ABSTRACT

Objective.

To document Grenadian women’s knowledge about cervical cancer and human papillomavirus (HPV) infection, as well as their attitudes towards primary cervical cancer screening methods.

Methods.

In this qualitative study, we used focus groups in Grenada to gather information concerning women’s knowledge about, attitudes towards and perceptions of screening for cervical cancer and general knowledge about HPV. Ten focus groups comprising 73 participants representing 5 of the 6 parishes in Grenada were conducted with women aged 19–59. Participants were asked about pelvic exams, Pap smears, HPV, reasons for seeking or avoiding cervical cancer screening and how different modalities of testing might affect their decision-making. Responses were then coded and organized into common themes.

Results.

While many respondents had heard of HPV, far fewer knew about its causative role in cervical cancer, how to prevent HPV infection or testing for the high-risk HPV types that cause almost all cases of cervical cancer. Many participants were aware that cervical cancer screening was beneficial, but numerous barriers to obtaining that screening were noted, including concerns about privacy and stigma, potential discomfort, and the cost and inconvenience involved.

Conclusions.

Our findings have implications for future cervical cancer screening efforts in Grenada. Central to these efforts should be a focus on educating Grenadians about the role of HPV infection in cervical cancer and the importance of early detection through screening. In addition, addressing issues of stigma and privacy are key to eliminating cervical cancer in Grenada.

Keywords
Uterine cervical neoplasms; papillomavirus infections; health knowledge, attitudes, practice; Grenada; women

RESUMEN

Objetivo.

Documentar los conocimientos de las mujeres granadinas sobre el cáncer cervicouterino y la infección por el virus de los papilomas humanos (VPH), así como sus actitudes hacia los métodos primarios de detección del cáncer cervicouterino.

Métodos.

En este estudio cualitativo, se han empleado grupos focales en Granada para recopilar información sobre los conocimientos, las actitudes y las percepciones de las mujeres sobre la detección del cáncer cervicouterino y nociones generales sobre el VPH. Participaron 73 mujeres de 19 a 59 años de edad, representantes de 5 de las 6 parroquias de Granada. Se formaron diez grupos focales, a los que se les preguntó sobre los exámenes pélvicos, las pruebas de Papanicolaou, el VPH, las razones para buscar o evitar la detección del cáncer cervicouterino y cómo las diferentes modalidades de examen podrían afectar sus decisiones. Luego se codificaron las respuestas y se organizaron en temas comunes.

Resultados.

Si bien muchas participantes habían oído hablar del VPH, un número considerablemente menor conocía su relación causal con el cáncer cervicouterino, cómo prevenir la infección por VPH o los exámenes de detección de los tipos del VPH de alto riesgo que causan casi todos los casos de cáncer cervicouterino. Muchas participantes sabían que los exámenes de detección del cáncer de cuello uterino eran convenientes, pero mencionaron numerosos obstáculos para obtenerlos, como las preocupaciones sobre la privacidad y la estigmatización, posibles molestias, así como el costo y los inconvenientes relacionados.

Conclusiones.

Nuestros hallazgos tienen implicaciones para la futura labor de detección del cáncer cervicouterino en Granada. En esta labor debería ser esencial adoptar un enfoque dirigido a educar a las granadinas sobre la relación de la infección por VPH con el cáncer cervicouterino y la importancia de la detección temprana mediante exámenes. Además, combatir los problemas de estigmatización y privacidad es clave para eliminar el cáncer cervicouterino en Granada.

Palabras clave
Neoplasias del cuello uterino; infecciones por papillomavirus; conocimientos, actitudes y práctica en salud; Grenada; mujeres

RESUMO

Objetivo.

Documentar o conhecimento das mulheres de Granada sobre o câncer do colo do útero e a infecção por papilomavírus humano (HPV), bem como suas atitudes em relação aos métodos de rastreamento de câncer do colo do útero primário.

Métodos.

Neste estudo qualitativo, usamos grupos focais em Granada para coletar informações sobre conhecimentos, atitudes e percepções das mulheres sobre o rastreamento de câncer do colo do útero e conhecimentos gerais sobre HPV. Foram conduzidos dez grupos focais, incluindo 73 participantes e representando 5 das 6 paróquias de Granada, com mulheres de 19 a 59 anos de idade. As participantes responderam perguntas sobre exames ginecológicos, Papanicolau, HPV, razões para procurar ou evitar o rastreamento de câncer do colo do útero e como diferentes modalidades de testes podem afetar sua tomada de decisão. As respostas foram codificadas e organizadas por temas comuns.

Resultados.

