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The Oncologist, 2024, XX, 1–9
https://doi.org/10.1093/oncolo/oyae305
Advance access publication 18 November 2024
Original Article
Barriers to adherence of posttreatment follow-up after
positive primary cervical cancer screening in Ethiopia:
amixed-methods study
Rahel Alemayehu*,1,2,, Clara Yolanda Stroetmann2, Abigiya Wondimagegnehu1,2,3,,
Friedemann Rabe2, Adamu Addissie1,2,3, Eva Johanna Kantelhardt2,4, Muluken Gizaw1,2,3
1Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa,
Ethiopia
2Global Health Working Group, Institute of Medical Epidemiology, Biometrics and Informatics, Martin-Luther-University Halle-Wittenberg,
Halle (Saale), Germany
3NCD Working Group, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
4Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
*Corresponding author: Rahel Alemayehu, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa,
Ethiopia (alemayehurahel471@gmail.com).
Abstract
Background: Even though it is preventable, cervical cancer contributes significantly to cancer-related mortality among Ethiopian women.
Follow-up visits after treatment of precancerous lesions are essential to monitor lesion recurrence. In our previous study, we found a level of
adherence to follow-up of 44.7%, but the reasons for low adherence have not been comprehensively explored within the Ethiopian context.
This study aimed to identify these reasons by interviewing 167 women who had missed their follow-up appointments as well as 30 health
professionals with experience in the field.
Methods: The study employed a mixed-methods approach: Quantitative data were collected through a telephone questionnaire conducted with
167 women who had a positive visual inspection with acetic acid (VIA) and had missed their follow-up appointments. Subsequently, in-depth
interviews were conducted with 30 healthcare professionals, and an inductive content analysis was carried out.
Results: In the patient interviews, the reasons given most often were “lack of information about the follow-up” (35; 21.1%), “forgetting the
appointment” (30; 18.1%), and “not seeing the need for follow-up” (24; 14.5%). Healthcare professionals identified various reasons such as lack
of knowledge, living in a remote area/changing living area, forgetfulness, fear, poor counseling, a shortage of trained healthcare providers to give
counseling and follow-up, and reminder-related barriers.
Conclusion: Lack of knowledge, forgetfulness, poor health-seeking behavior, and a lack of reminders were identified as barriers contributing
to the low uptake of rescreening. Further interventions should target these by creating community awareness, improving patient counseling,
tracing patients in need of follow-up, and making reminder calls or using SMS.
Key words: cervical cancer screening; adherence to follow-up; barriers; cryotherapy; Ethiopia.
Implications for Practice
This study may inform the development of healthcare policies and interventions tailored to address specific challenges faced by
patients with visual inspection with acetic acid (VIA)–positive lesions. It has highlighted areas where posttreatment follow-up services
can be improved and can help integrate follow-up services more seamlessly into existing healthcare systems. Our results may help in
adjustments to be made to interventions based on emerging challenges. By addressing the barriers to posttreatment follow-up after
positive VIA screening, healthcare systems can improve the effectiveness of cervical cancer screening programs and reduce the burden
of the disease.
Introduction
In high-resource countries, cervical cancer screening has
been shown to reduce the incidence and mortality of the
disease.1-3 However, in Ethiopia, cervical cancer is still the
second leading cause of cancer death among women, with
an estimated 7445 new cases and 5338 deaths in 2020.4 The
Ethiopian Ministry of Health (MoH) recommends cervical
cancer screening (CCS) via visual inspection with acetic acid
(VIA) every 5 years and intensied screening for women liv-
ing with HIV (every 2 years). Those with a previous positive
screening should rescreen 1 year after treatment.5 If pre-
cancerous lesions are found, those are usually treated with
Received: 27 May 2024; Accepted: 9 September 2024.
© The Author(s) 2024. Published by Oxford University Press.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/),
which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
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2The Oncologist, 2024, Vol. XX, No. XX
cryotherapy or thermal ablation, preferably in a single-visit
approach.
