BMC Women’s Health
Volume 21, article number: 180 (2021)
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Treatment and care for cervical cancer remains limited in Zimbabwe, despite the growing burden of disease among women. The aim of this study was to investigate strategies to remove barriers to access for women with cervical cancer to treatment and care in Harare, Zimbabwe.
A qualitative survey was conducted to generate evidence for this study. 84 participants were specifically selected for interviews and participation in focus group discussions. Participants were selected from among cervical cancer patients, caregivers of cervical cancer patients, health workers involved in caring for cervical cancer patients, and relevant policy makers in the Department of Health and Childcare. Participants were selected to ensure different characteristics in order to obtain different perspectives on the subjects studied. Discussion and interview guides were used as data collection tools and discussions / interviews were recorded, transcribed and translated into English. The inductive thematic analysis was performed using the Dedoose software.
Key subtopics that emerged in the study at the individual patient level were: provision of free or subsidized services, provision of transportation for treatment to healthcare facilities, and provision of Accommodation for patients in treatment. At the societal level, the sub-topics were: Strengthening health education in the communities and training of health workers and community engagement. Important subtopics at the level of the national health system were: establishing more screening and treatment health facilities, increasing the capacity of existing facilities, decentralizing some services, building multidisciplinary teams of health workers, developing and introducing standardized guidelines and reforming the delivery of the acquired immunodeficiency virus (AIDS ) into a fund that would fund priority areas of the disease.
This study revealed some notable strategies for improving access to treatment and care for cervical cancer in low-income families. It is recommended to improve domestic investment in health systems and reform health policies, which are based on strong political policies.
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Cervical cancer is the fourth most common cancer in women worldwide. A recently published GLOBOCAN report in 2018 found that 290,000 (51%) of the 570,000 new cases of cervical cancer worldwide occurred in women in low- to middle-income countries (500,000) (88%) [88%). 1]. Worldwide, the mean age of women diagnosed with cervical cancer was 53 years and ranged from 44 to 68 years [2]. In Zimbabwe, cervical cancer is the most commonly diagnosed cancer in women, and most cases are diagnosed at advanced stages. At least 2,270 cases of cervical cancer are reported annually, and the disease causes 1,451 deaths nationwide [3]. Despite the growing disease burden in the country, patients face a variety of multi-dimensional barriers (e.g., lack of physical access to health facilities, limited services, lack of knowledge, and high costs of services) to access screening, diagnosis, treatment, and care [4, 5 ]. These challenges could be the underlying factors causing approximately 80% of cases to be presented in advanced stages [6].
Given the global burden of cervical cancer, which disproportionately affects women in low income backgrounds reported several barriers to treatment and care carried out by researchers in the United States of America. Inadequate infrastructure, limited access to preventive human papillomavirus (HPV) vaccines, screening and treatment, and limited trained staff and training options continue to hamper efforts to improve access to treatment and care in less developed countries [7]. A similar review was carried out in Zimbabwe and identified similar challenges [8]. Health systems in low-income countries are overwhelmed with competing priorities and health care providers are often ill-prepared to meet the growing demand for their services. Inadequate resources, limited training opportunities and health worker brain drain are some of the challenges that overwhelm health workers in low to middle income countries [9]. A recent report from Latin America indicated that a high incidence of cervical cancer in this region is due to limited access to screening services and insufficient providers of diagnostic and therapeutic procedures. Geographical distances and cultural barriers were also cited as barriers to accessing and using recommended cervical cancer diagnosis and treatment services [10]. In South Africa, a recent study reported limited knowledge of cancer, a lack of biomedical treatment and stigma as barriers to linking women with cervical cancer with treatment and care [11].
Zimbabwe has seen a variety of economic challenges that arise too have led to a weakening of social services including the health system [12, 13]. Most women at risk for cervical cancer reside in rural areas (66%) and live far from the country’s only two treatment centers in the cities of Harare and Bulawayo [5, 8]. The country has about 105 cervical cancer early detection health facilities, most of which are located at the district level. Referral routes for women suspected of having cervical cancer go to provincial hospitals and then to the two treatment centers once the diagnosis of cervical cancer has been confirmed by histological tests, most of which are available in private laboratories. The treatment centers operate day clinics on weekdays, and although the services are subsidized, the cost is still out of reach for many. In addition, for chemotherapy, patients must purchase their own drugs and related goods such as needles and syringes. The treatment options available in the two treating hospitals are radiation therapy, chemotherapy, and surgery. However, radiation therapy services are sometimes unavailable due to frequent machine failures [5, 8].
