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International Journal of Cancer and Oncology
Int J Cancer Oncol Vol 7:1
ISSN:2377-0902OPEN ACCESS
Review Article
Perception of Cervical Cancer Screening Program among
Healthcare Workers in a District of Sri Lanka: A
Qualitative Study
Perera, KCM¹, Abeysena, HTCS², Mapitigama, N³
¹Senior Registrar in Community Medicine, Directorate of Non-Communicable Diseases, Ministry of Health, Sri Lanka
²Senior Professor in Community Medicine, University of Kelaniya, Sri Lanka
³Consultant Community Physician, Family Health Bureau, Ministry of Health, Sri Lanka
*Corresponding author: Dr. KCM Perera, Senior Registrar in Community Medicine, Directorate of Non-Communicable Diseases,
Ministry of Health, Sri Lanka; E-mail: chithranganieperea@yahoo.com
Citation: Perera, K.C.M., et al. Perception of Cervical Cancer Screening Program Among Healthcare Workers In A District Of Sri Lanka: A
Qualitative Study. (2021) Int J Cancer Oncol 8(1): 1-7.
Received date: October 30, 2020 Accepted date: March 27, 2021 Published date: March 31, 2021
Copyright: © 2021 Perera, K.C.M. This is an Open access article distributed under the terms of Creative Commons Attribution 4.0
DOI: 10.15436/2377-0902.21.3011
Abstract
Background: In 1998, conventional papanic0laou smear screening was included in the Well Woman Clinic (WWC)
program as a cervical cancer screening method. The objective of the study was to explore the perception of cervical
cancer screening programs among healthcare workers in a district of Sri Lanka.
Method: Focus group discussion (FGD) sessions (n=4) and In-depth interviews (n=10) were used to collect data. Eight
Public Health Midwives (PHMM) were selected for one FGD session. Public Health Midwives for each focus group
were selected from MOH areas according to their seniority and the sector of community representation. Key Infor-
mants were selected among health care workers, who engaged in the cervical cancer screening program. A convenient
sampling technique was used to select participants. Triangulation methodology was used to improve the quality of the
information. Descriptive codes were identied as common themes and categories. Codes and categories were revised
repeatedly until they gave an accurate representation of the data gathered. Finally, an amalgamated list of codes was
developed with FGDs. In the last summary results, were prepared. The analysis was made by manual content.
Results: Majority of the participants were Sinhalese (n=41, 97.6%), Buddhist (n=39, n=92.9%) and over 40 years of
age (n=31, n=73.8%). Some had >20 years of service in the eld(n=14, n=33.3%).Some participants mentioned the
low sensitivity of pap smears, unsatisfactory smears, and reporting delay as disadvantages of the pap smear screening
method. Increase community awareness, supervision of WWC activities, and conduction of mobile clinics indicated as
pathways to improve the coverage by participants. Healthcare workers expressed their positivity for HPV/DNA test as
its high sensitivity, while the majority stated to improve the coverage by vaginal specimens.
Conclusions: Increase community awareness, supervision of activities, conducting mobile clinics to cover hard to
reach population, and providing mobile pap kits were mainly stated to improve the quality of the program. Healthcare
workers in the Kalutara district were highly accepted the HPV/DNA new screening test for quality improvement and to
increase the coverage of the program.
Keywords: Cervical cancer screening; Healthcare workers; Perceptions
page no: 1
page no: 2
Citation: Perera, K.C.M., et al. Perception of Cervical Cancer Screening Program Among Healthcare Workers In A District Of Sri Lanka: A Qual-
itative Study. (2021) Int J Cancer Oncol 8(1): 1-7.
www.ommegaonline.org
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Introduction
Cervical cancer is an abnormal growth in the cells of the lower
part of the female uterus (cervix) that connects to the vagina and
most cervical cancers are originate from there[1]. According to
the incidence rate cervical cancer is the 2nd leading cause of fe-
male cancer in Sri Lanka and annually thousand seven hundred
and twenty-one new cases of cervical cancers are diagnosed and
690 women have died from the disease[2].
