Introduction
Materials and methods
Population and design
Collected information
Mixed methods data analysis
Results
Respondents’ characteristics
Characteristics | Early stage (n = 27) | Advanced stage (n = 68) | Total (n = 95) | |||
---|---|---|---|---|---|---|
n | % | n | % | n | % | |
Age, median [IQR]
| 49 | [41–57] | 52 | [42–60] | 51 | [42–59] |
Age group (years)
| ||||||
<40 | 5 | 18.5 | 12 | 17.6 | 17 | 17.9 |
40–59 | 18 | 66.7 | 37 | 54.4 | 55 | 57.9 |
≥60 | 4 | 14.8 | 19 | 27.9 | 23 | 24.2 |
Education level
| ||||||
None | 11 | 40.7 | 33 | 48.5 | 44 | 46.3 |
Primary | 8 | 29.6 | 20 | 29.4 | 28 | 29.5 |
Secondary and over | 8 | 29.6 | 15 | 22.0 | 23 | 24.2 |
Marital status
| ||||||
Married | 12 | 44.4 | 22 | 32.4 | 34 | 35.8 |
Widowed | 5 | 18.5 | 20 | 29.4 | 25 | 26.4 |
Living with partner | 6 | 22.2 | 12 | 17.6 | 18 | 18.9 |
Single or divorced | 4 | 14.8 | 14 | 20.6 | 18 | 18.9 |
Occupation
| ||||||
Employed | 17 | 63.0 | 39 | 57.4 | 56 | 58.9 |
Unemployed | 10 | 37.0 | 29 | 42.6 | 39 | 41.1 |
Number of biological children
| ||||||
< 5 | 12 | 44.4 | 31 | 45.6 | 43 | 45.3 |
≥5 | 15 | 55.6 | 37 | 54.4 | 52 | 54.7 |
HIV status
| ||||||
Positive | 9 | 33.3 | 9 | 13.2 | 18 | 18.9 |
Negative | 18 | 66.7 | 59 | 86.8 | 77 | 81.1 |
Place of living
| ||||||
Abidjan | 10 | 37.0 | 31 | 45.6 | 41 | 43.2 |
Other cities$ | 17 | 63.0 | 37 | 54.4 | 54 | 56.8 |
Health Insurance coverage
| ||||||
Insured | 6 | 22.2 | 3 | 4.4 | 9 | 9.5 |
Uninsured | 21 | 77.8 | 65 | 95.6 | 86 | 90.5 |
Monthly income (USD)
| ||||||
None | 8 | 29.6 | 25 | 36.8 | 33 | 34.7 |
<250 | 14 | 51.9 | 40 | 58.8 | 54 | 56.8 |
≥250 | 5 | 18.5 | 3 | 4.4 | 8 | 8.4 |
Estimated distance from home
to referral hospital (Kilometers)
| ||||||
< 100 | 12 | 44.4 | 36 | 52.9 | 48 | 50.5 |
≥ 100 | 15 | 55.6 | 12 | 47.1 | 47 | 49.5 |
Histological subtypes
| ||||||
Adenocarcinoma | 1 | 3.7 | 8 | 11.8 | 9 | 9.5 |
Squamous cell carcinoma | 26 | 96.3 | 60 | 88.2 | 86 | 90.5 |
Total time interval
® (days)
| ||||||
Median, [IQR] | 231 | [120–379] | 208 | [113–439] | 216 | [117–429] |
< 180 | 10 | 37.0 | 30 | 46.1 | 40 | 42.1 |
≥ 180 | 17 | 63.0 | 38 | 53.9 | 55 | 57.9 |
Number of pre-diagnosis visits
| ||||||
Median, [IQR] | 3 | [2–4] | 3 | [2–4] | 3 | [2–4] |
<3 | 9 | 33.3 | 24 | 35.3 | 33 | 34.7 |
≥3 | 18 | 66.7 | 44 | 64.7 | 62 | 65.3 |
Participant | Age (years) | City of residence | Education level | Socio-Economic Status | HIV Status | Health Insurance | FIGO stage |
---|---|---|---|---|---|---|---|
P1 | 59 | Abidjan | Primary | Low | Negative | Uninsured | III |
P2 | 38 | Lagunes | None | Low | Negative | Uninsured | IV |
P3 | 54 | Abidjan | None | Very Low | Positive | Uninsured | IV |
P4 | 34 | Abidjan | None | Very Low | Negative | Uninsured | III |
P5 | 56 | Zanzan | None | Low | Negative | Uninsured | III |
P6 | 38 | Abidjan | None | Low | Positive | Insured | I |
P7 | 36 | Abidjan | None | Very Low | Negative | Uninsured | III |