Several barriers to cancer treatment and care have been reported in Zimbabwe, including: resource scarcity, centralized diagnostic, treatment and palliative care services, skills shortages and high treatment costs [ 14]. Our recent study identified extensive multidimensional barriers to access to treatment and care. These included: few treatment centers, poor infrastructure, shortage of goods such as medicines, limited number of radiation therapy devices, frequent failures of radiation therapy machines, high costs for services, few specialists, lack of standardized guidelines, limited health information system related to cancer, lack of patient follow-up -up system, limited knowledge or inappropriate attitudes of health workers, frequent strikes by health workers and bureaucratic referral system. Lack of knowledge, fear of being diagnosed with cervical cancer, stigma (defined in our context as segregation or discrimination related to cervical cancer), misunderstandings (defined as wrong view or opinion due to lack of knowledge), and family influences, attitudes and beliefs were reported as societal barriers , Influence of traditional and spiritual healers [5, 15]. Strategies suggested in recent studies to combat stigma have included the involvement of traditional healers in interventions based on their community status [11, 16]. Kuguyo et al. [8] proposed an increase in cervical cancer screening and public education funding to promote early detection of the disease as some of the urgent actions in Zimbabwe. To date, most studies in low-income backgrounds have focused on screening and secondary prevention of cervical cancer. However, this study was intended to unpack some of the key and contextual strategies that could be implemented to improve women’s access to and inclusion in cervical cancer treatment and palliative care.
This study was a qualitative research conducted in Harare , Zimbabwe, as part of a sequential explanatory study using mixed methods. The main purpose of the study was to understand and explain some of the results of the quantitative studies. The main relevant results in the quantitative phase indicated significant barriers to entry to the treatment and care of cervical cancer in women who were not associated with socioeconomic status. In addition, cervical cancer treatment services were limited in the tertiary treatment facility where this study was also conducted. The qualitative approach became useful in exploring some of the key strategies that could be implemented to remove barriers to cervical cancer treatment and palliative care. A total of 84 participants were specifically enrolled in the study, of which 16 were in-depth interviews, 20 were key informants (i.e., health workers, policy makers, and spiritual leaders) and six focus groups with an average of eight participants were conducted in different study locations (see Fig. 1). All participants gave their written consent before participating in the study. The participants were selected in the communities, health facilities and key institutions. Participants were selected based on knowledge and experience gained from interacting with women with cervical cancer or similar conditions. In-depth interview and focus group participants were identified in surveys in the communities and health facilities. Important informants were identified primarily using the snowball technique. In these cases, health workers conducted surveys to suggest names of potential participants who should be considered for enrollment [17].
Figure 1 shows the flowchart for recruiting participants for the qualitative study. A total of 84 participants were recruited for the study, including 16 patients / carers, 20 key informants consisting of health workers, policy makers and spiritual leaders, and six focus groups of patients, carers and male partners.
All participants gave written consent while of interviews and discussions to be interviewed and recorded. Interview and discussion guides designed by the researchers were used as data collection tools in this study [Additional Files 1, 2 and 3]. The main research question for this analysis was to understand some of the approaches that could be used to improve access to cervical cancer treatment and care from different perspectives. The quantitative study had suggested significant barriers and limited services for cervical cancer in Harare, Zimbabwe. The interview / discussion questions used in the data collection tools were designed based on the results of the surveys and the general research questions. The researcher and his trained research assistant conducted the interviews and moderated the focus group discussions (FGDs) using the face-to-face approach. In-depth interviews and focus group discussions (FGDs) were conducted in local churches and community centers. In addition to the audio recordings, notes were made during each interview / discussion, particularly to observe the participants’ non-verbal communication. In-depth interviews and REA attendees received refreshments during the interview or discussion rounds and a $ 8 allowance each to compensate for their time and travel [18, 19].