Approximately 15% of women encounter recurrent or
residual precancerous lesions after treatment.6 The inuence
of the HIV status on recurrence rates has been discussed, but
while some studies have shown higher recurrence rates in
women living with HIV, clear evidence is still lacking.7-10
Studies in different settings have indicated high rates of
loss to follow-up after screening and treatment of precan-
cerous lesions, ranging from 32% to 80.3%.11-15 The level of
adherence to follow-up found in our previous study among a
cohort of 741 Ethiopian women in Oromia and Addis Ababa
was 44.7%.16 Due to resource limitations and poor organi-
zation of healthcare systems, limited adherence to follow-up
continues to be a problem in low- and middle-income coun-
tries and is associated with an elevated risk of developing cer-
vical cancer.17
Previous studies in other countries have identied various
barriers to compliance with follow-up requirements. These
include socio-demographic factors such as the women’s edu-
cational level, the inuence of male companions or partners,
nancial constraints per transportation to healthcare facili-
ties, and fear of adverse effects such as infertility. Furthermore,
facility-related barriers such as staff attitude, cost of service,
and inadequate counseling have also emerged.18-21
Identifying barriers to adhering to posttreatment follow-up
can help policy-makers and program managers address those
obstacles through designing effective interventions. This, in
turn, may enhance women’s adherence to posttreatment fol-
low-up to prevent the recurrence of precancerous cervical
lesions and their progression into invasive cancer. As of now,
little is known about barriers associated with nonadherence
in Ethiopia. Therefore, this study aimed to ll the gap by
exploring barriers to posttreatment follow-up in Addis Ababa
and the Oromia region of Ethiopia.
Methods
Study design and setting
This study was a continuation of a 2022 study involving 10
health centers located in 4 subcities of Addis Ababa and 4
hospitals in the Oromia region. The results from logbook
reviews and phone interviews were detailed in our previous
paper, which also provides a comprehensive overview of the
methodologies employed for the phone interviews, including
questionnaire and sampling procedures.16 This paper specif-
ically explores reasons for nonadherence to follow-up from
patients. The in-depth interviews (IDIs) focused on health
professionals’ experiences with facility and community-re-
lated barriers.
Quantitative data collection and analysis
All women with registered phone numbers (574 patients)
were invited to participate in a questionnaire-based phone
interview, and 399 responded. Of these, 365 received ini-
tial treatment of their precancerous lesion. The adherence to
post-treatment follow-up among our phone interview par-
ticipants was 54.2%; the remaining 167 women were ques-
tioned about the reasons for nonadherence to follow-up; 166
responded. As part of the quantitative questionnaire-based
interview, 9 choices based on our literature review were pro-
vided: lack of time, travel costs, “I forgot,” “I didn’t think
I needed follow-up,” fear of outcome, unsupportive spouse,
“not told to do so,” preference of other treatments, and the
option “other” where women could elaborate. The responses
to the “other” question were categorized by the 2 principal
investigators which led to the result in Figure 1.
Qualitative data collection and analysis
The qualitative IDIs with 30 healthcare professionals work-
ing in the eld of CCS were conducted by a team of 2 trained
research assistants and 1 of the principal investigators. Our
interview partners included medical directors of hospitals,
CCS service providers or focal personnel, noncommunicable
disease (NCD) team leaders, and maternal and child health
coordinators. The interviews were conducted in the local lan-
guage Amharic, audio-recorded, and supported by eld notes.
The interview guide (Supplement 1) developed by the prin-
cipal investigators aimed to explore barriers linked to post-
treatment follow-up adherence following CCS.
All the recorded interviews were transcribed and translated
into English verbatim. These translated data were uploaded
onto qcamap.org22 and subjected to coding using inductive
content analysis techniques, rst led by the principal inves-
tigator and then cross-checked by the research team. The
content analysis was geared toward synthesizing ndings
and identifying key themes, aligning with inductive category
formation methodology.23 The research question was: “What
aspects lead to loss of follow-up after treatment of precan-
cerous cervical lesions from a health worker’s perspective?”A
coding-recoding evaluation agreement was achieved.
Ethical approval
Our study adhered to ethical standards with clearance granted
by the School of Public Health, Addis Ababa University (Ref.
No.SPH/1321/14). All the interviewed participants were
informed about the study’s objectives, and their consent to
participate was obtained.