Muitas participantes já tinham ouvido falar do HPV, mas um número muito menor conhecia sua relação causal com o câncer do colo do útero, formas de prevenir a infecção por HPV ou os testes para os tipos de HPV de alto risco, que causam quase todos os casos de câncer do colo do útero. Muitas participantes sabiam que o rastreamento de câncer do colo do útero era benéfico, mas várias barreiras para o rastreamento foram indicadas, incluindo preocupações relacionadas à privacidade e ao estigma, o potencial desconforto e o custo e inconveniência envolvidos.

Conclusões.

Nossos achados têm implicações para as futuras iniciativas de rastreamento de câncer do colo do útero em Granada. Essas iniciativas devem se focar em educar a população de Granada sobre o papel da infecção por HPV no câncer do colo do útero e a importância da detecção precoce por meio do rastreamento. Além disso, é fundamental abordar questões de estigma e privacidade para eliminar o câncer do colo do útero em Granada.

Palavras-chave
Neoplasias do colo do útero; infecções por papillomavirus; conhecimentos, atitudes e prática em saúde; Granada; mulheres

Cervical cancer is one of the leading causes of morbidity and mortality in Latin America and the Caribbean, being the third most common type of cancer in the area and responsible for a yearly toll of 56 000 diagnoses and more than 28 000 deaths (¹1. Pilleron S, Cabasag CJ, Ferlay J, Bray F, Luciani S, Almonte M, et al. Cervical cancer burden in Latin America and the Caribbean: Where are we? Int J Cancer. 2020;147(6):1638–48.). The impact is particularly notable in the small island state of Grenada, as research has documented an even higher prevalence of cervical cancer and associated mortality than seen in the rest of Latin America and the Caribbean, with an observed prevalence of 52.4 cases of cervical cancer per 100 000 women (²2. Bahadoor-Yetman A, Riley L, Gibbons A, Fields PJ, Mapp-Alexander V, Hage R, et al. Prevalence of cervical cancer and associated mortality in Grenada, 2000–2010. Rev Panam Salud Publica. 2016;39:194–9.).

Grenada comprises three islands: Petit Martinique, Carriacou and Grenada, the latter being the largest of the three and home to most of its inhabitants. The island of Grenada is 300 km², and it is divided into six parishes; St. George’s is its largest city and capital. Of its 111 000 total population, more than 36 000 Grenadians are women between the ages of 15 and 65 years (³3. World Bank. Grenada [Internet]. Washington (DC): World Bank; 2022 [cited 2022 August 19]. Available from: https://data.worldbank.org/country/grenada
https://data.worldbank.org/country/grena... ). Public health care services, many offered for free or at a nominal cost, are provided by the Ministry of Health, which oversees 5 hospitals, 6 health centers and 30 smaller medical stations spread throughout the country (⁴4. Ministry of Health and Social Security, Grenada. Strategic Plan for Health 2016–2025 [Internet]. St. George’s: Ministry of Health and Social Security; 2016 [cited 2022 Nov 28]. Available from: https://info.undp.org/docs/pdc/Documents/BRB/GRENADA%20Health%20Sector%20Strategic%20Plan%202016-2015%20Approved.pdf
https://info.undp.org/docs/pdc/Documents... ).

Human papillomavirus (HPV) is the most common of all sexually transmitted infections, and the high-risk types of HPV cause nearly all cases of cervical cancer (⁵5. Eun TJ, Perkins RB. Screening for cervical cancer. Med Clin North Am. 2020;104(6):1063–78.). Most of these infections are spontaneously cleared by the immune system, and those that persist typically, although not always, take years to cause the cervical lesions that if left untreated can progress to cancer (⁵5. Eun TJ, Perkins RB. Screening for cervical cancer. Med Clin North Am. 2020;104(6):1063–78.). This makes cervical cancer highly preventable, and screening has long been the foundation of disease-control efforts in high-resource settings. Implementation of cytological screening in the United States resulted in the incidence of invasive cervical cancer declining by nearly 50% from 1975 to the present and total deaths from cervical and uterine cancer decreasing by more than 80% from 1930 to 2012 (⁶6. Rerucha CM, Caro RJ, Wheeler VL. Cervical cancer screening. Am Fam Physician. 2018;97(7):441–8.). Unfortunately, these gains have not been matched where the implementation of large-scale screening is more difficult: 85% of cervical cancer cases now occur in the developing world (⁶6. Rerucha CM, Caro RJ, Wheeler VL. Cervical cancer screening. Am Fam Physician. 2018;97(7):441–8.).