Interviews and REA were transcribed verbatim and, where appropriate, from Shona translated into English. The transcription and translation of audio recordings was carried out by the researcher and his assistant after a certain amount of training. Audio recordings of interviews / discussions were confidential and patients’ personal information was treated appropriately at the end of the study to protect privacy. Transcripts were identified by the unique identifier (e.g. IDI01, KII01, or FGD01) assigned to each participant (and provided by each participant at the beginning of the REA / interview) rather than personal information. Only after the transcription was completed were unique identifiers used to link the guides and the interview. All in-depth interviews, key whistle-blower interviews, and REA were manually coded line by line by the researcher using Dedoose software after topics / subtopics were created based on the research question and literature. Topics / subtopics were discussed between the researcher and his assistant and only topics / subtopics were considered that were acceptable. Manually generated thematic codes were processed in the same software to produce final results for the study. Coding highlights text of interest, and code is text that is of interest to a researcher and is used to identify topics / subtopics. The final topics were displayed as direct quotations [18, 19] and were based on the research question.
Most participants had high hopes that with adequate investment and solid policies, major barriers to access to cervical cancer treatment and care would be removed could become. A myriad of subtopics emerged related to some of the key strategies that could be implemented in the country to improve access and use of treatment and palliative care services for women with cervical cancer.
Most participants reported that treatment and care of cervical cancer had a high cost that most people could not afford, and so the government should consider free or subsidized services. Some said that human immunodeficiency virus (HIV) and tuberculosis (TB) are treated for free, so they felt that cervical cancer should also be considered for free treatment. Some respondents complained that the government and its partners only provided them with free screening services. However, if one is suspected of having cervical cancer, they would have to rely on a payout. A young nurse suggested a strategy to make it easier for patients with cervical cancer to access treatment and care:
« @@@ I think if the government could subsidize drugs so people can get them at a cheaper price, because someone from rural areas who is not working cannot afford the medication. » Caregiver, 20-30 years old from Goromonzi.
One REA participant mentioned that screening service usage is low because suspected cervical cancer incurs high treatment costs that they would not be able to afford. As a result, some women would choose not to be screened at all:
I don’t think screening is easy because if you are suspected of having cervical cancer, the next steps are to go to Confirmation required is very expensive. I think the government should cut cervical cancer treatment fees so people can be treated earlier. « Healthy woman, Hopely REA participant.
Another respondent reported that women with cervical cancer died from lack of resources So the government should do something to help them:
« I think the government could allow all women in Zimbabwe to get free cervical cancer treatment and that would alleviate the problem as many may actually die from it resources to receive treatment are lacking. « Cervical cancer survivor 50-60 years away from Shurugwi.
Most respondents alluded to the centralization of cancer care services, which posed challenges for women in rural areas. The high cost For transportation to treatment facilities, some women discourage early cervical treatment to look for rebs. One respondent said that addressing transportation issues would improve access to and use of treatment and care services for cervical cancer.
« @@@ Transportation costs need to be low if and when you want people to come for treatment and care there are huge ones, this has failed our purpose. So this is a very big political problem that we need to discuss. “Key informant for the World Health Organization (WHO) country office in Harare.
With only two cancer-treating health facilities in the country, most respondents reported problems with accommodation during treatment sessions. Some of the patients do not have relatives in major cities where treatment and care are provided and therefore face many problems. One respondent explained their challenges in accessing treatment and care:
« @@@ I have no relatives in Harare, so my challenges will be much greater and will include housing, food, transportation and also medication. » Women with cervical cancer, REA participant.
Some respondents indicated that the health education and awareness of cervical cancer delivered to communities was inadequate. Therefore, it took more to reach more people. Lack of knowledge about cervical cancer and its treatment has been a source of misunderstanding that further impeded access to and use of treatment services. One respondent revealed the limits of current awareness-raising and health education measures:
« @@@ … I don’t think we’re getting enough on education because we only give health education to those who have attended the health center, and we don’t have outreach programs to help us reach out to the churches. » Midwife, key informant from Harare Hospital.
“@@@… health workers need education to get all information out there. Now they are spreading the message that there are many cervical cancers and people should get checked out and stop there. Any other question that is asked cannot go any further. Therefore, we need to train and empower the lowest level of health workers who will reach the highest number of people in the communities. “Senior Pathologist, Key Informant at Parirenyatwa Hospital.
