A total of N = 61, interviews were conducted. The respondents were above legal age of 18 years old and resided in Lusaka City. The reported involvement of the respondents created the organizational chart (Fig. 1). The three predetermined themes are used to present the results of the analysis as reported by policymakers, special interest groups (advocacy groups, NGOs, media) and stakeholders (health care providers, teachers, church leaders).
Administration of cervical cancer prevention services in Zambia
Figure 1 illustrates the organizational chart of the administration of cervical cancer prevention services in Zambia with consideration given to the social and ecological levels of influence (intrapersonal, interpersonal, organizational, community and policy level). This figure was developed based on the reported involvement of respondents and their institutions in providing cervical cancer prevention services in Zambia. An additional file has an explanation on the components of Fig. 1 and how each item interacts [see Additional file 2].
Cervical cancer in general
Importance of cervical cancer
According to policy makers and special interest groups, cervical cancer is an important health issue in Zambia as evident from statistics. Special interest person 1 said, “[Looking at] the number of people with HIV since the two diseases go together, [cervical cancer] is a big problem. [It is] not as common as malaria but the outcome is normally death.” Similarly, some stakeholders said there are other health problems of equal importance to cervical cancer as illustrated by quote 1 in box 1 in Additional file 2 [see Additional file 2]. For health care providers, this view depended on their department: “I think cervical cancer is not given enough attention [considering] on average about 5 cases of cervical cancer [are detected] everyday by biopsy. When you are away from [cervical cancer] you don’t see it.” (Health care provider 1).
Worksite policy
Policymakers reported that there is no policy concerning cervical cancer prevention only a strategic plan which was being finalized. Only teachers and health care providers at clinics said there is a policy for the provision of the vaccine. Clinics were actively involved in both screening and vaccination compared to hospitals that were more involved in screening.
Workforce
Apart from a few health care providers who said that the number of staff in their department is enough for vaccination provision, the majority of the respondents (policymakers, special interest groups and stakeholders) said that the workforce for provision of screening and vaccination services was limited and overworked (quote 2 & 3 box 1, Additional file 2). Policy makers further reported that lack of finances makes it difficult to employ more nurses. They suggested that having a way of informing the community when nurses work outside the clinic (e.g. in schools, training programs) might improve the management system. Traditional healers suggested that collaborations are needed since they cannot provide blood transfusions, drip, oxygen or operations and equally doctors cannot provide exorcisms, treat demons and ghosts (quote 4, box 1, Additional file 2).
Information sources
Policy makers stipulated that they inform the public on cervical cancer though the media, meetings at schools for vaccine awareness, the mHealth project which will use SMS text messages and through existing community structures (traditional marriage counselors) (quote 5, box 1, Additional file 2). Special interest groups further included running community outreach programs, social media sites (Facebook), using brochures and brand ambassadors. Churches reported having health talks, health departments and encouraging members seek health care (quote 6, box 1, Additional file 2). Whether health care providers provided information on cervical cancer depended on their department or their patient’s signs (quote 7, box 1, Additional file 2). Teachers had meetings with health care providers and were given materials (handbooks, posters) for talking to pupils and parents though some had a different experience (quote 8, box 1, Additional file 2). “The girls were not given leaflets about the HPV vaccine. [The nurses] only left a poster to stick in the class and we wrote memos to the parents about the vaccine,” said teacher 1.
The respondents (policy makers, special interest groups, stakeholders) believe that the general public gains information by word-of-mouth (quote 9, box 1, Additional file 2). Policy makers also mentioned informal meetings (kitchen parties, church gatherings) and social media, while stakeholders mentioned peer educators, media, brochures, posters, workshops and public announcements (in churches, schools, markets).
Effectiveness of sensitization
Special interest groups and stakeholders agreed that more was needed for sensitization (quote 10, 11, & 12, box 1, Additional file 2):
The media is not doing enough. People should go into the community and sensitize the country. People don’t (.. .) screen unless they have symptoms. In fact, even among nurses (.. .) there is not enough sensitization. [Nurses] don’t know the cost of screening, (.. .) if it’s free or if doctors recommend [it]. (Health care provider 1).
