Client-Provider Issues

In many countries, both women and providers lack information about cervical cancer prevention options. Women may know little about the disease, may not trust preventive services, or may not know where services are available. Providers may adopt inappropriate medical protocols and use limited program resources inefficiently. Efforts to improve women’s awareness and provider knowledge of prevention options are essential to a successful cervical cancer prevention program. 

Increasing women’s awareness. 

A key challenge for programs is encouraging women at highest risk for treatable, precancerous lesions—often women in their thirties and forties—to seek services. Because many women in this age group have completed childbearing and therefore are not likely to access family planning or maternal health services, special approaches are required to inform them of the need for and availability of screening. The best approaches for increasing awareness among women in their post-reproductive years will vary from place to place, and should be developed with input from women themselves (see box below). Possible approaches include reaching women through local women’s or community groups; linking screening to an important event in an older woman’s life, such as becoming a grandmother; or linking screening to other mid-life health needs, such as contraceptive sterilization. Use of multiple communication strategies to promote screening is likely to be most successful.25

In many regions, the risk of developing cervical cancer is amplified by poverty and isolation. In Colombia, strategies such as special “cytology days” in shanty towns have been initiated using radio, megaphones, and church calls to encourage hard-to-reach women to attend.2 Overall, it is essential to ensure good quality of care at screening sites, treating women with respect and paying attention to their concerns. Program experience from many countries has demonstrated that women will not attend preventive care services if they believe that they will be treated poorly.2 

Increasing provider knowledge and skills. 

Program success depends upon (1) assisting providers in adopting a public health-oriented approach to screening and treatment, and (2) training them in the skills necessary to counsel clients and provide high-quality services that respect women’s concerns and needs. In many settings, it is important to ensure that non-physicians can effectively provide screening services so that screening coverage can be maximized. 

Experience from cervical cancer control efforts worldwide suggests that some policies in low-resource settings call for inappropriate service delivery approaches—for instance, screening women as frequently as every six months, focusing screening on younger women, and focusing treatment on advanced cancers. Widespread use of such practices prevents programs from achieving a significant health impact by draining program resources. Both pre-service and in-service provider training can address this issue by presenting clear information about the public health rationale for frequent screening, focusing on broad coverage of older women in their thirties and forties, and emphasizing treatment of precancerous conditions.

Providers also need appropriate training on key clinical and counseling issues related to cervical cancer prevention, along with ongoing supervisory support and assistance in establishing and maintaining referral links. Particularly important is ensuring the quality of screening programs. If Pap smears are used, for example, the smear must be properly collected, stored, and transported to a cytology laboratory, and results must be accurately interpreted and provided to clients within a reasonable time frame. If visual screening approaches are used, providers must be trained to properly identify abnormal tissue and know what action to take; sufficient practice with a trainer present is crucial to this process.

Appropriate counseling also is critical. Providers must be trained to establish a respectful rapport with women and address their fears and concerns; only then will women get the information they need and feel comfortable returning for required follow-up visits.