» @@@ … for health professionals, our curriculum may also need to be adapted to raise awareness of cancer when we do what we do with communicable Diseases have done. » Pharmacologist, key informant from Harare.
An apostolic cult prophet suggested improved health education in churches to improve early detection of cervical cancer:
« @@@ According to my church deliberations or prophecies, cancer persons should be the people in ours Educate churches. » Prophet of the Apostolic Sect, key informant from Zvimba.
Most respondents indicated that the community must work to promote the use of screening and treatment services for cervical cancer. Some of the community leaders who are vital because of their significant influence on the communities are local leaders, traditional healers, pastors, and prophets. A key informant had the following to say:
« @@@ … as Africans we know that if you are sick, you will introduce a village health worker or a traditional healer or doctor or nurse … » Key informant of Parirenyatwa Hospital.
A traditional healer affirmed the influence and importance of traditional healers in the early detection, treatment and utilization of cervical cancer:
« @@@ … we [traditional healers] see 80% of women with cervical cancer or the population of Zimbabwe consult traditional practitioners because they are accessible and their medicines are affordable. » Traditional healer, key informant from Harare.
“@@@… we heard about it [cervical cancer] and we prayed for people who came to church and had this challenge… ..but we [pastors] are not good informed about the disease as there is no platform for the Ministry of Health to connect with the Church, but we believe that such a platform is essential for health-related collaborations. « Senior pastor, key informant from Harare.
A sect apostolic prophet shared the importance of working with the government to improve access to cervical cancer treatment and care:
» @@@ … the best is for People who have the knowledge to come to centers like churches and speak to the parishioners, because the moment you speak to maybe 1,000 people, it means you have given almost 5,000 people information, because the 1,000 people will be that Spread the word out there… ”. Prophet of the apostolic sect, key informant from Zvimba.
Most of the respondents suggested setting up more facilities for the early detection and treatment of cervical cancer across the country. This is due to the insufficient number of health facilities offering these services. A nurse suggested the following strategy:
« @@@ … if they could also increase the number of hospitals in different provinces that treat cervical cancer because some are from Bulawayo and if you have no relative in Harare, What are you going to do? » Caregiver, 20-30 years old from Goromonzi.
« @@@ I think it can go a long way if there are mobile screening services, because remember that some of our facilities have patients about 3 miles have to run to gain access to them. » Senior Gynecologist, Key Informant at Harare Hospital.
Increasing capacity for cervical cancer screening and healthcare facility treatment has been a prominent sub-theme, especially among healthy women, women with cervical cancer and health workers. One health worker reported the following:
« I think three big areas: health education, capacity and cost are the main areas that we need to address, and others can add over time. » WHO expert, WHO country office key informant.
« … I think we need to improve the treatment centers available. Make sure they are working optimally before we think about setting up new centers. “Senior Oncologist, Key Informant of Parirenyatwa Hospital.
Another important issue is resolving persistent failures of radiation therapy equipment to ensure uninterrupted operation. A key source reported the following regarding the radiation therapy equipment:
« @@@ I also think that access to treatment was not consistent in the sense that there were times when machines used to treat patients did not work which can also be a negative push factor and urgently needs to be addressed. » Senior Oncologist, Key Informer, Parirenyatwa Hospital.
The standout strategy reported by most respondents was for the government to decentralize the treatment and management of cervical cancer to lower levels of healthcare across the country. A key informant reported the need to decentralize other services such as patient follow-up:
« @@@ Regarding the decentralization of some services, such as patient care. B. Follow-up services, however, I consider this to be essential. In terms of treatment, I think we need to improve the treatment centers available. Make sure they are working optimally before we think about setting up other centers. “Senior Oncologist, Key Informant of Parirenyatwa Hospital.
Another sub-topic that emerged was the need to build multidisciplinary teams of health workers to provide the comprehensive cervical cancer treatment services. Teamwork should not be underestimated given the multitude of levels of care that cervical cancer patients must go through as part of their treatment and care. Other registered practitioners such as traditional healers and prophets should also be engaged through their representative bodies to raise awareness and address stigmatizations and misunderstandings regarding cervical cancer:
We should not forget that we have other people claiming a lot knowing about cancer in communities and societies, be it herbalists, traditionalists, and spiritual healers saying things, and you know that psychologically or traditionally black people tend to believe them. “Senior Oncologist, Key Informant of Parirenyatwa Hospital.