Cervical cancer screening is a secondary preventive
strategy of early detection of abnormal tissues from the cervix
before the development of cervical cancer. In 1996, the concept
of the Well Woman Clinic (WWC) program was introduced to
Sri Lanka to screen women for some selected non-communica-
ble diseases and visual inspection was the method for cervical
cancer screening. In 1998, conventional papanicolaou smear
screening was included in the WWC program as a cervical can-
cer screening method.
After 20 years of existence of the program, in contrast
to the vigorous preventive measures, there is no marked reduc-
tion of incidence, morbidity, and mortality of cervical cancer in
Sri Lanka. Therefore, the cervical cancer prevention program
needs to be reviewed with special attention.
Pap smear has relatively low sensitivity (47%-62%),
and the specicity also varies between 60-95%[3]. There is a lag
period on average of 6-8 weeks between smear taking and report
delivery[4] but sometimes, the gap may be even longer[5] since the
cyto-screeners and the pathologists in certain centers are over-
loaded with their routine work, which leads to accumulation of
unscreened slides which are called backlogs[5].
Another major drawback of the present program is the
low coverage. National 35 year age cohort WWC coverage for
2016 was 52.8%[6], while the recommended target coverage for
the program is 80%[5].
At present, HPV/DNA screening is used as a cervical
cancer screening method in some developed countries. HPV/
DNA screening can be used as a primary screening method fol-
lowed by cytology i.e. HPV/DNA test with cytology triage[7].
The average sensitivity& specicity of the HPV/DNA test in 35
year age cohort women are 89% and 90% respectively[8].
The association between the level of knowledge and
practice of screening is signicant[9]. There was a signicant
increase in overall knowledge with higher levels of education.
A vast majority of the PHMM had an above-average over-
all knowledge and positive attitude towards cervical cytology
screening and identied it as a screening method[10]. Strengthen-
ing health education interventions for female healthcare workers
is essential, as they play a major role in communicating health
behaviors to the general public[11]. The objective of the study was
to explore the perception of cervical cancer screening programs
among healthcare workers in a district of Sri Lanka.
Methods
Two qualitative research techniques were used for the study.
i. Focus Group Discussion (FGD).
ii. In-Depth Interviews
Four focus group discussion sessions were carried out during
January 2019. The rst session was conducted as a pilot test.
There were no signicant alterations, therefore it was consid-
ered for the analysis. The study population comprised of Public
Health Midwives (PHMM) who were attached to MOH oces
in Kalutara district.
A conceptual framework for qualitative inquiries was
developed based on the literature[12,13]. Using this conceptual
framework a moderator guide to facilitate the FGD was devel-
oped for this study with the assistance of experts and reviewed
by a panel of experts to determine the correct question (sup-
plementary le 1). The Panel of experts has consisted of Two
Consultant Community Physicians, one Consultant Histopathol-
ogist, one Medical Ocer at Gender and Women’s Health Unit,
Family Health Bureau. The key component of the conceptual
framework was six appropriate and informative questions as
mentioned below;
• What do you understand about methods of cervical cancer
screening?
• What do you think about the cervical cancer screening pro-
gram in Sri Lanka?
• What are the existing problems in the cervical cancer screen-
ing program in Sri Lanka?
• What do you think about HPV/DNA screening test as a cervi-
cal cancer screening method?
• Was this an appropriate summary?
• Did you forget something?
Venues of FGD sessions were identied according to
the accessibility and comfort of participants from MOH areas
in Kalutara district. Four venues were identied for four FGDs.
Eight PHMM were selected by convenience sampling technique
for one FGD session, one month before the conduction of FGD.
Public Health Midwives were informed of the venue and the
time for the discussion. Public Health Midwives for each focus
group were selected from MOH areas according to their seniori-
ty and the representation of the mixture of urban and rural com-
munities.
