Equity in access and utilization of cervical cancer treatment and palliation services in Harare, Zimbabwe

Abstract

Background Cervical cancer is one the fastest growing public health challenges in low to middle income countries. About 85% of new diagnoses worldwide are reported in low-income countries and cervical cancer is the fourth cause of mortality in the same contexts. In Zimbabwe in 2018, 3186 new cases of cervical cancer were dignosed accounting for 18.2% of all new cases of cancer reported in that year. However; despite the growing burden of the disease, health systems in countries in the less developing world are too fragile to provide comprehensive treatment and care required by women who need them. This study was aimed at understanding access and utilization of cervical cancer treatment and palliative care and their associated determinants among women with the disease in Harare, Zimbabwe. Methods This study utilized a sequential explanatory mixed methods design, with quantitative study in the form of analytical cross sectional surveys being the major designs. Three surveys were designed and used namely; community, patient and health worker surveys. Qualitative study was used to understand deeper and explain unexpected and surprising results from the surveys. The qualitative data collection methods used in this study comprised of in-depth interviews, focus group discussions and key informant interviews. Data collection tools for the qualitative study were finalized after the analysis of results from surveys to guide the issues that needed exploration using qualitative techniques. The first step of this study was the design and validation of structured questionnaires for the three surveys. The validation process involved factor and principal component analyses to identify meaningful constructs relevant to the research questions. After obtaining the meaningful constructs, Cronbach’s internal consistency coefficient analysis was conducted and constructs with coefficients ≥0.70 were retained in the questionnaires. Data collection of the surveys was conducted in communities selected through a multistage random sampling approach and treatment health facilities in Harare.

Findings This research revealed that the designed structured questionnaires for community, patient and health worker surveys to investigate access and utilization of cervical cancer treatment and palliative care services were valid and reliable for use in surveys. This study showed that socio-demographic factors played a minor role in explaining disparities in access and uptake of cervical cancer screening treatment and palliative care in Zimbabwe. Societal and health system determinants played a major role in entrenching inequities to access and utilization of cervical cancer treatment and palliative care. Health system barriers played a key role in influencing access and usage of treatment and care among women with cervical cancer. This research further revealed that while general awareness, knowledge of risk factors, prevention and treatment of cervical cancer were relatively high, knowledge of causes remained relatively low. Utilization of cervical cancer screening and access to regular doctors were relatively high among women with cervical cancer. Some of the major barriers to access and usage of cervical cancer services identified in this study were : limited resources, limited health worker knowledge about cervical cancer, centralized services, limited physical infrastructure, limited human resources especially specialists, limited donor support and competing priorities on the part of the government. This study also revealed a myriad of model strategies that could be considered to improve access and usage of cervical cancer treatment and palliative care services. Conclusions This study revealed a plethora of evidence relevant to cervical cancer programme and policy development in low-income settings affected by the growing burden of cervical cancer. The consideration and implementation of the model strategies reported in this study might go a long way in addressing the majority of the impediments to access and utilization of cervical cancer treatment and care in Zimbabwe and other similar contexts. However, the success of future cervical cancer programmes is hinged on the strengthening of the National Cancer Control Programme and key strategies in the Ministry of Health and Child Care. It is proposed that this lead institution take ownership and stewardship of policies and interventions including coordinating different partners. Furthermore, wider dissemination of relevant research, wider stakeholder engagements and collaborations and strong political will of the government is required to invest and mobilize resources to strengthen non-communicable disease interventions Key words: Cervical cancer, Zimbabwe, equity, access, utilization, sequential explanatory mixed design, determinants, treatment, palliative care.