The multidisciplinary approach to under-treatment and treatment of cervical cancer has been reinforced in particular by oncologists:
What we also lack with regard to cancer treatment is this multidisciplinary approach, because if You then have multiple disciplines, all come together to work together at least for the patient’s good and at the end of the day you will find that you get reinforcement and collaboration from whatever needs to be done for the patient. If I may say in this department we don’t have social workers and psychologists, I mean we have oncology nurses, but they can’t double up to be everything. « Senior oncologist, key informant at Parirenyatwa Hospital.
Another key informant explained palliative care and how it is delivered by multiple healthcare workers using a team approach:
Palliative care is the treatment that a patient receives from the point of time It is also a multidisciplinary approach that involves oncologists, physicists, radiographers, nurses, welfare, family and church. ”Oncology Nurse, Key Informant at Parirenyatwa Hospital.
Another sub-topic What emerged from the study was the development and implementation of referral and treatment guidelines at all levels of the healthcare system. One respondent explained the need for guidelines:
Yes, people can say we refer a patient, but I can think we need guidelines to enable a patient with a suspected uterus cervical cancer know I will go to this place to see either Doctor A or Doctor B or Doctor a Cervical Cancer Clinic where they go straight to the Cervical Cancer Clinic without having to be booked to a general clinic because this helps. « Senior Oncologist, Key Informant of Parirenyatwa Hospital.
Another key informant reiterated the need to develop guidelines with the involvement of a multidisciplinary team of health workers:
» @@@ … we need guidelines from a multidisciplinary Team. It has to be the whole team. It has to be pathologists, it has to be oncologists, it has to be gynecologists, it has to be the nurses, it has to be epidemiologists who come together to look at the data, and it has to be the population developing guidelines that work for us here in Zimbabwe. “Senior Pathologist, Key Informant of Parirenyatwa Hospital.
The AIDS levy was introduced to mobilize domestic resources for increased treatment and care of HIV / AIDS in Zimbabwe. However, HIV / AIDS is a known risk factor for cervical cancer, but the same fund is not earmarked for the treatment of cervical cancer. Some respondents said the AIDS levy needs to be reformed to fund priority areas of disease, including cervical cancer:
I think there is so much cancer to talk about now. The need is that people may feel overwhelmed if they have another tax in addition to the AIDS tax. However, I would recommend lowering the AIDS levy and then dividing the AIDS levy and the cancer levy, but not calling it AIDS levy in the hope that they will then share with cancer. There should be a separate budget for cancer. “Senior Oncologist, Key Informant at Parirenyatwa Hospital.
As the burden of cervical cancer increases, particularly in low-income countries [1, 7], there are opportunities to improve existing health systems to access treatment and care improve. This study revealed some of the strategies that could be implemented in Zimbabwe in the short to long term. At the individual patient level, this study suggests the following strategies: eliminating user fees or subsidizing services, providing transportation to treatment for health facilities through vouchers or cash, and providing shelter for women with cervical cancer during their treatment. At the societal level, our results suggested the following interventions: Strengthening community health education and training health workers and community engagement. Finally, at the level of the national health system, our results suggest the following actions: establishment of more screening and treatment facilities, increasing capacity in the existing screening and treatment facilities, decentralizing some services such as follow-up examinations, setting up multidisciplinary health teams in early detection and staff Treatment of health care facilities, the development and implementation of standardized guidelines and the reform of the AIDS levy into a fund to finance priority areas of disease including cervical cancer. While these strategies may not be exhaustive, they are a good starting point for making cervical cancer treatment and care a priority in low-income contexts.
This study showed that eliminating user fees or subsidizing treatment was imperative to remove the burden of high costs that hinder the association of women with cervical cancer with treatment and care. This finding is in line with the reports in the United States, in which the Clinton Health Access Initiative and the American Cancer Society found that cost is a major barrier to timely, quality care worldwide, and 2015 partnered to optimize cancer drug market to improve access to affordable treatment [20]. Nyakabau et al. [14] recommended the availability of free or affordable and accessible chemotherapy in public health settings to improve access and use of treatment services. In a recent systematic review, researchers found that fee waiver policies are one of the key strategies to improve access to and uptake of care for mothers and newborns in sub-Saharan Africa [21]. Another study in Malawi found that user charges are a significant barrier to access to health care and reduce the detection of serious infectious diseases [21, 22]. These results confirm our findings, which have shown sub-optimal access to treatment and care for cervical cancer due to the high cost.