Results
Patients’ characteristics
In Table 1, an overview of the socio-demographic character-
istics of the 166 patients is presented. The median age was 34
years. Almost three-fourths (120, 72.3%) of the interviewed
women were currently married, and most (148, 89.2%) had
at least 1 child. The majority were either illiterate (32, 19.3%)
or had only primary education (48, 28.9%). More than one-
third were “housewife/unemployed” (57, 34.3%), while the
private sector (42, 25.3%) and government employees (39,
23.5%) also participated. The median self-reported income
was 3000 ETB (52.8 USD) per month.
Patients’ reasons for not attending follow-up
The most common predened reasons selected were not being
informed about the follow-up (35, 21.1%) and forgetting the
appointment (30, 18.1%). Other common reasons chosen by
respondents included not perceiving the follow-up as neces-
sary/feeling healthy (24, 14.5%) and lack of time (19, 11.4%).
Among the reasons, participants cited independently included
having moved or being temporarily away (20, 12%), which
were signicant factors in missing appointments (Figure 1).
Health professionals’ perspectives
Characteristics of the 30 interviewed health professionals
are displayed in Table 2. Eighteen (60%) were females, with
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The Oncologist, 2024, Vol. XX, No. XX 3
a median age of 32.5 years. More than three-fourths (23,
76.7%) received special training on CCS.
Barriers to adhering to follow-up were categorized into
2 distinct groups: patient-related and facility-related bar-
riers (Supplement 2). Patient-related barriers included
socioeconomic hindrances, lack of awareness, poor
health-seeking behavior, residency-related barriers (like living
in a very remote area/changing living area, or difculty tak-
ing public transport to the health facility), forgetfulness, and
fear. Facility-related barriers included a shortage of trained
Figure 1. Reasons for not adhering to follow-up appointments as stated by patients (n = 166; one answer per patient).
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4The Oncologist, 2024, Vol. XX, No. XX
healthcare providers, decient counseling practices, and
reminder-related barriers, such as a lack of staff to facilitate
reminder calls, no telephone in the CCS unit, frequent change
of logbook, and improper documentation of patient data.
Patient-related barriers
During the IDIs, the participants emphasized socioeconomic
factors that impeded women from attending follow-up
appointments. They described heavy workloads at home that
prevented most women from leaving, with insufcient time
for their own health. An NCD team leader portrayed this sit-
uation, stating: “Women’s burden in the community is high
from performing different activities including child raising,
social activity, community engagement, and income-gener-
ating activities. So, they are too busy to take the screening
and treatment programs” (age 32). Participants discussed
the inuence of husbands in women’s health decisions, with
1 CCS service provider noting: “[The] husbands’ inuence
is another factor since most women economically depend
on their husbands. So, they have to respect their husbands’
decisions to undergo treatment and follow-up” (age 30). Also,
transportation costs were identied as a possible challenge to
accessing follow-up services. An NCD team leader pointed
out: “They may also have an economic problem such as lack
of money for transportation” (age 52).
The geographical distance to the health facility was also
considered an impeding factor for both patients and health-
care providers, as illustrated in the following quote: “We try
to contact them directly in person by searching for their per-
manent residence location based on the contact information
from the patient’s card collaboratively with the health exten-
sion workers. This process works for only those clients whose
location is in our woreda[administrative region]” (CCS ser-
vice provider, age 34). A medical director expressed the belief
that women who frequently change their place of residence
are at higher risk of missing their follow-up screening, say-
ing: “They may move after screening and treatment. But the
permanent residents return for follow-up. One factor for not
coming back for their follow-up is being a non-permanent
resident” (age 35).
Another prevalent subtheme was the lack of awareness
about cervical cancer preventive measures, as expressed by
1 participant: “The biggest barrier on the patient side is the
awareness gap, because most of the clients’ awareness about
the importance of follow-up is very low” (CCS focal person,
age 34). The lack of awareness was particularly problematic
because women undergoing screening typically remain asymp-
tomatic and perceive themselves as healthy. The absence of
noticeable symptoms and the limited understanding of the
screening’s preventive effect were recognized as signicant
Table 1. Socio-demographic characteristics of patients who did not adhere to follow-up (n = 166).