Respondents from special interest groups suggested that brochures should be printed in local languages and not only English to maximize coverage. The media (television, radio) was generally considered effective. The media reported having health related programs and some networks also had a health desk devoted to coving health related topics. They requested that health experts should have a more permanent partnership with the media by making themselves available when needed, assisting in program sponsorship and building capacity in health care reporters. Stakeholders recommended sensitizing the community by having workshops, hospital consultations and using public figures (quote 13, box 1, Additional file 2). Health care provider 2 said, “The former first lady [used to be] on television all the time talking about cervical cancer and we had an overwhelming response. The [patients] who were coming told us that [they] heard about it from the first lady.”
Policy makers thought that Zambians living in urban areas like Lusaka are more informed about cervical cancer than those in rural areas. They suggested that providing excellent services at clinics might improve practice.
Knowledge
During discussions with the public, special interest groups reported talking about symptoms (bleeding), causes (HPV, traditional practices including douching and intravaginal insertion of herbs in particular tobacco), prevention (male circumcision, washing of foreskin, condoms, behavior change, screening, monogamy), and treatment (temporal break from sexual activity, clinical treatment, herbal remedies for early stages) (quote 14, box 1, Additional file 2). Traditional healers included more causes of cervical cancer as mentioned by special interest person 2, “causes I mention[ed are] witchcraft, (.. .) unhygienic conditions, (.. .) bad sexual habits, bad methods of sex, and sometimes drugs. Herbal drugs which a woman inserts [in her vagina] that cause friction during [intercourse] and bruises the cervix.” Some churches had unique views on cervical cancer causes (diet i.e. meat eating, spiritual attack, allowed by God), prevention (by having the spirit of God, faith) and treatment (by faith, prayers, divine healing, trusting the will of God, casting out spirits of sickness, using anointed items).
Social support
Special interest groups reported that men were interested in cervical cancer prevention and offering support to women (quote 15, box 1, Additional file 2). Health care providers had a contrary view (quote 16, box 1, Additional file 2):
There are [a] few [women] that are supported by [their] husband. The few that I have seen are those that have post-coital bleeding. The husband gets concerned and escorts his wife to find out why she is bleeding after sex all of a sudden. Otherwise most women walk in by themselves. (Health care provider 2).
“Most men are uncircumcised and the uncircumcised carry the virus. Men should be involved but not everyone is willing to be circumcised though most are doing so now,” said health care provider 3.
Screening
Screening age recommendation
Unlike health care providers, the stakeholders at churches and schools had no involvement in the screening program. Policy makers specified that screening age will be from 25 to 59 years old. This is based on the natural history of the disease, country level data over the past few years and HIV/AIDS prevalence:
HIV infected [women] should start screening as soon as they become sexually active. [There is] no age range or screening interval [for them]. For HIV unknown or negative screening starts at 25. Previously we used to say, ‘As long as you are sexually active.’ (Policy maker 1).
In spite of these guidelines, special interest groups and health care providers were not fully aware on the screening age recommendations. Some health care providers specified that screening should be started from puberty (10, 12 or 15 years old) because of the difficulty of certifying virginity or from reproductive ages. Most respondents from special interest groups and health care providers said screening should be conducted as long as a woman was sexually active or from age 25 to 55 and above (quote 17 & 18, box 2, Additional file 2). Special interest group respondents further said that screening should be done every year regardless of HIV status, though it used to be every 2 or 3 years for HIV negative women.
Screening uptake and barriers
Policy makers stated that screening coverage in Lusaka was low and fear of dying drives screening uptake. The respondents (policy makers, special interest groups and stakeholders) generally agreed that screening uptake was facilitated by having awareness and knowledge. Policy makers and health care providers also said that knowing someone who had cervical cancer and partners support increases uptake of screening. Special interest groups and health care providers said women usually come for screening if they were curious about their health and if they have symptoms:
Zambians don’t go for health care if nothing hurts. (.. .) So people who have themselves checked are usually those who feel pain or something. [Then] because of sensitization and people learning about the cancer they can’t feel, they [decide] to get checked. That was the case for me. I was like, ‘Oh my gosh! You can have it and not feel it? Let me go check it.’ (Special interest person 3).
Apart from having limited screening facilities/programs (quote 19, box 2, Additional file 2), lack of awareness, lack of knowledge and fear (of dying, pain, unknown, stigma, a positive result) was sighted by most respondents (policy makers, special interest groups and stakeholders) as barriers to uptake of screening. Policy makers further said that partner’s influence in decision making (e.g. husband might refuse to abstain during treatment) as a barrier (quote 20, box 2, Additional file 2). Special interest groups and health care providers also added lack of symptoms and beliefs (cultural, religious, misconceptions) as barriers. Respondents from special interest groups further mentioned feeling shy of male doctors, procrastination and refusal to return for call-back as reasons of low uptake (quote 21, box 2, Additional file 2).