When selecting PHMM, attention was paid not to inter-
rupt their routine duty activities and preferred less traveling to
reduce the inconvenience of traveling and to improve participa-
tion but this may cause the reduction of representativeness of the
study sample to some extent. Before data collection, informed
consent was obtained from the selected PHMM. Each FGD was
carried out on a day when clinics were not held and was conve-
nient for PHMM, who had participated in the study. A properly
ventilated and lighted place was selected to conduct the session
in the venue selected.
The rst author, who had undergone advanced train-
ing on conducting FGDs, was the moderator of the FGDs. One
science graduate was recruited as an assistant moderator to give
background support by arranging the meeting room, taking re-
cords, handling distractions, and debrieng with the moderator
after each session. Non-verbal messages were taken to notes. All
three FGDs were audio-recorded with the permission of partici-
pants.
Moderator bias was reduced by staying neutral (tone of
voice, facial expression, body language…etc.) during an inter-
view as much as possible. The moderator refrained from asking
leading questions, which was aided by the use of an interviewer
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Perception of Cervical Cancer Screening Program
Perera, K.C.M., et al.
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guide. The information collected at each interview was summa-
rized at the end of each interview. Only ongoing ideas/views of
participants were used to prepare transcripts and care was taken
not to manipulate original ideas of the participant by the moder-
ator’s interpretation of views.
Audiotapes were transcribed verbatim by the rst au-
thor on the day of an interview. Both audio and verbal transcripts
were compared to ensure comprehensibility. They were repeat-
edly read and re-read to prepare descriptive codes, which con-
sisted of all emerging information. The results were then tabu-
lated. The rst interview was transcribed and interpreted before
moving in to the next interview. The rst author was coded the
data. Descriptive codes were modied to identify broad themes
and categories from the derived data. These categories were spe-
cic and mutually exclusive. Transcripts were again reviewed to
ensure that all have been categorized. An exhaustive list of codes
was developed that ensuring all important information had been
included. These steps were followed up in all four FGDs and an
amalgamated list of codes was developed under a broad theme.
The analysis was made by manual content. Finally, the summary
results were prepared.
Key Informant Interviews were the next qualitative data
collection method used to explore the perception of the cervical
cancer screening program in Sri Lanka among health care work-
ers in MOH areas of Kalutara district. Ten KIIs were carried
out during the December 2018. Key Informants were selected
from categories involved in a cervical cancer screening program
in Kalutara district such as Medical Ocers of Maternal and
Child Health (MOMCH), Medical Ocers of Health (MOOH),
Public Health Nursing Sisters (PHNSS), and Medical Laborato-
ry Technologists (MLTT).The convenience sampling technique
was used to ensure variability and to improve the quality of the
information gathered. Each KII was conducted separately as it
was more convenient for participants to give their views freely.
A conceptual framework for qualitative inquiries was
developed based on the literature[12,13]. Using this conceptual
framework, a moderator guide to facilitate the KIIs was devel-
oped for this study with the assistance of experts and reviewed
by the same panel of experts as for FGDs (supplementary le 2).
Venues of the KIIs were identied according to the ac-
cessibility and comfort of Key Informants from MOH areas in
the Kalutara district. Ten health care workers, who have engaged
in the cervical cancer screening program in the Kalutara district,
were selected as KIs, one month before conducting KIIs. Key
Informants were informed of the venue and time for the discus-
sion.
All interviews were conducted by the rst author. In-
formed consent was obtained before an interview. Notes were
taken by the rst author for each participant in separate le.
The duration of an interview was around 30 minutes. At the end
of each interview, the rst author summarized the information
gained to the participant to ensure comprehensiveness.
Moderator bias was reduced by staying neutral (tone
of voice, facial expression, body language, etc.) during an inter-
view as much as possible. Triangulation methodology was used
to improve the quality of the information. Formally written notes
by the rst author at the end of each interview were subjected to
read and re-read several times and descriptive codes were pre-
pared according to emerging ideas. These categories were spe-
cic and mutually exclusive. The analysis was made by manual
content. Finally, an amalgamated list of codes was developed
with FGDs. In the last summary, results were prepared.