Variable Units Frequency (%)
n = 166
Age ≤29 years 35 (21.1%)
30–34 years 53 (31.9%)
35–39 years 47 (28.3%)
≥40 years 31 (18.7%)
Median age (IQR) 34 years (8)
Marital status Married 120 (72.3%)
Divorced 25 (15.1%)
Single 13 (7.8%)
Widowed 8 (4.8%)
Parity 0 18 (10.8%)
1 52 (31.3%)
2 45 (27.1%)
3 22 (13.3%)
>3 29 (17.5%)
Educational Status Illiterate 32 (19.3%)
Can read and write 13 (7.8%)
Primary education 48 (28.9%)
Secondary education 38 (22.9%)
College 35 (21.1%)
Occupation Housewife/unemployed 57 (34.3%)
Private employee 42 (25.3%)
Government employee 39 (23.5%)
Daily laborer 14 (8.4)
Merchant 9 (5.4%)
Farmer 1 (0.6%)
Unknown 4 (2.4%)
Monthly income Median 3000 ETB (52.8 USD)a
aConverted using http://www.forbes.com.
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The Oncologist, 2024, Vol. XX, No. XX 5
barriers by various interviewees, expressed in the following
statements: “Especially those who come from rural areas, if
they don’t understand the importance or if they don’t see any
signs, they may be left behind” (medical director, age 43), and
“since there are no physical symptoms, they see if they live
far from the hospital, they decide not to spend the transport
fee and conclude that they are ne” (CCS service provider,
age 45).
Another interviewee explained that, when asking patients
why they delayed the follow-up screening, “they used to men-
tion that they were ne; they observed no symptoms or they
forgot their appointment” (CCS focal person, age 34). This
statement also emphasized the absence of symptoms as a
predicament and additionally introduced forgetting the fol-
low-up appointment as a common explanation for missing
or delaying the follow-up screening. A perception that was
shared by another interviewee who said, when asking his cli-
ents “why they didn’t show up for their follow-up appoint-
ment on the scheduled date, the majority of them said they
had forgotten” (CCS service provider, age 28).
Finally, a fear of pain during examination or treatment
emerged as a recurring motive. One NCD team leader claimed:
“The major barrier [is] the fear the clients have towards the
metal speculum. Some of them even after taking the screening
for the rst time won’t come again for follow-up since they
remember the procedure with the metal speculum” (age 30).
Another participant shared: “When we conduct cryotherapy,
there might be some kind of pain or bleeding in some cases,
so due to the fear of such kinds of symptoms, they didn’t
want to receive the treatment” (NCD team leader, age 29).
In 1 specic case, when an NCD team leader asked a client
for her reasons not to come back for the follow-up screening,
“the answer was fear of the pain of the [cryotherapy] pro-
cess” (age 29).
Health facility-related barriers
The second group of barriers discussed during the IDIs was
factors related to the structure and equipment of the health
facilities, and on a grander scale, the healthcare system. One
central topic was poor counseling by healthcare providers.
Interview partners expressed the belief that clients are will-
ing to follow the advice given by healthcare professionals
but often do not receive adequate counseling. For example,
1 NCD team leader stated: “From my experience, our com-
munity believes and accepts advice from health professionals
if well informed. But if in-depth counseling is not given, and
if it is given in a rush, it could be one reason” (age 52). Some
of the health professionals argued that poor counseling was
related to an insufcient number of healthcare providers. A
medical director said: “[Patients do not] get good counsel-
ing due to the lack of health care providers in cervical cancer
screening units. […] There are only two healthcare providers
there. Even there was one previously. There is a lack of time,
so I don’t think they give attention to counseling” (age 36).
According to most of the interviewed partners, the shortage
of trained staff did not only affect the quality of the counsel-
ing but also the provision of the follow-up screening itself.
As pointed out in the following remark, most health centers
employed only 1 person providing CCS, without a backup: “In
most health facilities, in health centers that have a shortage of
personnel, there is only one trained health care provider. Most
of the time, they are nurses or midwives. When the nurse or
midwife placed there has night duty and becomes the day
off, the clients lose the service due to this” (CCS service pro-
vider, age 35). Furthermore, the participants explained that
the health professionals providing CCS were often required
to assist in other parts of the health facility and were therefore
unable to provide the service. Examples included: “Due to dif-
ferent campaign programs like vaccination programs which
include polio and COVID-19 vaccination[…]the precancer-
ous cervical cancer screening program may halt the service
for the duration of the campaign work” (CCS service pro-
vider, age 28), and “during these times [when I am working
on another hospital task], this room is closed; mothers won’t
be able to nd me, and as a result, they leave without being
rescreened” (CCS service provider, age 45). Especially those
clients who came to the health center for screening but did
not encounter anyone, there were often lost to follow-up.