Increasing screening and HPV vaccination are key to reducing the substantial burden of cervical cancer in Grenada. This is particularly true in the context of the generalized shift towards direct testing for high-risk HPV types, which requires less-frequent tests than Pap tests alone (⁶6. Rerucha CM, Caro RJ, Wheeler VL. Cervical cancer screening. Am Fam Physician. 2018;97(7):441–8.). Currently, women in Grenada can obtain cervical cancer screening at public or private facilities. The number of tests conducted nationwide is not readily available, but there is evidence that screening services are not actively pursued by most Grenadian women (⁷7. Bahadoor-Yetman A. Prevalence of cervical lesions, cervical cancer, and associated mortality in Grenada (2000-2010) [master’s thesis]. St. George’s: St. George’s University; 2013.). Indeed, it is the very prevalence of cervical cancer morbidity and mortality in Grenada that is the best indication that the current process of screening and follow up is insufficient.

Successful screening programs require broad participation, but many women in Grenada have an incomplete understanding of HPV infection and its relationship to cervical cancer (⁸8. Richards C, Thomas-Purcell KB, Vemulapalli KC, Primus-Joseph M, McBurnie-James A, Standifer M, et al. Woman to woman: implementation of a cervical cancer education training program for Grenadian lay health advisors. J Cancer Educ. 2020;35:557–62, ⁹9. Thomas-Purcell KB, Tarver WL, Richards C, Primus-Joseph M, McBarnette B. Grenadian women’s perspectives on screening for breast and cervical cancers: a participatory approach to understanding prevention. Glob J Health Educ Promot. 2016;17(3):1–16.). Therefore, we held a series of focus group discussions with Grenadian women to gauge their knowledge about HPV infection and cervical cancer and attitudes towards screening for cervical cancer, including testing for high-risk HPV types. We explicitly solicited discussion of HPV infection in this study in anticipation of shifts in screening modalities, as well as to ascertain how efforts to increase screening might interface with future efforts to promote HPV vaccination. We anticipate this knowledge will inform further development of culturally acceptable approaches to and methods of primary screening for cervical cancer that work towards the goal of eliminating cervical cancer in Grenada.

METHODS

In this qualitative study, we analyzed data collected by women’s health care professionals from 10 separate focus groups held between 2018 and 2019 at several locations in the capital, St. George’s. The study population was defined as women who were possibly at risk for cervical cancer, and participants were selected from a purposive sample and recruited by the investigators through organizations that provide health care and social services to Grenadian women. Bus fare, snacks and educational materials were provided as incentives, and participants donated their time. The research plan was approved by the Institutional Review Board at St. George’s University.

There were 73 participants in total, and focus groups ranged from 3 to 18 participants, with a median group size of 7. Sessions lasted approximately 90 minutes. Before the focus group session, each woman signed a consent form approved by the Institutional Review Board at St. George’s University and answered a few demographic questions, including providing her age and home parish. Participants were aged 19 to 59 years, and 5 of Grenada’s 6 parishes were represented. Groups contained women from a variety of socioeconomic and educational backgrounds.

Each session began with an orientation briefing and used a standardized set of discussion prompts (Box 1). Participants were asked about their knowledge of pelvic exams, Pap smears, HPV, reasons for seeking or avoiding cervical cancer screening and how different modalities of testing (including sample self-collection, testing for high-risk HPV types, the use of mobile clinics) and reporting of results might affect their decision-making. A single facilitator conducted each focus group, and multiple members of the research team were present at each session to provide support and ensure consistent delivery. Each session ended with a short verbal educational session contextualizing the discussions and providing basic information about HPV infection and cervical cancer. The audio from participants’ responses during the discussion was recorded and then later manually transcribed by university students who had also attended the session.

Individual transcribed responses were de-identified during the process of transcription; researchers were subsequently unaware of which participant provided which response. The resulting data were analyzed through a process of identifying themes and codes (¹⁰10. Charmaz K. Constructing grounded theory: a practical guide through qualitative analysis. Thousand Oaks (CA): Sage; 2006.). Initially, two researchers (ES and AB) reviewed the transcribed responses and developed a controlled vocabulary of codes. They then independently applied one or more codes to each response, reviewing their choices with one another until a consensus was reached for each response. Working with CHP and JM, they then defined broader themes under which each code could be organized.

RESULTS

Four broad themes emerged (Table 1), and responses representative of each theme are included below.

Theme 1: knowledge about screening rationale and methods

When questioned about the reasons for getting a pelvic exam or Pap smear, many respondents knew that it had something to do with cancer.

It was unclear, however, if participants understood the differences between a pelvic exam, a Pap smear and an HPV test.

Theme 2: knowledge about HPV and cervical cancer

Many participants responded that they had heard of HPV prior to the discussion, and a good number said that they had some knowledge of the disease and its etiology. The extent of the respondents’ knowledge, however, varied a great deal: indeed some responses were factually incorrect (denoted as [*]).