Results
Among the total of 42 healthcare workers, thirty- two have par-
ticipated in four FGD sessions and 10 have participated in ten
KIIs. Among these, 41(97.6%) were Sinhalese, 39(92.9%) were
Buddhist and 14 (33.3%) had working experience >20 years in
the eld (Table 1).
Table 1: Distribution of participants of FGDs and KIIs according to
age, religion, race, and service in the eld in completed years
Characteristics of participant Number of
sta (n=42)
Percentage %
Age in completed years
>40 31 73.8
≤40 11 26.2
Total 42 100
Religion
Buddhist 39 92.9
Catholic 3 7.2
Total 42 100
Race
Sinhalese 41 97.6
Tamil 1 2.4
Total 42 100
Service in the eld in completedyears
> 20
≤5-20 14 33.3
28 66.7
Total 42 100
Following the four FGD sessions and 10 KIIs altogeth-
er eleven major themes were identied (Table 2). The results of
the study component are presented under the following themes
according to perceptions of the cervical cancer screening pro-
gram in Sri Lanka by healthcare workers in a district.
Table 2: Main themes & codes emerged from qualitative data collection
techniquesregarding the perception of cervical cancer screening pro-
gram among health care workers in Kalutara district
Main themes Main codes emerged (number of instances)
Cervical cancer
screening
Early detection (20), Morbidity (20), Healthy
mother (18), Progression of pre-cancers (14),
Deaths from cancers (12)
Conventional pap
smear screening
test
Sensitivity (15), Cytology (15), Technology
(12),Unsatisfactory smears (8), Reporting de-
lay (8),Transportation (3) , Un-tracing reports
(2)
Poor coverage Public health sta (21), Estimated popula-
tion(16), I% population(15), Social level (15),
Migration (14), Job (14), Family issues (9),
Education level (7)
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Citation: Perera, K.C.M., et al. Perception of Cervical Cancer Screening Program Among Healthcare Workers In A District Of Sri Lanka: A Qual-
itative Study. (2021) Int J Cancer Oncol 8(1): 1-7.
www.ommegaonline.org
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Improve coverage Community awareness (24), Supervision (18),
Mobile clinics (18), Saturday clinics (12), Per-
formance appraisal (11), Community mobili-
zation (10), Reviews (7),
Supply manage-
ment
Supply (28), Stock return (20),Annual sched-
ule (5)
Report writing Clear (8), Accurate (50, Cytology monthly re-
turn (3)
Positive follow-up Public health sta (18), Attitudes of sta (11),
Register (5)
HPV/DNA screen-
ing test
Sensitivity (18), Long term convenience (15),
Pap smear test (15), Health sta workload (12),
colposcopy (5) , Liquid based cytology (3)
Vaginal HPV/DNA
specimen collection
method
Coverage (28), Provider collected (24), Clin-
ic non-attendees (22), Convenient (22), Home
(8), Privacy (6), Self-collected (5)
Needs identied Special sta trainings(26), Supervision (23),
Colposcopy facilities (4), Insurance (4), TV
advertisement (3)
Barriers to cervical
cancer screening
Not feeling ill (12), Fear of ndings (10), Fear
of pain (8), Cultural believes (4)
Cervical cancer situation in Sri Lanka: One Informant ex-
pressed her perception as follows. “I too work in the eld >10
years now…In my area…One mother was diagnosed at a late
stage of cervical cancer…she was never screened for cervical
cancer [pap test]…She died at a very young age…..I exactly
can’t remember her age… “I am sure, below 50 years…”.
