Table 2 Potential challenges and opportunities in developing and implementing population-based screening in Cameroon according to micro-, meso-, and macro-level factors

From: Challenges and opportunities associated with cervical cancer screening programs in a low income, high HIV prevalence context

  Challenges Opportunities
Micro-level (Individual) Factors
Awareness and knowledge Older women were more likely to believe myths and misconceptions about cervical cancer Nearly all women were aware of at least one type of cancer – cervical and breast cancer most commonly
Risk perceptions and health-seeking behaviors Limited knowledge of the relationship of HPV and cervical cancer Younger women were more likely to demonstrate knowledge of risk factors associated with each type of cancer
Varied perception of risk associated with age, HIV status, adherence to myths and misconceptions and perceived risk of cervical cancer Nearly all women were aware of increased risk of cancer diagnosis in their community
All women had never been screened for cervical cancer Younger women and those with higher education were more likely to take preventive actions to minimize their exposure to risk
Knowing someone diagnosed with cancer strongly influences perception of risk and willingness to initiative preventative behaviors
Those that were aware of the risks of cervical cancer were more likely to encourage others to take preventive measures against cervical cancer
Lack of access to information about cervical cancer screening services Women did not have access to any source to obtain information about cervical cancer which made it possible for false and negative information about cervical cancer to spread in their communities Women sought information about cervical cancer from internet sources or private health facilities offering screening and other services related to cervical cancer
Cost as a deterrent to cervical cancer screening Absence of publicly funded cervical cancer screening programs Available at a few private health facilities, but these services are expensive so many women cannot access them
Difficulties with personal finances due to high unemployment rates in the country places paying for cervical cancer prevention as low on the list of priorities Women were likely to appear for cervical cancer screening if it was free and transportation costs were reimbursed
The cost of transportation to health facilities is an additional financial deterrent  
Meso-level (Community Norms and Social Networks) Factors
Social networks and social norms The type of information about cervical cancer is determined by the amount of cervical cancer knowledge that community has and how much they are attached to myths and misconceptions about cervical cancer Community education and stigma reduction around cervical cancer is likely to have a high impact because individual’s knowledge and behaviors are shaped by and conform to expectations is set by the level of awareness in their community
Cultural norms and the role of men Men do not take much interest in women’s health issues or encourage preventative behaviors as a result of cultural expectations of how men should conduct themselves Younger women are encouraging men to be proactive in taking concrete action to help prevent their spouses from getting cervical cancer (ie: not having multiple partners, encouraging their wives to participate in regular screening, etc.)
Men with negative attitudes about cervical cancer believe there is very little to be done to prevent cervical cancer Men with higher levels of education demonstrated better knowledge of risk factors and was more likely to demonstrate a positive attitude to cervical cancer prevention
HIV and health-related social stigma Ignorance and fear of death contribute to the stigma surrounding cervical cancer Lots of opportunity for stigma reduction activities in communities
The belief that cervical cancer is untreatable fuels stigma
Disease associated with women’s reproductive organs contribute to stigma given cultural norms around female sexuality
Macro-level (Structural: Health System and Policy) Factors
Weak health system and lack of infrastructure Lack of cervical cancer screening facilities in the regional hospital requires travel to large urban centers for screening Private clinics have made cervical cancer screening
Limited basic equipment for screening
Shortage of trained health care workers who can keep up with demand
Weak health care system and poor condition of physical health centers
Emphasis on HIV/AIDS within the health system leaving little space for competing health priorities
Shift to private facilities leading to higher costs for patients with limited trust in providers’ skills
Lack of cancer prevention policies Lack of comprehensive policies that can aid awareness and encourage positive attitudes to cervical cancer screening
Cervical cancer screening in in the context of HIV/AIDS care and treatment program Women not living with HIV or of unknown status did not want to seek screening from services integrated with HIV/AIDS care because of potential HIV-related stigma they may face Integration of cervical cancer screening within HIV care and treatment programs
Interest in community-based cervical cancer screening programs which can be accessed in community settings or done in their own homes
Lack of cancer prevention policies Limited commitment from government and politicians to improve population health Interest from age-eligible women to be educated on cervical cancer prevention
Rural–urban disparities in health care infrastructure and supplies