Theme 3: reasons for avoiding cervical cancer screening

Some respondents were aware of the availability of cervical cancer screening services, yet still actively avoided obtaining them. They volunteered several reasons for doing so, including the following.

Pain.

Many respondents identified physical discomfort or pain, from either their own experience or as reported by others, as a reason for avoiding cervical cancer screening.

Confidentiality.

Many participants expressed concern that their information might be disclosed by health workers or that people they knew would see them while they were accessing screening services.

Fear.

Many respondents noted that they were reluctant to be screened because they were afraid of the results they might receive.

Accessibility.

The cost and inconvenience involved in obtaining screening or treatment was a common concern.

Theme 4: need for further information

A critical theme that emerged from participants’ responses was the need for more information about HPV and cervical cancer.

DISCUSSION AND CONCLUSIONS

This study documents Grenadian women in their own words and what they understand about HPV and cervical cancer screening. Critical insights for health professionals planning future interventions to reduce cancer emerged from these women’s voices. While many women had some awareness of HPV, their knowledge of its relationship to cervical cancer was inconsistent. Many were also unaware of the importance of screening itself: that precancerous lesions and cervical cancer are more easily treated when they are detected earlier. Providing education about this point is crucial because it would reinforce the utility of screening and follow up. Conveying that cervical cancer is preventable should help lessen commonly expressed resistance to screening and the fatalism associated with the idea of a positive test.

Providing education about the ubiquity of HPV infection could also reduce the pervasive stigma surrounding screening for HPV and cervical cancer (⁹9. Thomas-Purcell KB, Tarver WL, Richards C, Primus-Joseph M, McBarnette B. Grenadian women’s perspectives on screening for breast and cervical cancers: a participatory approach to understanding prevention. Glob J Health Educ Promot. 2016;17(3):1–16.). It was notable how often considerations of privacy and potential stigma were voiced by respondents as being barriers to seeking screening services. One challenge to privacy is the context of Grenada itself: it is difficult to anonymously seek medical services when surrounded by people one knows, particularly in a smaller village. This also indicates a need for further education of health care workers about the importance of protecting patients’ privacy and publicizing existing protections more widely to patients.

One limitation of this study was the difficulty in finding a suitably broad geographical cross-section of participants to interview. While the original intent was to conduct focus groups in several different parishes, this led to scheduling difficulties, as many potential participants from smaller villages have very long commutes during the workweek. The investigators compensated for this by hosting sessions in St. George’s during the workday, attempting to recruit participants living in many parts of the island.

Another challenge was the fact that many participants were hesitant to talk about HPV or other reproductive health issues. This was particularly true when focus groups were primarily composed of acquaintances, such as from a single workplace. However, the investigators found that the method of the focus group itself was helpful in eliciting responses: the longer the discussion went on, the more candid people became. Indeed, in some cases the most reticent-seeming respondents had shared the most by the end of the session.

This was an exploratory study rather than an interventional one; however, two potential indications of the utility of more education were apparent. First, the women seemed to have an active interest in learning more about these issues. In most sessions, participants requested information to take back to their peers or that additional educational sessions be held in their communities. Second, by the end of the session, many participants who had not previously done so expressed an interest in obtaining an HPV test.

Increasing the intensity and effectiveness of screening is crucial to controlling cervical cancer in Grenada. The resources available for public health promotional efforts are finite, so it is vital to understand women’s knowledge of, and attitudes towards, screening for HPV and cervical cancer. The findings of this study can inform the development of culturally appropriate interventions that will eliminate cervical cancer in Grenada.

Disclaimer.

The authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública/Pan American Journal of Public Health or those of the Pan American Health Organization.

Acknowledgements.

First and foremost, we are grateful to the women who shared their experiences with us. For many, participation required them to travel and to rearrange their family responsibilities, and we are humbled by their generosity. Karlene Jones, Lil James and Vilma Gracelyn Paul were skillful facilitators. This study was also made possible by the individuals and organizations that helped us recruit participants and secure locations for our focus groups, including Godwin Thomas from the Technical and Allied Workers’ Union, Carol Hyacinth at Tri-Island Echoes, Sonia Nixon, Trans-Nemwil Insurance, Legal Aid and Counselling Clinic Grenada, Conception Dance Theatre, Grenada Planned Parenthood Association, St. Joseph’s Convent and Grenada National Organisation of Women. We would also like to thank the Ministry of Social Development, Housing and Community Empowerment and the Ministry of Health for many fruitful discussions. We also thank Avi Bahadoor-Yetman for reviewing and making suggestions about the final manuscript. Finally, Richard Gordon, former director of the Latin American and Caribbean Studies Institute at the University of Georgia, provided creative inspiration for the project.

REFERENCES

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