Another young Informant claimed her perception as
follows. “It’s good to have cytology-based screening method
in Sri Lanka….cervical cancer…second commonest among our
females…I got to know many turning points in cervical cancer
screening program…..in Sri Lanka… ….Organized screening,
target age cohort, two age cohort screening…….Screening at 45
years of age as a target cohort was initiated recently…to im-
prove the pre-cancer detection rate among Sri Lankan women
before converting into cervical cancer…..earlier 35 age cohort
was the only target cohort”
Conventional pap smear screening test in Sri Lanka: One
Medical Laboratory Technologist, who was engaged in cy-
to-screening expressed her perception as follows. ‘The biggest
disadvantage of conventional cytology is missing cervical ab-
normalities……[suboptimal sensitivity]. Only 20% of cells are
smeared on the glass slide…taken by a spatula…all other cells
are wasted…Although it’s an advanced method of screening…in
comparison to subjective visual diagnosis…conventional cytol-
ogy alone can miss cervical lesions.” “I received monthly 500-
600 pap smears to screen…I do it without any delay…[no back
logs]. There can’t be any reporting delay…I usually send the
report within one month…..”.
Transportation delay should not be categorized under
“reporting delay”….In some MOH oces smears are kept at
the MOH oce…until more are collected..…They are sending
delayed smears to the laboratory….and erroneously catego-
rized as a…reporting delay….I asked them to send slides every
week…….”
Another cyto-screener expressed his perception as fol-
lows. “Health sta who are obtaining pap smears, need to adhere
to correct technique…I am in real trouble with unsatisfactory
smears… I informed several times to relevant MOH.”
Poor coverage of the National Cervical Cancer Screening
Program in Sri Lanka.….” : A Midwife from an urban sector
stated her perception as follows. “I nd very dicult to cater
with…educated women….They are not willing to…even…lis-
ten to us….especially women with high social level are reluctant
to attend…community clinics.”
Another Public Health Nursing Sister who works in
the rural sector explained her perception as follows. “In my
MOH area most of the women are engaging with a job…It is
nd hard to catch them and get to a clinic….many of others…
catering with family issues...Our coverage is …….around 50%
in 2017…”
Improve coverage of the National Cervical Cancer Screening
Program in Sri Lanka: One Informant claimed her perception
as follows. “I think the most important is to increase community
awareness…..Midwives are playing a major role in that…When,
I visited the eld…., I realized still the community awareness
is poor…Informative leaets, posters…hand bills can be used
in that.”
Another Informant from the medical profession ex-
pressed her perception as follows. “District level quarterly re-
views are very important….to identify trends of each MOH
area…easy to take action for identied problems…… [at ear-
liest]. At the regional level…we use to conduct an annual re-
gional appraisal for WWC performance….~…… performance
in supervision…for supervisory ocers…..I think it gives a big
magnitude for motivating people….”
Another Informant stated her perception as follows.
“Mobile clinics at workplaces are…very important to cover…
working mothers…Conducting mobile clinics in schools..….In
school health days are some of best practices….,,We used to
do”. “At each monthly conference……PHMM were asked to
present their plan… progress in coverage…., In the last quarter
of the year… ….central clinic is amalgamating with WWC….
conducting on Saturdays at MOOH oce…..It was a measure
to catch-up uncovered women for the year….”“If we get mo-
bile pap kits…to conduct mobile clinics…It is very benetted…
Early we were provided some amounts of kits…I exactly can’t
remember, maybe in 2 years back……”
Supply management of the National Cervical Cancer Screen-
ing Program in Sri Lanka: One Informant expressed her
perception as follows. “In-charge ocer in Regional Medical
Supply Division, Kalutara is maintaining stocks adequately …
quarterly stock return is sending to the Family Health Bureau…
before to the 5th of the next month in the following quarter….
getting next quarter stocks according to the previous stock bal-
ance return….I think it’s very important in uninterrupted supply
management…….’
Report writing: One cyto-screener indicated his perception as
follows. “some referral forms are not clear…They don’t write
accurate information….I informed relevant MOH ocers…
[many times]. Some are still as same…It’s very important to
write accurate information to get an idea about the client.”