Our study reported that the challenges of transportation to treatment from healthcare facilities are addressed by measures to provide transportation assistance in the form of cash or coupons for women with cervical cancer could be reduced. However, this can be a short to medium term intervention in low income situations. A US study reported that the accessibility of patient transports or treatment centers could be improved through national commitment to the development of infrastructure such as road and rail networks, improved geographical distribution of treatment facilities, and infrastructure support from non-governmental organizations (NGOs) and industry [7]. However, this finding is long-term and more sustainable for environments with a high incidence of cervical cancer. Such investments will take time and, due to limited resources and competing priorities, require strong political will in low-income settings [5, 6, 7].
With cervical cancer treatment modalities, women typically spend many days visiting treatment facilities visit to receive treatment, be it radiation therapy or chemotherapy, or a combination of different modalities. Unfortunately, at least 80% of cervical cancer patients in low-income situations arrive late and spend many days receiving treatment and care in tertiary health facilities [6]. In most cases, placement challenges pose an obstacle to access and use of treatment and care services for patients living outside of major cities. One strategy to address these challenges is to have the government and its partners provide shelter for cervical cancer patients during their treatment phase. Anecdotally, the Tariro hostel in Harare Hospital housed cancer patients who were being treated at Parirenyatwa Hospital until it was closed in 2007 due to a lack of resources. Redesigning the home to host cancer patients outside of Harare would greatly improve the challenges of housing and transportation, which were the top barriers to treatment engagement and compliance in this study.
This study found that Strengthening health education and training of health workers at all levels of the health system are essential measures to improve access and use in the treatment of cervical cancer. It has been reported that a lack of awareness is a barrier to cervical cancer uptake in low income families [23]. A South African study reported the importance of community cancer awareness interventions involving traditional healers, churches and youth to address stigma and other social ills related to cervical cancer [11]. Researchers in the United States reported that collaboration between nations, international organizations, and industry to develop and launch workshops, courses, and exchange programs was key to improving healthcare knowledge and skills about cancer [7]. In Zimbabwe, researchers reported the importance of prioritizing the training of health workers in primary care to help decentralize some services and improve links with prevention and health services [4]. Our work supports the results and recommendations of the studies cited [6, 7, 11] and reinforces the need for comprehensive community health education and training for the training of health workers. Cervical cancer health education and awareness raising is not available in schools and colleges in Zimbabwe and this could be detected. The collaboration between government, academic institutions, international organizations and industry is not to be underestimated.
The results of this study showed the importance of community engagement through community leaders such as traditional or local leaders, pastors, prophets and traditional healers. These have a significant impact on communities that could be used to encourage the use of cervical cancer prevention and curative services. Community involvement is imperative given the complexities associated with cervical cancer as a disease and its treatment modalities [20]. Involving community leaders such as local chiefs, traditional healers, pastors, and prophets is important to advance the early detection and treatment of cervical cancer. Researchers in South Africa reported that anti-stigma interventions in cervical cancer could support traditional healers as they play a vital role in society [11]. Our study supports this proposed intervention and further extends it to other community leaders demanding respect in African communities.
Increasing the number and optimal distribution of cervical cancer screening and treatment facilities was a key sub-topic in our study. Another important sub-topic was strengthening the capacity of existing cervical cancer screening and treatment facilities to improve links with screening and treatment services. Recent studies have shown that cervical cancer and weak systems services are unevenly distributed to provide comprehensive prevention and healing services in low-income countries [6,7,8,11,20]. Capacity building for cervical cancer treatment and care would involve a list of things including human resources, equipment, physical infrastructure, goods, information systems, financial resources and leadership [24]. A Kenyan study reported that reliance on radiation therapy equipment across the country was a cause of poor health outcomes and higher cancer mortality rates [25]. Another study in the US found that patients with advanced gynecological cancer wanted doctors to play a more active role in their psychosocial needs. Some of the needs identified were emotional, spiritual, patient-family communication, patient involvement and advance decision making [26]. These results support the results of our present study. Despite the constraints and competing priorities, most low-income countries have strong political will, and subregional, regional and international collaborations are potential mechanisms for building sustainable capacity [6].