P8 | 43 | Bas-Sassandra | Primary | Low | Negative | Uninsured | III |
P9 | 43 | Abidjan | Primary | Low | Positive | Uninsured | II |
P10 | 49 | Comoé | Primary | Very Low | Positive | Uninsured | II |
P11 | 38 | Abidjan | Secondary and over | Medium | Negative | Insured | II |
P12 | 49 | Abidjan | Secondary and over | Medium | Negative | Uninsured | IV |
Characteristics | KI (1) | KI (2) | KI (3) | KI (4) | KI (5) | KI (6) |
---|---|---|---|---|---|---|
Age (years) | 48 | 44 | 59 | 36 | 45 | 49 |
Gender | W | M | W | M | M | M |
Designation | Midwives | Oncologist | Midwives | Gyneacologist | Gyneacologist | Oncologist |
Working experience (years) | 10 | 9 | 22 | 9 | 15 | 11 |
Factors associated with advanced cervical cancer
Patient related factors
Cancer Stage at diagnosis | ||||||
---|---|---|---|---|---|---|
Early stage (I/II) | Advanced stage (III/IV) | Unadjusted OR (95% CI) | P value | Adjusted OR (95% CI) | P value | |
Factors
| n/N | n/N | ||||
Age group (years)
| 0.36 | |||||
<40 | 5/17 | 12/17 | 1 | |||
40–59 | 18/55 | 37/55 | 0.8 [0.2–2.8] | |||
≥60 | 4/23 | 19/23 | 2.0 [0.4–8.9] | |||
Education level
| ||||||
None | 11/44 | 33/44 | 1 | 0.70 | ||
Primary | 8/28 | 20/28 | 0.8 [0.3–2.4] | |||
Secondary and over | 8/23 | 15/23 | 0.6 [0.2–1.9] | |||
Marital status
| 0.32 | |||||
Married | 12/34 | 22/34 | 1 | |||
Living with partner | 6/18 | 12/18 | 1.1 [0.3–3.6] | |||
Widowed or single or divorced | 9/43 | 34/43 | 2.0 [0.7–5.7] | |||
Occupation
| ||||||
Employed | 17/56 | 39/56 | 1 | |||
Unemployed | 10/39 | 29/39 | 1.2 [0.51–3.16] | 0.61 | ||
Place of living
| ||||||
Abidjan | 10/41 | 31/41 | 1 | |||
Other cities$ | 17/54 | 37/54 | 0.7 [0.3–1.7] | 0.44 | ||
Menopause
| ||||||
No | 15/36 | 21/36 | 1 | |||
Yes | 12/59 | 44/59 | 2.8 [1.1–7.0] |
0.02
| - | - |
HIV Status
| ||||||
Positive | 9/18 | 9/18 | 1 | 1 | ||
Negative | 18/77 | 59/77 | 3.3 [1.1–9.5] |
0.02
| 5.4 [1.6–17.7] |
0.006
|
Health insurance coverage
| ||||||
Yes | 6/9 | 3/9 | 1 | 1 | ||
No | 21/86 | 65/86 | 6.2 [1.4–26.9] |
0.01
| 13.1[2.0–85.5] |
0.007
|
Prior Knowledge of cervical cancer™
| ||||||
Yes | 19/51 | 32/51 | 1 | 1 | ||
No | 8/44 | 36/44 | 2.7 [1.0–6.9] |
0.04
| 2.1 [0.7–6.3] | 0.16* |
Use traditional healers
©
| ||||||
No | 22/63 | 51/63 | 1 | |||
Yes | 5/32 | 27/32 | 2.9 [1.0–8.5] |
0.05
| - | - |
Access to specialized facilities
¥
| ||||||
Reference | 25/76 | 51/76 | 1 | 1 | ||
Directly | 2/19 | 17/19 | 4.2 [0.9–19.4] |
0.07
| 7.1 [1.1–44.0] |
0.01
|
Number of pre-diagnosis visits
| ||||||
<3 | 9/33 | 24/33 | 1 | |||
≥3 | 18/62 | 44/62 | 0.9 [0.3–2.3] | 0.85 | ||
Histological subtypes
| ||||||
Adenocarcinoma | 1/9 | 8/9 | 1 | |||
Squamous cell carcinoma | 26/86 | 60/86 | 0.3 [0.03–2.4] | 0.25 | ||
Total time interval
®
| ||||||
<180 | 10/40 | 30/40 | 1 | |||
≥180 | 17/55 | 38/55 | 0.7 [0.3–1.8] | 0.52 |
