Acceptability, simplicity, and relevance of the new human papillomavirus/DNA test among 35-year-old ever-married women in a district of Sri Lanka: focus group discussions - BMC Women's Health - BioMed Central
Thirty-five years age cohort of ever-married women (n = 24) participated in the study. Most of the participants engaged in FGDs were Sinhalese (70.9%, n = 17), Buddhist (75%, n = 18),and Non-working (75%, n = 18).Out of the total participants, 20.8% (n = 5) had not completed years of school education beyond the 5th grade level and another 12.5% (n = 3) of the participants remained at the 6–11th grade level of education. The majority (62.5%, n = 15) were educated up to the level of Ordinary Level (O/L) passed education. Out of the participants, 20.8% (n = 5) were done Advanced Level (A/L) passed education. Some of the participants (16.7%, n = 4) were done a degree and above-passed education (Table 1).
Following three FGD sessions, altogether six major themes were identified to express the acceptability, relevance, and simplicity of the new HPV/DNA screening test implementation and screen positive follow-up (Table 2). The results of the study component are presented under the following themes according to the knowledge, attitudes, and perceptions of participants of the relevant emerged theme.
(i) Cervical cancer situation in SriLanka
Most study participants claimed the cervical cancer incidence was still high in Sri Lanka. A participant particularly paid attention to some preventive measures for cervical cancers. This was expressed in this way:
"I got to know that in contrast to the vigorous preventive measures… including vaccination against HPV infection, screening with pap test, still annually a high number of new cervical cancer cases are reported…markedly" (Participant, urban sector).
Few participants stated that cervical cancer is the second most commonest female cancer in Sri Lanka according to the incidence rate. A participant expressed that cervical cancer ranks as the third commonest cancer according to the age-specific incidence rate among 15–44 years, women as follows:
"I recently read one newspaper article, it says…cervical cancer is the second commonest female cancer in Sri Lanka, but among 15-44 years women it ranks as third…" (Participant, urban sector).
Most of the study participants indicated the treatment of cervical cancer was costly. One of the participants stated her experience as follows:
"My relative sister is suffering from cervical cancer…it was a late diagnosis…She had undergone an abdominal hysterectomy…Now the biggest problem is she is on the course of chemotherapy…., She has to spend big money on some drugs…I don't know the exact price…" (Participant, rural sector).
The lack of treatment facilities for cervical cancer in the rural sector of Sri Lanka was an issue mentioned by a few participants. A participant had this to say:
"One of my known cervical cancer patients has to travel daily to Colombo for chemotherapy, lack of treatment facilities in the rural sector is a big issue. And the cost for transport, transport difficulties, unable to occupy and carry out routine work is an extra burden for the patient…" (Participant, rural sector).
One expressed chemotherapy as the key challenge for a patient under treatment for cervical cancer by the following quote:
"It was such a worse experience than anything…, The biggest problems following the chemotherapy were loss of appetite, nausea, constipation, poor sleep, and lack of energy…[seems somebody has to look after her]. Nobody, she does her work slowly" (Participant, urban sector).
Some discussants mentioned that deaths due to cervical cancers are high in Sri Lanka. This was captured this way:
"I exactly can't remember the number of deaths due to cervical cancer in last year… but it says still it's high…" (Participant, estate sector).
Two study participants admitted that deaths due to cervical cancer remain stable for a long duration. The place to seek treatment is also related to the financial situation of the women. This was how one of the participants presented it:
"You can see clearly, irrespective of the development of treatment facilities…deaths due to cervical cancer remain stable for a long duration of years...access for treatment centres and treatment cost plays important role in this regard" (Participant, urban sector).
- (ii)
Human papillomavirus infection, and cervical cancer
Most of the participants gained knowledge on the effects of HPV infection and its association with cervical cancer following the community awareness sessions carried out in the district. A participant admitted in her words:
"I got to know effects related to HPV infection, carcinogenic and non-carcinogenic…all cervical cancers are virtually associated with…HPV infection" (Participant, rural sector).
From the views of the few discussants, they were the first time heard about the HPV virus and HPV infection as a cervical cancer precursor. A participant had this to say:
"I never knew that there is a virus called HPV…Which has a cervical cancer carcinogenic effect…I heard that HPV infection as an initial cervical cancer stage…[precursor], Which could be detected by screening" (Participant, rural sector).
One indicated some serotypes of HPV are more carcinogenic than others and the contribution of HPV serotypes 16 and 18 to cervical cancer is high among all high-risk carcinogenic HPV serotypes and this was pointed out this way:
"There are highly carcinogenic virus types too… I have explained the variety of high-risk HPV serotypes, It was around 15…. I can't remember all but HPV types 16 and 18 are contributed to 70% of cervical cancer cases…" (Participant, urban sector).
