Barriers and Motivators for Uptake of Cervical Cancer Prevention Strategies in Eastern Europe: The Perspective from Latvia

The incidence of cervical cancer (CC) in eastern European countries, including Latvia, is high. Following the implementation of a state-funded human papillomavirus (HPV) vaccination programme in Latvia (2010), uptake of the HPV vaccine has been low (53.4% in 2012). In that context, this study explored knowledge, behaviours, and attitudes toward CC prevention strategies in Latvian women.

A mixed-methods study of Latvian women, consisting of surveys (158 completed) and 10 semi-structured interviews, was conducted in Riga, Latvia, in September and October 2015. The majority of participants for the survey were recruited from colposcopy clinics. Sample findings from the survey:

• Most women (67%, n = 105) understood that the smear test is a screening tool to identify precancerous cervical changes.
• Detailed knowledge of HPV infection and the HPV vaccine was deficient, although 73% (n = 115) and 70% (n = 90), respectively, claimed to have heard of them.
• Younger age was significantly correlated with general HPV knowledge and HPV vaccine knowledge. Higher educational attainment was associated with a higher HPV testing knowledge score.
• Only 4% (n = 5) had received the HPV vaccine.

Sample findings from the interviews:

• The practice of annual gynaecological checkups was prevalent, and it appears to have been passed down the generations and accepted as the norm. Reproductive organs were seen as more valuable than other organs, whereby they needed to be protected. Most women attended cervical screening (CS) annually; they described a feeling of "fear" that something would be missed if they waited the recommended 3 years, and having annual smears made them feel "safe". It was not clear whether the women fully understood that the CS was different from the annual gynaecological checkup.
• The women had little understanding of the examinations or tests that were performed during their annual checkups. It was apparent that there was considerable trust vested in doctors. Their advice was not to be questioned; nor was it felt necessary to conduct independent research.
• Perceived barriers to screening included that many women may not have heard of CS, or they were asymptomatic, and so they simply ignored the invitation letter. Access and time were other factors.
• Some women correctly identified that HPV was transmitted through sexual contact, whereas others were not sure how it was transmitted. The causal relationship between HPV and the development of CC was acknowledged, but the strength/seriousness of the association was not. The prevalence of HPV in Latvian women was underestimated.
• Latvia is described as a religious country; therefore the women believed that HPV would not be spoken of openly, stemming from the misconception that HPV infection is synonymous with sexual promiscuity. Negative views were expressed toward the HPV vaccine because it was felt that the available scientific information was inadequate. Fear of the side effects of such a new vaccine was reported as a major barrier to vaccine acceptance.
• "Scared" and "shame" were the most frequently quoted emotions - e.g., "shame" was used alongside the possibility of discussing sexual behaviours with parents or healthcare professionals.

In short, the findings highlight "the complex interactions that exist between knowledge, self-perceived health, and importance of health that govern CC prevention uptake. There was a lack of awareness of the high incidence of CC in Latvia, resulting in poor self-perceived susceptibility, as well as an ingrained cultural practice of annual gynecology checkups and a mistrust of the government-funded programs."

Overall, there was good awareness of the Latvian national CS programme; therefore, "lack of compliance would suggest there is an issue with acceptability and/or communication about the justification of the recommended practice. Healthcare professionals may also find the national program problematic because some women cited their gynecologist's recommendation as a reason for opportunistic CS. This study showed that there was a great amount of trust placed in the advice of the doctor, and therefore one could argue that to increase participation with national CS the focus should be on changing the attitudes of healthcare professionals."

Continuing, the researchers suggest that participation in organised CS "can be increased through greater patient engagement. To achieve this, awareness of CC needs to be increased, and the use of media outlets provides one possible method of accomplishing this. In addition, healthcare professionals have a vital role to play in patient education and in endorsing participation" in the national CS programme.

In conclusion: "The current CS behaviors in Latvian women appear to be governed by their lack of knowledge of the principles of screening and causes of CC. The results could be extrapolated to many eastern European countries that share a common Soviet heritage with Latvia, and they could give clinicians and policymakers insights into the misconceptions that need to be overcome to achieve greater patient engagement with CC prevention initiatives."