Another frequently mentioned issue was the insufcient
reminder system. While many health professionals described
solely relying on appointment cards, only a minority said they
called patients regularly. The reasons for not being able to
call clients touched on different aspects. Lacking the neces-
sary telephone was pointed out by 1 NCD team leader: “The
rst thing that I want to mention in this area is that health
professionals in the department didn’t make phone calls as
reminders for follow-up examinations. Maybe they have dif-
ferent reasons for that including a lack of ofce telephone
access and a mobile card” (age 29). One CCS provider even
described using her private phone to make the phone calls:
“In my previous experience, I called clients as a reminder for
their appointment date, and they came for their follow-up.
But later, they saved my phone number and called me outside
of working hours, including midnight, just to discuss other
medical conditions” (age 32). Some participants also related
the decient reminder system with the shortage of staff:
“Since only one health care provider is working here, there is
Table 2. Characteristics of interviewed health professionals (n = 30).
Variables Categories Frequency
Sex Male 12
Female 18
Age ≤29 years 5
30–34 years 14
35–39 years 5
≥40 years 6
Median age (IQR) 32.5 (6)
Work position CCS focal or service provider 16
Medical director 3
NCD team leader 9
MCH coordinator 2
Work experience on
the position in years
≤2 years 17
3–5 years 9
6–10 years 4
CCS training Yes 23
No 7
Cryotherapy training Yes 22
No 8
Abbreviation: MCH: maternal and child health.
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6The Oncologist, 2024, Vol. XX, No. XX
a problem with tracking and calling appointed women. […] If
there are two healthcare providers, it may be easier to select
post-treatment follow-up mothers or untreated mothers and
make calls to remind them” (CCS service provider, age 29)
A third aspect mentioned regularly in relation to the
reminder system was the quality of the documentation.
Difculties regarding the logbook documentation were
described by this CCS service provider: “I occasionally come
across documentation issues such as illegible handwriting,
unregistered phone numbers, incorrectly addressed names,
and missing appointment dates” (age 30). Additionally,
frequent changes of the logbook format were mentioned:
“Sometimes, it [the logbook] is changed after we use only the
rst page. It is extra work to nd the old one. […] If it is
changed within months or weeks, we lose mothers in between
because we don’t focus on the old logbooks” (CCS service
provider, age 29).
Actions to be taken by responsible bodies of the
healthcare system
The IDI participants suggested different strategies (Figure 2)
for all involved stakeholders to address the given barriers
across all levels of the healthcare system to subsequently
improve the adherence to follow-up. The stakeholders include
the MoH, health bureaus, health facilities, and health profes-
sionals who work in CCS departments. The MoH is responsi-
ble for providing high-quality beginner and refresher trainings
for CCS and cryotherapy; in those trainings, the importance
of follow-up and in-depth counseling should be stressed, and
guideline adherence promoted. Subsequently, the MoH might
offer a system of supervision and allow feedback discussions
with health professionals and health facilities. Together with
the health facilities, the MoH should ensure that the mate-
rials necessary for CCS and treatment are available. Besides
those materials, health facilities should provide rooms that
are easy to locate and allow appropriate privacy while con-
ducting CCS as well as phone access for reminder calls in
all CCS units. What is more, some of the interviewed staff
shared their disappointment about missing linkage with other
departments within the same health facility, such as gynaecol-
ogy, out patient department (OPD), and HIV departments.
The health professionals providing CCS should uphold a high
standard of care, provide good information and counseling,
track women in need of follow-up, and make reminder calls.
Finally, all stakeholders were encouraged to work together to
raise community awareness.
Discussion
In this study, the most common reasons given by women who
did not attend rescreening 1 year after treatment for precan-
cerous lesions were not being aware of the follow-up, forget-
fulness, perceiving follow-up as not needed, feeling healthy,
moving to another place, being temporarily away, and lack of
time. The ndings from the IDIs conducted with health pro-
fessionals aligned around barriers to posttreatment follow-up,
including lack awareness, forgetfulness, poor health-seeking
behavior, residency-related barriers, and lack of time due to
household responsibilities. Moreover, the health professionals
reported health-facility-related barriers such as a shortage of
trained healthcare providers, a poor counseling service, and
the lack of a reminder system.