Among participants, most stated the mode of transmission of HPV is exclusively sexual. One of the discussants captured it this way:
"I came to do screening test for HPV/DNA on the given appointment date…I've noticed in the clinic, informative posters were hanging on clinic walls…It says… HPV infection is exclusively sexually transmitted…" (Participant, rural sector).
From the views of some study participants, primary preventive methods for cervicovaginal HPV infection are readily available in Sri Lanka. Fortunately, their understanding of preventive measures is great. One said:
"There are some primary preventive methods for cervicovaginal HPV infection in Sri Lanka, condoms during a sexual relationship, and recently introduced vaccines…" (Participant, estate sector).
Few discussants noted persistent HPV infection may lead to cervical cancer. One of the participants remarks:
"It says high-risk carcinogenic HPV infection may progress into cervical cancer after about 10 to 15 years [persistent infection]…" (Participant, urban sector).
- (iii)
Pap test and HPV/DNA test as a cervical cancer screening method
Most of the study participants stated that the pap test is a National Cervical Cancer screening method in Sri Lanka and they knew that it can be done at either the MOH office level or hospital WWCs. This was captured this way:
"My one of the closest friends had some clinical signs and symptoms…She had undergone repeated pap tests for cervical cancer screening as requested by the Gynecologist. First pap smear, she has done at a MOH area WWC…and repeated ones at hospital WWC" (Participant, rural sector).
For some, suboptimal sensitivity of the pap test was a priority. Therefore missing many cervical precancerous lesions is unavoidable. One of the participants expressed it this way:
"I recently went to do my first pap screening test, The biggest problem of the pap test is…missing lesions...[suboptimal sensitivity]. Many chances to miss cervical abnormalities by a pap test only…" (Participant, rural sector).
Few discussants mentioned they would get the pap report with a lag period time. This was presented this way:
"I was asked to attend WWC for a pap test in the middle of this year by the area PHM…I did it so "My pap report received only after 6wks…luckily it was normal… [No Intraepithelial Malignancy]". (Participant, estate sector).
One participant indicated that the routine screening interval of the pap test is once in every 5 years and shared her experience this way:
"My pap report was normal….nothing else to be done, only routine follow-up after 5 years…" (Participant, urban sector).
From the views of most of the participants HPV/DNA test is an advanced screening test to detect cervical precancerous lesions as its sensitivity is high. According to one participant:
"It is wonderful to have such an advanced screening test with high detection rate…[sensitivity] as cervical cancer is one of the commonest cancer among Sri Lankan females…" (Participant, rural sector).
Some participants relied more on the higher accuracy of the HPV/DNA test due to cobas 4800 machine screening report. One of the participants remarked:
"HPV/DNA screening test is a cobas 4800 machine screened test…[accurate]. Screening never depends on any individual. I can't explain the variability that might occur in screenings based on personals [cytology]…" (Participant, urban sector).
The HPV/DNA test detects the initial precursor before the cervical lesion development was, expressed by most of the participants. A participant described her experience this way:
"I was at a community awareness session in the district…It was explained that HPV is one of the earliest stages that can be identified as a cervical cancer precursor. HPV/DNA test detects the presence of HPV virus in the smear…" (Participant, rural sector).
Few participants greatly appreciated getting of such an advanced screening test free of charge in the Government sector to reduce the burden of cervical cancer in Sri Lanka. A participant shared her experience this way:
"It was such an opportunity to screen for cervical cancer free of charge...such an advanced test…I am not well aware of the exact cost of the test, but it says it is expensive…much more expensive than a pap test" (Participant, estate sector).
The advantage of getting a quick test report was mentioned by two participants and this was pointed out this way:
"After passing one week following the test…My area PHM informed me that my test report can be collected, I did it…" (Participant, rural sector).
- iv.
HPV/DNA test specimen collection procedure and screening implementation
Most of the participants perceived an HPV/DNA screening test as a convenient and neutral test by their experience after exposure to the specimen collection at WWCs. A participant shared her experience this way:
"I've undergone a pap test early in this year at a community WWC, It is very similar to the pap test…Specimen collection was done by using a broom-like device, instead of the wooden spatula in the pap test, and then putting it into a liquid container. Push the broom-like device against the bottom of the vial 10 times, forcing the bristles to bend apart. Swirl the broom vigorously after pushing…simple and convenient, I thought it is painful, but the specimen collection was without any pain[neutral]" (Participant, rural sector).
HPV/DNA test is perceived as an easy test by some participants. According to one participant:
"I was really afraid to undergo HPV/DNA screening, but It is an easy and comfortable test…" (Participant, estate sector).
Few discussants noted that the HPV/DNA test is a quick one. One said:
"…for me, It was such a quick test, but I exactly couldn't calculate the time spent on the procedure, may be around 15 min…" (Participant, urban sector).