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Perera, K.C.M., et al.
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Positive follow-up of the pap results in Sri Lanka: “Area
Midwife needs to carry out close follow-up in such clients…
follow-up their referrals…re-referrals….compliance with the
management…repeated observational home visits…Then only
it will happen as expected….”
A Public Health Nursing Sister stated her perception as
follows. “earlier we maintained a “CR book’ …to follow up pap
positives…at the MOH oce… …Recently we were provided
a special register……It’s called positive follow-up register for
clients with an abnormal test reports….”
HPV/DNA screening test in Sri Lanka: One Informant
indicated her perception as follows. “In my MOH area, several
women were informed ……repeated clinic visit for a pap test…
They were positive for HPV/DNA…This new test is based on
PCR technique…Its detection rate is high….[sensitivity]. I ex-
actly can’t remember, which types were positive……”
One cyto-screener, described his perception as fol-
lows. “If this test is being implemented…The need of pap is
reducing…Only HPV/DNA positives are subjected for pap test”.
“HPV/DNA negatives are re-screened only after 10 years….the
routine follow-up period is long….The workload of cytoscreen-
ers, Histopathologists will be markedly reduced…..I believe this
HPV/DNA test is worthwhile to incorporate….into the National
Cervical Cancer screening program in Sri Lanka…..”
Vaginal HPV/DNA specimen collection method in Sri Lan-
ka: Vaginal HPV/DNA specimen collection is doing …without
speculum examination…It can collect by a provider…or else…
self collected…It is the best method to improve the coverage of
the program….”
One Public Health Nursing Sister, claimed her percep-
tion as follows. ‘Vaginal HPV/DNA specimen collection meth-
od should apply…..only for clinic non-attendees….as services
provided by the WWC is not only pap screening….So…Clients
are missing the opportunity of getting…other services by well
woman clinics…..This method is exclusively suitable for clin-
ic non-attendees…..”“I think midwife collected vaginal speci-
men…more suitable to a country like in Sri Lanka…..The spec-
imen should be properly obtained with the correct technique.
…Otherwise, it’s a waste.” Midwives can collect specimens…
When they do home visits even…assuring more privacy for cli-
ents……It is the best method to cover clinic non-attendees….”
Needs identied in the National Cervical cancer Screening
program in Sri Lanka: One Informant expressed her percep-
tion as follows.“Updated knowledge, the new technique, correct
technology, refresher course of training are must, to improve the
quality of the program….Trainings should conduct under exper-
tise….”“I identied gaps in the district….~……in local supervi-
sion by MOH supervisory sta…”
One Public Health Nursing Sister described her percep-
tion as follows. ‘Recently we received a one abnormal cytolo-
gy report…referred for colposcopy by MOH…She was asked
to revisit twice for colposcopy procedure…[machine was under
repair]. She is a school teacher. She did it in private sector……
Whole Kalutara district has only one colposcopy center……”
Barriers to cervical cancer screening in Sri Lanka: One Sis-
ter indicated her perception as follows. “Women are reluctant
to attend clinics…It’s because they don’t feel ill…..They are so
fond of their routine work…….rather than attending clinics..
….some are afraid of nding illness….They are fear …”
A Midwife claimed her perception as follows. “Some women
who had undergone pap screening…give wrong information….
speculum insertion...[very painful. Seems to be a very unpleasant
experience].Fear of pain…. in the procedure.” “Certain amount
of cultural…...religious believes also have negative impact…in
my PHM area…..”
Discussion
Cervical cancer is the 2nd leading cause of female cancer in Sri
Lanka[2]. Hence in 1998, Sri Lanka took an initiative to include
screening for cervical cancer with conventional papanicolaou
(pap) smear in the Well Woman Clinics (WWCs). Howev-
er, even after 20 years of cervical cancer screening (with pap
smears), there is no marked reduction in incidence, morbidity,
and mortality of cervical cancer in Sri Lanka. Two major draw-
backs of the present program are, the suboptimal sensitivity of
the pap smear to detect Cervical Intraepithelial Neoplasia (CIN)
and the low coverage of the cervical cancer screening program.