The decentralization of some cervical cancer services was another key strategy reported in our study. Recently, researchers in Tanzania suggested that the decentralization of service delivery for cervical cancer services is one of the most important factors in initiating and expanding screening and treatment [22]. In Kenya, the government and its global partners set up three additional cancer treatment centers in 2015 to decentralize diagnosis, treatment and care services and reach more people [23]. Nyakabau et al. [15] In Zimbabwe, the decentralization of some services has also been offered as a political priority in the nation to remove barriers in the cancer continuum of care.
The results show that building multidisciplinary teams of health workers is of strategic importance. to improve access to quality care and the use of treatment services. Taplin and colleagues [27] reported the effectiveness of multidisciplinary care teams (MDTs) in the continuum of cancer treatment from screening to end of life. The multidisciplinary care of the team improved follow-up care and compliance with prescribed procedures, and shortened the time from diagnosis to treatment [27]. In Zimbabwe this concept is still not in place due to several factors, the main part of which is a limited number of specialists [5]. The government and its partners need to pursue some of these effective approaches.
Another important finding was that developing and implementing guidelines for the treatment and management of cervical cancer across the country was an urgent priority. The availability of guides and educational resources for a complex disease like cervical cancer should not be underestimated against the backdrop of poor health workforce well-being, leading to downsizing in the country’s public health facilities that care for a large part of the population [14, 15]. The alignment of the existing health infrastructure with cancer management is underpinned by the implementation of effective guidelines [5, 14]. Within a solid policy framework, the government can effectively coordinate all activities to ensure comprehensive cancer treatment and care.
A notable finding of our research has been the need to convert the AIDS levy into a fund that prioritizes interventions for others Funded conditions such as cervical cancer. The AIDS levy was introduced in 1999 to mobilize resources to fight HIV / AIDS in Zimbabwe [28]. The Fund has performed well in raising resources for HIV / AIDS intervention and demonstrating its commitment to fighting the disease, with the addition of several global partners to provide more resources [29]. However, such a funding mechanism requires a review to take into account other emerging diseases such as cervical cancer. Treatment of cervical cancer is multimodal and complex, and the government needs to prioritize the high morbidity and mortality rates among women. In addition, donor funding for non-communicable diseases has remained low in recent years [29], indicating that low-income countries need to develop innovative strategies to raise domestic resources to finance non-communicable diseases. However; In low- to middle-income countries, domestic funding for non-communicable diseases has been dominated by the impoverishment of expense funding [28]. While the introduction of another levy on top of the existing levy in Zimbabwe would be catastrophic for the already overwhelmed workforce, the review of the AIDS levy to re-prioritize conditions for beneficiaries may be a plausible starting point for raising domestic resources for priority conditions. Other innovative funding mechanisms such as « sin taxes » imposed on products such as tobacco and alcohol can be introduced to complement the reformed AIDS levy. Collaborations between government, international organizations, and industry could also realize more innovative strategies to mobilize resources to improve cervical cancer treatment and care links in low-income settings.
To the best of our knowledge, few studies have explored strategies that could be implemented to remove broader barriers to treating cervical cancer and linking low-income care. Future guidelines for policy to combat cervical cancer in low income families should take into account: (1) solid and realistic policies based on strong political will; (2) broader health system strengthening or diagonal approaches; (3) community engagement; and (4) working with international organizations and industry to mobilize sufficient resources to fund interventions. Our study should be reviewed taking into account some caveats. First, data was collected in Harare and therefore the results cannot be transferred to other contexts. Second, the study collected limited demographic information from participants to ensure the confidentiality that the researcher guaranteed during the consent process. Finally, some key policy makers in the Department of Health were not available for interviews, so the researcher had to work with those available. Despite some caveats, this study had a fair share of strengths. The sample for this study consisted of different participants including: men, healthy women, women with cervical cancer, caregivers, managers of NGOs involved in cancer interventions, some health ministry policymakers, health workers, traditional healers, pastors and prophets. This resulted in a greater variety of perspectives that enriched our findings. This qualitative study and a second phase of sequential explanatory design using mixed methods resulted in problems being studied very carefully in order to understand them better than could have been achieved with quantitative design alone. Our study was further enriched by observations of the participants’ non-verbal communication, which was critical to understanding the subject under study. To the best of our knowledge, this study was the first primary research conducted in Zimbabwe to explore strategies that could be implemented to remove barriers to access and use of cervical cancer treatment and care. Future policy directions may emanate from this work and other literature from similar contexts.