The telephone participants mentioned not being aware
of the follow-up as a common reason for not adhering to
follow-up recommendations. A cohort study conducted in
Cameroon also reported the lack of information as a main
barrier to rescreening.24 Most of our IDI participants also
agreed that the lack of awareness was one of the main bar-
riers to women’s adherence to their posttreatment follow-up.
Poor health-seeking behavior was another barrier discussed.
Health professionals stressed that women might think that
there is no need to go to the health facility if they do not feel
sick, which can be explained by a lack of awareness and poor
understanding of the importance of posttreatment follow-up.
Figure 2. Recommended actions by responsible bodies in the healthcare system to improve cervical cancer screening follow-up adherence mentioned
by the health professionals.
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The Oncologist, 2024, Vol. XX, No. XX 7
Studies conducted in southwest Nigeria,25 the United States,26
and a multicountry research project in Bolivia, Peru, Kenya,
South Africa, and Mexico20 also support this nding. This
issue can probably be minimized by effective counseling.
Conversely, poor counseling services were cited as a barrier.
This is supported by a qualitative study in Cameroon that
found inadequate counseling as a barrier to follow-up of pre-
cancerous lesion treatment.21 A study in Jamaica showed that
women who were given advice on follow-up timing were 6
times more likely to seek appropriate follow-up.27 Other stud-
ies also showed that adherence to follow-up was associated
with effective communication, being informed of their screen-
ing results, and having correct awareness of the outcome.28
Hence, counseling can serve as a tool for educating patients
on the necessity of follow-up procedures, addressing fear, pro-
viding emotional support, and overcoming barriers. Adequate
and culturally adaptive counseling should be given to patients
to improve adherence to follow-up.
Forgetting the appointment was mentioned by both the
patients and health professionals as one of the main reasons
for the loss of follow-up. This might be due to patients’ lack
of attention due to other responsibilities or the lack of a
reminder. These ndings align with a study based on a review
of several studies showing “forgetting appointments” as one
of the most common barriers to follow-up.28 Apart from good
counseling, reminder systems could be one effective way of
diminishing this barrier; the Ethiopian cervical cancer preven-
tion and control guideline recommends “telephone women at
home or at work” and “health extension workers and case
managers to contact women directly at home.”5 A study in
Honduras found that reminder phone calls were highly suc-
cessful at recalling women for HPV retesting.29 Another study
conducted in Kenya revealed that sending SMS reminders
for revisits resulted in a 5-fold rise in the number of patients
who received clinically appropriate care following a positive
screening result.30 The Tanzanian study also found that the
majority of HPV-positive women attended their follow-up
appointment after receiving a text message.31 However,
despite the guideline suggesting to telephone women who
do not return for follow-up, in the IDIs, it became clear that
these reminder systems are not yet well implemented due to
various reasons, including missing telecommunication equip-
ment, difculties in tracking eligible patients due to frequent
changes of screening logbooks, and a shortage of staff.
Staff shortage was also discussed as a key problem in pro-
viding the required services for follow-up; in particular, the
absence of healthcare providers conducting the screening
during operation hours, insufcient personnel to ensure ade-
quate documentation, and a lack of time to provide adequate
counseling posed as major challenges. Problems with trained
staff not working at respective sites and additional respon-
sibilities of service providers other than CCS and treatment
were already identied in the health facility assessment of the
Addis tesfa project in Ethiopia.14 A study that summarizes the
experiences of research projects in different countries came to
similar conclusions regarding staff shortages and their effect
on follow-up.20
Another identied barrier was the fear of pain during an
examination or therapy. This nding is consistent with a review
of several studies that identied “fear of diagnosis and treat-
ment” as one of the obstacles to follow-up.28 Some people may
skip rescreenings out of fear of experiencing pain. Severe pain
during these procedures is not generally anticipated. Women
who experience severe pain on their rst visit should receive
extra attention and counseling for the following visits, and it
is critical for patients to express their fears and discomfort in
order to receive appropriate support and treatment.