Therefore, the cervical cancer prevention program needs to be
reviewed with special attention.
The majority of healthcare workers have expressed
their high satisfaction about the planning and organization of the
present cervical cancer screening program as a preventive mea-
sure to reduce the incidence, morbidity, and associated mortality
of cervical cancer and many were positive of the recent addition
of 45 year age cohort too as a target age cohort for screening
irrespective of the work burden to public health sta and cyto-
screeners as the coverage of the program in 35 years old women
was poor, this second age cohort of screening will cause to catch
missed lesions at t it’s precursor stage.
According to health care workers, a high social level and
education level are not always positive with good health-seeking
behavior and some of them were reluctant to listen to the public
health eld sta. Some other important factors for poor cervical
cancer screening program coverage in the district as they high-
lighted were the migration of women for foreign employment,
working women, especially in estates, and family issues.
The majority of them expressed that the program needs
to be improved in both quality and coverage. To improve the
coverage, community awareness, community mobilization, and
supervision on ongoing activities by supervisory sta were men-
tioned as important measures. A cross-sectional study among
community health care workers to assess the knowledge, atti-
tude, and practice of cervical cancer and its screening amongst
community health workers in India has also reported similar re-
sults[9].
Conducting mobile clinics and Saturday clinics, district
reviews and regional performance appraisals were some of the
best practices in the district and evidenced by the improvement
of the coverage from 52.8% in 2016 to 60.9% in 2018. They em-
phasized that short TV advertisement related to the importance
of cervical cancer screening and insurance coverage for pap test/
HPV/DNA test in the private sector would be attractive mea-
sures for future improvement of the cervical cancer screening
program coverage.
page no: 6
Citation: Perera, K.C.M., et al. Perception of Cervical Cancer Screening Program Among Healthcare Workers In A District Of Sri Lanka: A Qual-
itative Study. (2021) Int J Cancer Oncol 8(1): 1-7.
www.ommegaonline.org
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Proof
Only a few health care workers highlighted the prob-
lem of pap cytology reporting delay and untraceable reports.
Reporting delay may be either truly associated with the delay of
cyto-screening procedure at the laboratory or it can be a trans-
portation delay from MOH oces to the reference laboratory. So
MOH needs to take a measure to transport pap smears weekly to
the laboratory, irrespective of the number of slides at the oce.
Some health care workers mentioned the unsatisfactory smear
rate which showed the necessity of technological updates among
the health sta. A descriptive cross-sectional study carried out
among PHMM attached to all MOH divisions in Galle district
was reported similar results[10], which gives the direction of im-
provement of the existing cervical cancer screening program.
The majority indicated that the supply management
was smooth without any interruption from the central level
and some healthcare workers complained about the accuracy
of pap referrals, where MOH should pay special attention and
train PHMM on in-service training days. All three cyto-screen-
ers have mentioned many diculties in sending cyto-screening
monthly return before the 5th of the following month including
non-availability of Consultant Histopathologists in some institu-
tions.
No issues related to the follow-up of screen-positive
women in the district. Public health sta actively campaigned
on that. Positive follow-up of screen-positive women mainly
depended on Attitudes of the public health sta as believed by
some healthcare workers. The recently introduced positive fol-
low-up register was a very useful tool for more organized fol-
low-up.
The majority of them were concerned about the af-
fordability of the HPV/DNA test in thin prep cell collection
media. Further they highlighted the cost of the Liquid-Based
cyto-screening. In spite of the aordability, an HPV/DNA
screening test was highly acceptable among health care workers
in the district to improve the detection rate of cervical lesions to
reduce some categories of healthcare workers’ work burden and
the convenience for the target women due to lengthy screening
interval.
