryotherapy machine received, distribution issues Tips for the cryotherapy machine were limited in size and easily damaged (not easily replaced) Other materials (speculum, acetic acid, examination table) were also difficult to procure | Human resources Training more than 1–2 providers in each facility to offer screening means that screening can continue if a single provider leaves or is off-duty Space and infrastructure Providers screen at night to maximize privacy Providers offer mobile screening service, taking materials to another space in the hospital Materials Having spare parts, such as tips, available could facilitate maintenance over time Providers procured materials (i.e. speculum) from other units or facilities Providers purchased their own acetic acid Some facilities were able to redirect funds to purchase some supplies such as gloves Other VIA was viewed as an appropriate screening method because it considered environmental constraints |