Community and Provider Perceptions and Experiences of Cervical Cancer Screening in Rural Bolivia: A Qualitative Study

Abstract

Abstract Background: Despite efforts to increase cervical cancer screening access in rural Bolivia, uptake remains low. Bolivia has one of the highest cervical cancer mortality rates in the Americas. As it redoubles efforts to deliver universal health care, the Bolivian government needs information on the factors constraining cervical cancer screening access, and utilization, especially in rural areas. Methods: Our qualitative study explored cervical cancer screening barriers and described community and provider perceptions and experiences of care. Bolivian and US researchers analyzed data collected from eight focus groups with male and female community members (n=80) and interviews with healthcare providers (n=6) in four purposively selected rural communities in Monteagudo, Bolivia. Deductive and inductive codes were used to thematically analyze data using MaxQDA software. Results: Four themes emerged from the data: lack of knowledge/misconceptions, health system inadequacy, lack of confidence in providers, and opportunities for improvement. Both men and women displayed misconceptions about the causes of cervical cancer, its consequences, the recommended screening frequency, and the means of accessing care. Providers noted community members’ lack of knowledge and low risk-perception as utilization barriers but also highlighted poor health service quality and inconsistent health education as factors. Poor healthcare quality was a significant barrier; this included poor patient-provider communication, lack of transportation to screening facilities, and severe delays in receiving test results. Providers also noted problems with provider training and physical space for screening. Community members reported low confidence in nurses to perform screening, preferring doctors and specialists. They also expressed discomfort in having male healthcare providers conduct screening. Providers reported low confidence in government officials to support cervical cancer screening improvements. Suggestions for improvements included more intensive cervical cancer outreach to rural areas, mobile screening, and having specialists train lower-level providers to perform screening. Conclusions: Our findings suggest that poor healthcare quality has affected screening uptake in addition to physical barriers to care. They indicate a need for initiatives to reduce reporting time for Pap test results, the incorporation of community-based HPV self-testing into screening protocols, and the implementation of programs to improve community confidence in providers’ ability to perform screening.