Table 2 The barriers and facilitators for adherence to follow-up for HR-HPV-positive women with premalignant cervical lesions: the perspectives of CAPASAM users and health personnel
Variables | Barriers and facilitators by dimensions and subdimensions | User testimonials | Testimonials from healthcare professionals |
|---|---|---|---|
Socioeconomic factors | Low income | “Why don’t people go? People don’t go because of money for transportation." W38y Barrier | “Many of them tell us that sometimes they don’t have [money] for bus fare because they come from different places. There are women who come from farther away so, sometimes, the main thing is money.” W45y Barrier |
The role of family provider | “Many times, it’s the economy because, in my case, I have to work.” W51y Barrier | “The life of the woman also influences, I mean, whether she’s a worker or a housewife.” M30 y Barrier | |
Factors related to CAPASAM health personnel | Long waiting times for testing | “At the health services, some of them ask you to take a card [to register for the test]. They give it to you early but don’t get to you until noon.” W35y Barrier | “There continue to be comments that [at the HFs] there are specific service cards or days, which should not be, given the zero-rejection policies.” M30y Barrier |
Long waiting times to receive the results | “She goes to a private provider because the results take up to three months to arrive at the health services.” W40y Barrier | “I consider that the waiting times are long because the health services don’t send samples to the Jurisdiction daily and the Jurisdiction returns them to CAPASAM only once a week. Then it takes another week for the samples to be processed, another three or four days for them to be diagnosed by the cytotechnologist and the results corroborated by the pathologist, and it takes another week for CAPASAM to send the results to the Jurisdiction and from there to the [corresponding] health facility.” W41y Barrier | |
Distance of CAPASAM facilities from users’ homes | “The distance. For example, the bus or public van sometimes takes longer than you think.” W48y Barrier | “Jurisdiction 1 covers populations that, for us, are not very far away, but in reality, it (the CAPASAM health facility) is far away for them, sometimes up to two or three hours from them, so it can influence [their decision not to adhere to follow-up].” W30y Barrier | |
Scarce diffusion of service hours | “Institutions are sometimes [only open] from Monday to Friday and that’s it, and she [her cousin] works from Monday to Friday until six in the evening.” W47y Barrier | “Not many people know that CAPASAM exists and what it does. Not many people know, and I think it’s a great area of opportunity to create more publicity about what’s done here, because I feel that there are a lot of people missing us.” W30y Barrier | |
Dignified treatment (health responsiveness) by CAPASAM health personnel | “I like it. They always take good care of me.” W40y Facilitator | No testimonies identified | |
Free services | “The tests are free; if we don’t have money and they cost a lot [private care], then it would be stressful. But since they’re free, they don’t cost us. Well, now they’re giving us payment facilities.” W44y Facilitator | “Regarding factors that influence [whether] women undergo tests, I believe that women go to these health services to have these tests done because they´re free of charge.” W41y Facilitator | |
Health campaigns in remote populations | “I had the test done during a campaign, a study on Papillomavirus.” W40y Facilitator | “With health fairs in the community to attract patients.” W41y Facilitator | |
Factors related to CAPASAM users | Feelings of shame, fear, and uncertainty | “Sometimes it’s fear… shame, not wanting to be looked at, but it’s necessary.” W55y Barrier | “Sometimes, [with respect] to a gynecological consultation, many women don´t go to male doctors, only to female doctors. They say ‘oh no, it’s a male doctor; I don’t want to go to a male doctor,’ out of shyness.” W55y Barrier |
Fear of testing positive | “When they told me that the Pap smear results were abnormal, I thought it was cancer before coming here.” W44y Barrier | “You tell them their result, that there’s an abnormal finding, and they immediately think that it means a malignant condition when it’s something that’s very timely for treatment and doesn’t mean that it’s already an advanced cancer.” W41y Barrier | |
A positive attitude among users when making decisions | “I looked for a way to ask for permission [at work], so yes, it’s possible, everything is possible.” W43y Facilitator | No testimonies identified | |
Factors related to user knowledge about cervical cancer screening tests and results | Unfamiliarity with tests and results | “They asked us if we wanted to do a study. I don’t know what they did to me. And then they told me that it [the result] had come out abnormal and that I had to come for a colpo… I don’t know what it’s called.” W49y Barrier | “They don’t even understand what a colposcopy study is.” M48y. Barrier |
Doubts regarding the test results | “I had my Pap smear done last year and they told me it went well, and now that I do it again, they tell me it’s abnormal. I was left with doubt: do lesions appear so quickly?” W40y Barrier | No testimonies identified | |
General knowledge about cervical cancer | Unfamiliarity with the disease | “The truth is I don’t think a lot about that [cervical cancer]. I don’t understand what it is and I don’t know why [it develops] either.” W47y Barrier | “A large number of women don´t know what the injury’s about. They’re not very aware of the topic; sometimes they hear about it but don´t assimilate it or don’t analyze what’s happening.” W30y Barrier |
Limited knowledge about the relationship between cervical cancer and HPV | “I don’t know what it is and I don’t know what causes it, either […] hmmm, from sexual relations.” W48y Barrier | “I think that in 90% of the cases that come here, women and their partners don’t know what HPV is, what it’s about.” W30y Barrier | |
Misinformation about the form of transmission | “Because of having several partners, because of sexually transmitted infections, right? When you go to the bathroom… a public bathroom.” W45y Barrier | “Some users believe that they acquired the infection by sitting in a public bathroom.” W30y Barrier | |
Factors related to culture and gender | Patriarchal attitudes | “Sometimes the husband has a lot of influence, because there are people who don’t let them [the women] go to the doctor if it’s a man, alas! Well, I think it counts a lot. Instead of siding with him, I tell him, well, that’s my case. And instead of supporting me, he says -nooo! What do you think you’re doing, why? From then on, it seems that it goes down instead of raising [my] morale.” W47y | “There are still many taboos. In very remote communities, some women still report that their husbands don’t want them to go for sample collection because they [those who collect the samples] are going to see their wives. That part: -no, don’t go-, that type of thought still exists.” W41y |
The tendency of partners to blame the women for contracting the disease | “We must protect ourselves because men, we don’t know If they protect themselves. I could be there [have sex] only with him, but him, I don’t know. They go out, they work outside, but they blame us.” W41y Barrier | “Unfortunately, they’re driven by the taboo that if some type of problem is detected, then other family problems will surface, such as infidelities and other types of circumstances.” M30y Barrier | |
Access to conditional-transfer programs | PROSPERA program | “There are women who don’t go [to the doctor] anymore because they no longer get support from PROSPERA [government program]. The government educated us wrong because it’s for our own health. But people don’t go [to the doctor], if they don’t receive anything. With PROSPERA, the nurses had a notebook and they’d tell us ‘it’s time for your Pap smear’; It was mandatory because, if you didn’t go, they’d deduct money from you.” W40y Barrier | “Previously, there was also the PROSPERA program: they called the ladies to talks, to appointments, and, yes, they gave them financial help.” W51y Barrier |