Strategies to enhance the implementation of the Ethiopian national guidelines for cervical cancer screening among women in Ethiopia

Abstract

Background: An estimated 80% of cancer patients in developing countries present with advanced stage of cancer at their first visit to health care facilities. According to, WHO in 2022, an estimated 660 000 women were diagnosed with cervical cancer worldwide and about 350 000 women died from the disease. Effective primary which is HPV vaccination, awareness of cervical cancer and secondary prevention approaches; screening for, and treating precancerous lesions will prevent most cervical cancer cases (WHO 2020:8). When diagnosed, cervical cancer is one of the most successfully treatable forms of cancer, as long as it is detected early and managed effectively. With a comprehensive approach including implementing the national cervical cancer screening guideline throughout all health facilities to follow the primary, secondary and tertiary prevention for, cervical cancer prevention, screen and treat cervical malignancy can be eliminated as a public health problem within a generation. Cervical cancer affects an estimated 22 million women over the age of 15 worldwide, accounting for 25.8% to 32% of all female cancers. Each year, 6294 women are diagnosed with cervical cancer, with 4884 dying as a result (Bruni et al 2019: 9). Cervical cancer is the most common cancer in Ethiopia, accounting for 13.4% of all malignancies, and women account for around two-thirds of all cancer deaths. Only 0.6% of Ethiopian women aged 18 to 69 were screened for cervical cancer (FMOH:2020:12). This indicated that in Ethiopia cervical cancer screening uptake is very low and majority of the women don’t have an access or lack information about the disease in furthermore, most of the prevention methods primary, secondary and tertiary prevention were not implemented as recommended by the national guideline throughout the health facilities.Therefore, the purpose of this research was to develop strategies to enhance the implementation of the Ethiopian National Cervical Cancer Screening Guidelines among women in Ethiopia. Methods and material: Mixed method approach with sequential explanatory design was employed. Fourteen cervical cancer screening health facilities were identified with simple random sampling method from the two regions of the country the study has three phases. Phase one quantitative data was obtained through a validated checklist adapted from the National Cervical Cancer Screening Guidelines to obtain data from fourteen managers of selected health centres furthermore; observation was made on cervical cancer screening logbook, health education registry and VIA result registration books to collect cervical cancer screening service statistics data. Descriptive statistics was employed to analyse quantitative data. Phase two qualitative study phenomenological qualitative design was employed, fourteen focus group discussions with health workers and twenty-eight in-depth interview were conducted with women. Semi structured open ended focus group and in-depth interview guide was developed to collect qualitative data. Thematic analysis was utilized for data analysis. Phase three strategies development five experts were selected with purposive sampling methods who had better knowledge and experience in the field of area self-administered structured data collection method was employed. The questioner contents nine interim strategies. Data was analysed manually by using simple calculator to assess the level of acceptance, experts rated each strategy using a four point Likert scale ranging from “Strongly disagree” to “Strongly agree‟. Each strategy was scored out of 40, with a mean score of 30 (75%) considered the threshold for acceptability. After data analysis quantitative and qualitative findings were triangulated. Finally, strategies were developed after an extensive review and validation by experts. Results: Overall, findings of this study revealed that majority of cervical cancer screening procedures and activities were not fully implemented based on the national cervical cancer screening guideline of the country resulting in an adverse impact on the uptake of cervical cancer screening. The quantitative findings revealed that, majority of health facilities have a challenge to address screening and treatment. The main problem was unavailability of room for screening, lack of skilled manpower including limited training, and shortage of important instruments cryotherapy machine to perform cryotherapy treatment to treat premalignant lesions for VIA positive women. There was no well-established referral and information system, no tracing mechanism to clients who are lost from follow up. The qualitative finding identifies that, a significant portion of women lack knowledge about the disease and its screening process and did not know where services are available. Misconception, cultural influence and unavailability of preventive HPV vaccine for girls, were reasons for late presentation with advanced stages of the disease and a factor for high prevalence and full-blown cervical cancer in the country. Although the guideline clearly outlines what health professionals should do such as primary prevention through awareness raising, secondary prevention through timely identification and treatment, provision of information about available services, and implementation of screening procedures most health workers were not consistently carrying out these recommended activities. These shortcomings collectively contributed to adverse impacts on the uptake of cervical cancer screening. Conclusion: In conclusion, it is imperative for the Federal Ministry of Health (FMOH) to prioritise women’s health, particularly strengthened cervical cancer screening programmes through implementing cervical cancer screening procedures and activities fully implemented in accordance with the national cervical cancer screening and prevention guideline. The government must take proactive measures to raise awareness of the importance of screening and ensure services are readily available and accessible across all communities. Expanding public healthcare facilities nationwide will enhance the provision of cervical cancer screening, ultimately improving health outcomes for women and reducing the burden of disease. Recommendation: The findings of this study served as a foundation for developing practical strategies aimed at improving the implementation of the national cervical cancer screening guideline and increasing screening uptake among women. The evidence generated has important implications for stakeholders at multiple levels, including policymakers, programme planners, program implementers, regional health bureaus, MOH, woreda health office administrators, and healthcare service providers by highlighting the challenges and identifying potential solutions, the study contributes to bridging existing gaps and advancing knowledge on cervical cancer screening services, and further research is recommended such as Involvement of male partners or husbands, family members and community leader, exploration of the experiences of survivors regarding cervical cancer screening.