In summary, our study has expanded the scientific body of knowledge by highlighting some of the key policy interventions that could be implemented to address the links to the treatment and care of Women with cervical cancer in a low-income setting improve. The policy interventions identified are certainly not exhaustive, but they are a good starting point to address the challenges women face in the country. Improved domestic investment in health systems and health policy reform based on strong political will are broader strategies that should be prioritized to sustainably reduce morbidity and mortality from cervical cancer in a low-income context.
The during The data sets used and / or analyzed in the current study are available from the relevant author upon reasoned request.
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We are grateful to the women, men, patients, and health workers who participated in our study. Special recognition goes to our research assistants: Tatenda Mudehwe, Ethel Mutanga, Stawa Saidi, Irene Mushore, Samantha Munamati and Humfrey Mlambo, who helped with the data acquisition and analysis for this study.
This study was sponsored by the Letten Foundation, Norway, funded. The funding organization was not involved in the design, data collection, analysis, interpretation or development of this manuscript. The views expressed in this manuscript are solely those of the authors and not of the funding organization.
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OT: researcher, concept and study design; GD: co-supervisor, conception, critical revision and processing; AMN: conception, critical revision and editing; WK: clinical supervision; critical revision and editing; SH, supervisor, concept and study design, critical revision and editing; BSP, critical revision and editing. All authors have reviewed and approved this manuscript.
Correspondence
Oscar Tapera.
This study was conducted as part of a PhD at the University of Pretoria and was approved by several ethics committees / panels: (1) University of Pretoria, Faculty of Health Sciences Ethics Committee (REC 487/17). (2) Harare Hospital Ethics Committee (HCHEC 271017/77). (3) Joint Research Ethics Committee of Parirenyatwa and the University of Zimbabwe (JREC 33A / 18). (4) Zimbabwe Medical Research Council (MRCZ / A / 2271). All participants in this study were given written consent prior to the interviews. Consent forms were administered by the researchers in the participant’s language; H. Englisch oder Shona (Landessprache, die von der Mehrheit der Menschen in Simbabwe gesprochen wird).
Open Access Dieser Artikel unterliegt den Bestimmungen einer Creative Commons Attribution 4.0 International License, die die Verwendung, Weitergabe, Anpassung, Verbreitung und Reproduktion in jedem Medium oder Format ermöglicht, sofern Sie dem / den ursprünglichen Autor (en) und der Quelle die entsprechenden Angaben machen. Geben Sie einen Link zur Creative Commons-Lizenz an und geben Sie an, ob Änderungen vorgenommen wurden. Die Bilder oder anderes Material von Drittanbietern in diesem Artikel sind in der Creative Commons-Lizenz des Artikels enthalten, sofern in einer Kreditlinie für das Material nichts anderes angegeben ist. Wenn das Material nicht in der Creative Commons-Lizenz des Artikels enthalten ist und Ihre beabsichtigte Verwendung nicht durch gesetzliche Bestimmungen zulässig ist oder die zulässige Verwendung überschreitet, müssen Sie die Genehmigung direkt vom Inhaber des Urheberrechts einholen. Eine Kopie dieser Lizenz finden Sie unter http://creativecommons.org/licenses/by/4.0/. Der Verzicht auf die gemeinfreie Creative Commons-Widmung (http://creativecommons.org/publicdomain/zero/1.0/) gilt für die in diesem Artikel zur Verfügung gestellten Daten, sofern in einer Kreditlinie zu den Daten nichts anderes angegeben ist.
Tapera, O., Dreyer, G., Nyakabau, A.M. et al. Modellstrategien zur Beseitigung von Hindernissen für die Behandlung von Gebärmutterhalskrebs und die Palliativversorgung von Frauen in Simbabwe: ein Ansatz für die öffentliche Gesundheit.
BMC Women’s Health 21, 180 (2021). https://doi.org/10.1186/s12905-021-01322-4
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