During the IDIs, geographical distance from the health facil-
ity, transport costs, and changing the place of residence were
frequently discussed as patient-related barriers to adhering to
a follow-up screening. A study in Honduras also mentioned
moving away from the clinic area as a barrier to follow-up
adherence.29
Another barrier in this study was the husband’s inuence
on the health-seeking behavior of the clients, in line with
studies in Cameroon21 and Mexico20 that showed male part-
ners’ inuence and lack of support to attend follow-up visits
as barriers to follow-up. In another study conducted in rural
Lilongwe, Malawi, male companions were mentioned as both
barriers and valuable sources of support including encour-
agement, emotional support, and assistance in overcoming
transportation obstacles.32 The clients’ responsibilities such
as childcare were also discussed in our study. Research to
identify hurdles to follow-up in Latina women with abnormal
Pap smears who were referred for colposcopy also identied
childcare responsibility as a barrier.26
Strengths and limitations
To our knowledge, this mixed-methods study was the rst of
its kind to give insight into barriers to adherence to follow-up
recommendations in Addis Ababa and the Oromia region. The
ndings from both methods complement each other, including
perspectives from different health professionals that allow for
a broad picture of the health facility-related barriers. However,
IDIs were conducted only with healthcare providers since we
were unable to interview patients in person. We tried to tackle
this issue by addressing reasons for not attending follow-up
during the quantitative telephone interviews.
Conclusion
This mixed-methods study assessed various barriers to fol-
low-up after treatment for cervical precancerous lesions in
Ethiopia. We identied that the lack of a patient tracking sys-
tem and a lack of reminders contributed to the low uptake
of rescreening. Forgetfulness, fear, lack of awareness, poor
health-seeking behavior, residency-related barriers like living
in a remote area or changing living area, and socioeconomic
barriers such as lack of time due to household responsibili-
ties, the husband’s inuence, and a lack of money to travel
were identied as patient-related barriers, while a shortage of
trained healthcare providers, poor counseling, and an insuf-
cient reminder system were the health facility-related barriers
to follow-up adherence.
Effective interventions, such as creating community aware-
ness, improving patient counseling, improving the system of
tracing patients in need of follow-up, and making reminder
calls should be targeted by different stakeholders to tackle
these barriers. In line with efforts to up-scale the digitalization
of health systems, patients should also directly benet. Health
workers could directly inform patients 1 year after the treat-
ment of suspicious cervical ndings, for instance, through
SMS reminders. Given the massive governmental efforts in
Ethiopia to offer primary screening, rescreening compliance
in high-risk patients should be a priority to ensure the success
of the whole program.
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8The Oncologist, 2024, Vol. XX, No. XX
Acknowledgments
The authors would like to thank the data collectors and
patients for their participation.
Author contributions
Rahel Alemayehu: Study design, provision of patients, collec-
tion and assembly of data, data analysis and interpretation,
manuscript writing, nal approval of the manuscript. Clara
Yolanda Stroetmann: Study design, provision of patients,
collection and assembly of data, data analysis and interpre-
tation, manuscript writing, nal approval of the manuscript.
Abigiya Wondimagegnehu: Study design, data analysis and
interpretation, manuscript writing, nal approval of the
manuscript. Friedemann Rabe: Study design, data analysis
and interpretation, manuscript writing, nal approval of the
manuscript. Adamu Addissie: Study design, data analysis and
interpretation, nal approval of the manuscript. Eva Johanna
Kantelhardt: Study design, data analysis and interpreta-
tion, manuscript writing, nal approval of the manuscript.
Muluken Gizaw: Study design, data analysis and interpreta-
tion, manuscript writing, nal approval of the manuscript.
Funding
This work was supported through the German Ministry
of Research and Education (grant 01KA2220B) and
the Else Kroener-Fresenius-Foundation (grant 2018_
HA31SP). The study was also supported by a grant from
Hospital Partnership through Deutsche Gesellschaft für
InternationaleZusammenarbeit, funded by the Ministry for
Economic Cooperation and Development (ID 81281315).
This research was also funded in part by the Science
for Africa Foundation to the Developing Excellence in
Leadership, Training and Science in Africa program (Del-22-
008), with support from Wellcome Trust and the UK Foreign,
Commonwealth & Development Ofce, and is part of the
EDCPT2 program supported by the European Union.
Conflicts of interest
None declared.
Data availability
Due to condentiality, the data are not available publicly but
can be made available upon reasonable request to the rst
author.
Supplementary material
Supplementary material is available at The Oncologist online.
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