As shown in Table 1, FGD participants included WLHs between the ages of 35 and 66. Half (50.0%) of the women surveyed had a college or technical education, and half (50.0%) received disability benefits. The majority (87.2%) of women resided in the district, representing wards 8 (40.6%), 7 (15.6%), 1 (12.5%) and 5 (also 12.5%) . Wards 7 and 8 have the lowest socio-economic status and the highest unemployment rate .
Almost all WLHs indicated that they were currently insured (94.4%) and had a usual source of care (91.7%). A quarter (25.6%) of women indicated that they had a history of cervical cancer or hysterectomy. Regarding their history of cervical cancer screening, 94.4% indicated that they had had a Pap test in their lifetime and 77.7% indicated that they had had a Pap test in the last 12 months.
Overview of key themes
A visual/graphical representation of the key themes, raised during the FGD sessions by WLH, is presented in Fig. 1.
Based on the six focus groups, four thematic categories emerged (Table 2).
Knowledge about cervical cancer and HPV
Specifically in terms of general knowledge about cervical cancer and HPV, most women accurately identified cervical cancer risk factors by citing lifestyle behaviors such as as smoking and unprotected sex (see Fig. 1a). They also acknowledged that having HIV and not having a Pap test as recommended increases their risk of cervical cancer (“With HIV, I think we are more prone to infections, therefore there is a greater chance of contracting cervical cancer”). Prevention methods identified by the women included safe sex practices, healthy diet, exercise, and HPV vaccination (see Fig. 1b). A few women said they didn’t think cervical cancer was preventable.
While participants conveyed adequate knowledge of cervical cancer, many were unaware of HPV. Some of the women mentioned that they had never heard of HPV or had heard of it but had no additional knowledge beyond that. A few of the women said they only knew the term “HPV” because they had recently been exposed to HPV vaccine advertisements on billboards, radio and television, but ‘they didn’t know HPV was sexually transmitted (“I don’t remember being told it was sexually transmitted, that’s the first [time] I heard it “). Knowledge about cervical cancer screening was also low among our participants. The women could not explain what the Pap test is and what it entails; for example, some women mistakenly associated the Pap test with general testing for STDs (as opposed to identifying cellular changes or abnormal cells in the cervix). It was also not clear to our participants when a first Pap test should be initiated: some mentioned that it should be initiated during a woman’s first menstrual cycle. Finally, although our participants were aware that cervical cancer screening guidelines differed for WLH, many were unsure of the specific guidelines.
Barriers and Facilitators to Cervical Cancer Screening
When asked about barriers to cervical cancer screening (see Fig. 1c), women in our study said they were less likely to get screened due to their lack of knowledge about cervical cancer (“There is very little information that allows us to learn more about it”), other competing priorities (such as having to take care of her family), not not remembering the screening and not being able to go to their regular exams due to the COVID-19 pandemic.Due to the COVID-19 pandemic, they said they did not feel safe when they would go to their provider’s office, unless it was an emergency (“Uh, going to the office right now for a pap test and stuff like that is very dangerous, so we really need to one you can make at home.”. Some even expressed that if it was not offered by their provider, they would not seek testing unless they had abnormal symptoms.
Identified screening facilitators (see Fig. 1d) were more knowledgeable about cervical cancer risk factors and their susceptibility to HPV as WLH: “It is easier to get an infection even if I taking my meds as usual, so it’s a priority to get a Pap test whenever needed.” They also indicated that having a family history of cervical cancer or knowing someone affected by cervical cancer made them more aware of cervical cancer and more likely to adhere to recommended screenings (“My sister died of it. Uh, I’m getting checked for but uh, I had high-grade lesions and, uh, I had my cervix removed.”). Of the women who reported having had a Pap test in the past 12 months, many directly attributed their adherence to the screening to direct recommendations from their provider (“I have to do this, uh, but you know, it’s a bit difficult with the coronavirus, right? So, uh, but in general, I’m motivated by my doctor, the gynecologist”).. They mentioned receiving reminder notices (mail or calls) from their providers when they are due for their next screening (“I get a letter in the mail a week before it’s supposed to be done and then I get a notice , […] they call me more because they know I don’t like them”).
Ways to increase knowledge and adherence to cervical cancer screening
To better understand how to address knowledge gaps among the target population, we asked women to share their usual source of health information and their preferences for health education (see Fig. 1e) . Women indicated that they obtained their health information (general, cervical cancer, and HPV-specific) through a variety of channels: in-person education with their providers, conversations with peers or in group settings such as support groups, group discussions for research studies. , community/organization initiated workshops (“A lot, I get a lot of my information through focus groups and studies, etc.”). Some women indicated that they also obtained their health information through written materials such as pamphlets, although they also acknowledged that literacy level should be taken into account (“I think they should spell it out a bit more clearly when they write the cancer brochure”). , and that some may prefer picture messages (“So I think a picture is always good for the person who can’t read as well as someone else or has problems”).
Impact of the COVID-19 pandemic on sources of health information
Due to the COVID-19 pandemic, the women noted that they could no longer have these in-person education sessions. As most sessions ceased or migrated to an online platform, they had to quickly switch and rely on remote and technology-based communication channels (“We don’t know how long this case COVID-19 is going on, so I’m comfortable with video calls and phone calls from my doctor instead of going to the office.”) Other forms of media channels mentioned by women were the internet, the television, radio, e-mail, text messaging (“You know, the newsgroup and […] support groups on Zoom, and that’s a good way to spread the information, of course emails, texts because there are a lot of women who don’t know about this. ), videos, advertisements and social media (“Yes, social media, word of mouth, because you know, […] we’ve been together for years, we network so we know different things, we communicate with each other and we pass messages and things like that. When one person tells another, we find out together and do things together to find out things like that. ». Although some women acknowledged that messages that used fear tactics could work for some, they pointed out that messages conveying a sense of urgency were also effective (“Not really fear, but worry, a message of concern and how, how important it is for you to know about HPV.”).