Acceptability was high among health care workers for
the vaginal HPV/DNA specimen collection method to improve
the coverage of the program. They claimed that it should be
limited to clinic non-attendees only as from WWCs many other
services are provided to women. They also mentioned that the
provider collected vaginal specimen screening method is suit-
able for Sri Lanka but the literacy rate of women may vary and
if the client was not taking the specimen correctly ultimately test
kit would be wasted. Therefore PHMM collected vaginal spec-
imens at either clinic setting or while during their home visits
were preferred by healthcare workers to improve the coverage
of cervical cancer screening program.
Colposcopic facilities in the district need to be more
strengthened to assure the smooth functioning of the cervical
cancer screening program, in the district. Some of the important
barriers of cervical cancer screening as mentioned by the health-
care workers in the district were women not feeling ill, fear of
ndings, unnecessary fear of speculum insertion associated pain
and some cultural beliefs, which gives a similar pattern to the
study carried out in 2018 in Canada[14]. A cross-sectional sur-
vey among 219 female health care workers including PHMM
(68.9%) selected by using the convenience sampling technique
from 6 districts in Sri Lanka was given similar results[11].
To overcome the problems associated with the present
cervical cancer screening program new HPV/DNA test could be
attempted after careful assessment of its cost-eectiveness as the
suitability of HPV/DNA screening was well assessed in the Sri
Lankan setting. It is essential that narrowing of the existing gap
between the perception and practice of cervical cancer screening
should be initiated by introducing more educational programs
for workers and encouraging them to practice in screening cam-
paigns.
This study was restricted to one district out of 25 dis-
tricts in Sri Lanka due to logistic constraints. The population
characteristics and the public health infrastructure of the district
favored generalizability of the research ndings to the whole
country of Sri Lanka.
Conclusions and Recommendations
Healthcare workers in Kalutara district were highly accepted
the HPV/DNA new screening test for the quality improvement
of the program and the vaginal HPV/DNA specimen screening
method was mentioned to increase the coverage of the National
Cervical Cancer Screening Program in Sri Lanka.
Acknowledgment: We are grateful to the study participants, re-
search assistant (note-taker) and the Post Graduate Institute of
Medicine, University of Colombo.
Funding: Self- funded by the rst author.
Availability of data and materials: The datasets used to ana-
lyze in this study are available at the corresponding author on
reasonable request.
Authors contribution: KCMP has participated in the design of
the study, was the moderator of FGD sessions and IDIs, per-
formed the broad thematic analysis, and drafted the version of
the manuscript. HTCSA and NM participated in the design of
the study. HTCSA has supervised the descriptive codes, and
performed broad thematic analysis, and interpreted data. Both
HTCSA and NM were helped to draft the manuscript. All three
authors were read and approved the nal manuscript.
Ethical approval and consent to participate: Ethical clearance
was obtained from the Ethics Review Committee (ERC), Na-
tional Institute of Health Science (NIHS), Kalutara Sri Lanka
(Ref. number NIHS/ERC/18/06R). Informed written consent
was obtained from each of the selected participants during the
study. Condentiality was highly maintained, while handing
over individual HPV/DNA result reports. Administrative clear-
ance to conduct the study was obtained from Provincial Direc-
tor of Health Services/Western Province, Regional Director of
Health Services/Kalutara district, Director/ District General
Hospital Kalutara.
Consent for publication: Not applicable.
Competing interests: The authors were declared that they have
no competing interests.
Abbreviations: WWC: Well Woman Clinic; ASCUS: Atypical
page no: 7
Short title
Perception of Cervical Cancer Screening Program
Perera, K.C.M., et al.
Galley
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Squamous Cells of Undetermined Signicance
CIN: Cervical Intraepithelial Neoplasia; MOH: Medical Ocer
of Health; PHM: Public Health Midwife; FGD: Focus Group
Discussions; KII; Key Informant Interview; PCR: Polymerase
Chain Reaction
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