“... I used to get tested for cervical cancer every year at the HIV clinic where I received my medication. The last time was in 2017.“ (P6, 38 years old, stage I)”Before the illness, I didn’t use to consult the gynaecologist because I had no disease.“ (P2, 38 years old, stage IV).“Africans do not visit gynaecologist except for childbirth or other serious health problems. And often, in our culture, we say to avoid waking up the sleeping illness. Laughing.“ (P8, 43 years old, stage III)
“Biopsy is still expensive. I was lucky enough to have it done the same day it was prescribed and to be diagnosed at an early stage because my insurance covered more than half of the costs.” (P11, 38 years old, stage II)“I couldn’t do the biopsy the same day it was prescribed because of lack of money. So I waited two weeks before coming back to do it for free at the university hospital.” (P7, 36 years old, stage III)
“At the beginning, I didn’t consider my illness, I thought it was common. It was a few months later, when I saw that I was bleeding too much and becoming very weakened, I went directly to the university hospital.” (P1, 59 years old, stage III)
Health providers-related factors
1. Lack of patient information and awareness about cervical cancer and screening by healthcare providers
“If I went to the gynaecologist before my illness, it was also to orient me and help me avoid other illnesses. He prescribed blood tests and echography, but he never told me about cervical cancer and did not proposed me to do a pap test.” (P12, 49 years old, stage IV).“The doctor I was following asked me to do this test every year. Each time I was tested, he never gave me the result. I didn’t even know why I was doing it… For the past four years, I have not returned for this test.” (P3, 54 years old, stage IV)
2. Inadequate knowledge of the signs and symptoms of cervical cancer
“At the General Hospital, the doctor who examined me gave me a blood test, then told me that I had malaria.” (P5, 56 years old, stage III)“[...] As the bleeding persisted, I went to see a midwife at the general hospital. After examination, she told me that my cervix was open. If at least she knew the small signs of cervical cancer, she would have referred me immediately to the specialized hospital to see a gynecologist.” (P7, 36 years old, stage III)“[...] When I arrived at the dispensary, the nurse gave me two injections to stop the blood, then asked me to come back a week later. I didn’t return because the injections were very painful and worsening my condition.” (P5, 56 years old, stage III)
Health system factors
Inadequate national awareness and screening campaigns
“[…] There is more awareness campaigns on breast cancer than cervical cancer. Those who talk about cervical cancer don’t give enough information about its causes and symptoms.” (P12, 49 years old, stage IV)“I have heard that the message about cervical cancer and screening is played only on the radio. However, in my village, I don’t have a radio. That’s why I didn’t have access to information about it before my illness.” (P4, 34 years old, stage III)