Well-organized community awareness and field staff performance for the new HPV/DNA test implementation was highly appreciated by most of the participants. A participant admitted in her words:
"I got to know information regarding this new screening test from the community awareness programme held at our MOH area, and leaflets were distributed among participants there…Lectures and discussions were carried out. I've seen an informative poster in all three languages, containing important details regarding HPV infection…Participants asked questions, and cleared doubts…I am so lucky, I got an opportunity to clarify doubts from my area PHM…after I got selected for a free HPV/DNA test…She visited me twice to make me aware…to reduce the anxiety…" (Participant, estate sector).
Some were satisfied with the clinic facilities and clinic staff's performance in implementing HPV/DNA screening test. One of the participants shared her experience this way:
"Unlike the pap test, I doubted how this new test is being carried out in our clinic setup… I have noticed the clinic appointment schedule is displayed on the wall, a few more specific items were available at the clinic…If you go to a clinic, in addition to normal WWC clinic items, you can see unopen test kits, special marker pens to write the identification numbers are also available there…" (Participant, rural sector).
Sharp bins to discard clinical wastes are available at clinic premises. The environment following a clinic session was exemplified by the following quote:
"That clinic day, I was the last person…and I noticed at the end of clinic session…all brushes, which were used to obtain specimen was disposed to a sharp bin, clinic environment was so clean and clear…" (Participant, estate sector).
- xxii.
HPV/DNA screen positive follow-up with pap test and colposcopy
Most discussants admitted the necessity of repeated clinic visits for a pap test and colposcopy in HPV/DNA screen positive follow-up as exemplified by the following two quotes:
"I was informed HPV/DNA screen positive results by MOH….I was called up at the MOH office…MOH personally handed over my report…[anxiety]. It was explained that all HPV/DNA screen positives are not associated with cervical cancer…only need to undergo a pap test within the next 6 weeks…to reassure"
"if the pap test is negative,…then to repeat an HPV/DNA test after 1 year…When the pap test is positive,…Then to be subjected to a colposcopy within one month after the test[to exclude cervical lesion]. Colposcopy is the gold standard test to diagnose cervical lesions as I heard" (Participant, urban sector).
For some discussants, irrespective of the repeated clinic visits HPV/DNA screen positive follow-up is very useful. It significantly reduced the cervical cancer burden in Sri Lanka due to the early detection of cervical cancer precursors. This was presented this way:
"I would be happy to do all relevant follow-up tests…related to HPV/DNA test, despite I have to go for repeated clinic visits …as I would say it's an advanced cervical cancer screening method, with a high detection rate of early stages of cervical cancer[precursor]. Therefore it reduces the burden of morbidity, treatment cost, and mortality of cervical cancer" (Participant, urban sector).
- (vi)
Challenges associated with HPV/DNA screening
All of the participants had seen the specimen collection brush only on the day of specimen collection in the WWC. One participant shared her experience as follows:
"I went to the WWC on the scheduled day, I was informed the specimen is collected by using a brush… the First time I've seen the brush at the clinic day only...It's actually like a broom" (Participant, urban sector).
Fear of hurting themselves was the biggest barrier associated with the HPV/DNA screening. Further, some thought even HPV/DNA specimen collection is very painful. One of the participants presented it this way:
"I was really scared [hurting myself] of participating in HPV/DNA screening… as I thought the specimen collection is very painful, there is no pain, only a tingling sensation, nothing else…" (Participant, estate sector).
Some participants doubted whether this test is administered correctly by the health staff. One participant described her experience this way:
"We were shown some videos of HPV/DNA specimen collection during the community awareness sessions in the district, I was wondering how such a different screening test could be able to correctly administer by our staff suddenly…" (Participant, rural sector).
Prior conduction of well-organized staff training for HPV/DNA specimen collection and training was very useful to raise the community participation in the study. This was presented this way:
"I got to know that well-organized staff training under expertise was conducted at district level on HPV/DNA specimen collection and screening…" (Participant, urban sector).
Two participants pointed out that continuous monitoring and supervision of this new HPV/DNA screening implementation is essential to assure the standards. One of the discussants captured it this way:
"Staff may not adhere to screening norms…need continuous monitoring and supervision of HPV/DNA specimen collection and screening". (Participant, rural sector).
One said issues arising in test implementation must be discussed with expertise periodically as exemplified by the following quote:
"I know how difficult to implement a new test…many issues need to be sorted out…It is essential to conduct periodical reviews with expertise…" (Participant, urban sector).
There was marked acceptability among participants (n = 23, 95.8%) for HPV/DNA screening tests to be incorporated into the National Cervical Cancer Screening Programme in Sri Lank as a primary cervical cancer screening method, irrespective of all difficulties in repeated clinic visits for a pap test and colposcopy in the screen-positive follow-up.
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