Self-sampled screening
According to policy makers and a few special interest groups, low resource HPV deoxyribonucleic acid (DNA) testing and self-sampling kits are being considered for introduction if they pass future feasibility trials. However, most respondents from special interest groups and health care providers had never heard about self-sampled screening and their views were varied. Their main concern was the ease of use (quote 22 & 23, box 2, Additional file 2).
Vaccination
Unlike policy makers, District Health Office respondents, WHO respondents, healthcare providers at clinics and most teachers, respondents from other target sectors stated that they did not have any involvement in the pilot of the HPV vaccine and therefore did not have much information. Furthermore, vaccination for cervical cancer is beyond the scope of traditional healers although there are traditional ways of vaccination against measles and other diseases using herbs, tattoos, steaming, and/or talismans. All churches interviewed agreed that vaccination must be encouraged.
Vaccine administration
Policy makers reported learning several lessons in administration, vaccine handing and cost cutting by running the two vaccination demonstrations (quote 24, box 3, Additional file 2). They found that public schools were more likely to participate than private schools (quote 25, box 3, Additional file 2), and stakeholders noticed that not all schools participated in the vaccination program (quote 26 & 27, box 3, Additional file 2). Policy makers further noted that school based vaccination had a higher coverage and cost compared to facility based with the biggest challenge being accessing out of school girls:
Health seeking behavior in Zambia is not the best. [A woman] will not go to the clinic unless she is sick. (.. .) So expecting healthy people to voluntarily come for vaccination is difficult. [Furthermore], people are [protective of] their children and won’t voluntarily bring them. So we said it’s better we follow them. (Policy maker 2).
Vaccination age recommendation
Respondents from special interest groups and stakeholders were aware that the vaccine was administered to grade 4 girls and out of school girls age 10. Nevertheless, some schools were strict on vaccinating only 9 or 10 year old grade 4 girls (quote 28, box 3, Additional file 2). Health care providers at the hospital who gave their opinion on age had mixed views, ranging from only vaccinating virgins to giving adults the option (quote 29, box 3, Additional file 2): “It is better to be administered as a choice at adult ages,” said health care provider 1.
Vaccination uptake and barriers
It was reported by policy makers and stakeholders that uptake of the vaccine was due to having awareness, knowledge, fear of having or dying from cancer and knowing someone who had cancer. Policy makers also mentioned that well travelled people were more likely to request the vaccine. Stakeholders noticed that people who saw others practice vaccination without experiencing side effects made them want to have the vaccine (quote 30 & 31, box 3, Additional file 2). Policy makers believe that uptake of the vaccine will increase over time when people start seeking the vaccine themselves because of seeing the benefits.
Policy makers said sensitization on vaccination was effective but there was poor social mobilization because of low funds which lead to misunderstandings (age limit, side effects). Policy makers and stakeholders agreed that lack of awareness and knowledge was a barrier to vaccination uptake. Special interest groups and stakeholders further added fear of side effects (myth of infertility). Policy makers and stakeholders also said that religious beliefs (quote 32 & 33, box 3, Additional file 2) and policy restrictions (on age, gender) reduced uptake (quote 34, note 3, Additional file 2): “Even parents with children in older grades wanted the vaccine. Others were even tried to reduce their [age] to 10 years old. They were very much willing.” (Teacher 2).
Vaccination coverage
According to policy makers, vaccination coverage was higher in Zambia compared to other countries. Special interest groups commended the work of the MoH in sensitization that resulted to a relatively good vaccination uptake. Therefore, there are plans to do a national rollout as reported by policy maker 2, “When we do a national rollout because of the lessons that were learnt and scien[tific evidence]. We will not be using the 3 dose [vaccine. This] (.. .) will reduce cost. We will be doing the 2 dose [vaccine].” Limited resources make it difficult to remove restrictions on age range as well as gender even though special interest groups and some stakeholders supported the vaccination of boys (quote 35, 36 & 37, box 3, Additional file 2). Teachers in particular disapproved the vaccination of boys because of nurses’ instruction (quote 38, box 3, Additional file 2), “[Parents] were encouraged to take boys for circumcision [and] most of them did it during the holiday that year. [Some boys] came to report that they had been circumcised. I gave them books and other materials for motivation,” said teacher 2.