Written by Swastika Shrestha, Research Manager at Birat Nepal Medical Trust in Nepal and co-author of the research article Feasibility of the HPV self-sampling pathway in Kathmandu Valley, Nepal using a person-centred design approach
“What does a name mean?” Shakespeare’s famous quotes. However, it turns out there’s more to a name than one might think. When I researched cervical cancer, I found that the majority of women did not know that cervical cancer and uterine cancer were different entities. Cervical cancer is known as “cervical cancer” and uterine cancer is known as “uterine cancer” in Nepal. These strangely similar sounding names have confused many women – causing them to use the terms interchangeably. So I would find myself explaining the difference between the two to the women I interviewed. When I had to explain to a cervical cancer survivor that she actually had a sexually transmitted infection that led to her cancer, I was anxious for a few days. I wondered if I was doing the right thing because she had already beaten cancer and was living happily with her husband who she had reported as her only sexual partner. I also met some groups of women who reported that they often chose to “test the private part water” i.e. papsmals. However, many of them did not understand that the test was done to check for any abnormalities in the cells that could indicate cervical cancer. The women said they did the water test to rule out any uterine cancer. Many women in Nepal do not have information about cervical cancer and that it can be prevented if checked and detected early.
For my research I also interviewed some young educated urban women who engaged in premarital sex. Premarital sex – more common in urban Nepal than some people would like – is still frowned upon by wider society. These young women seemed well aware of the need for testing for Sexually Transmitted Infections (STDs). However, they were reluctant to see gynecologists who often seemed to ask about their marital status when requesting STD tests. They indicated that self-testing kits for STDs would be in their favor if such services were available in the country – which unfortunately is not available to date. However, they added that even if such services existed, they would have to find ways to sneak the kits into their homes and dispose of the packaging without any family members noticing. Thus, even when women are aware of the need for screening, there are social barriers that women, especially single women, must face to get screened without being judged.
In the context of women living in rural areas, they are often busy with housework and farm work. This means that they often do not have the time to visit hospitals even when their health care needs are pressing, let alone for preventive care. Research shows that late diagnosis of cervical cancer is often common among illiterate women who often belong to less privileged families with lower socio-economic status (Gyenwali et al, 2013). This necessitates the urgency of screening as the cost burden of cervical cancer treatment for such households can prove devastating. If only women in rural areas had access to self-sampling services, they could test for preventable diseases much more easily and thus prevent any costs that could be incurred for future treatment.
My visit to the Bhaktapur Cancer Hospital, one of the only cancer-specialized public hospitals in the capital, was a reality check in itself for me. There I saw dozens of people queuing for their turn to check out. They came from all over the country from the rural village of Dumi in the West to Phulbari in the East. Not only did they have to bear the cost of treatment, but they also had to spend quite a lot on their transportation to the city and their accommodation and food in the expensive capital. The public health care sector in Nepal is poorly equipped and lacks adequate human and financial resources for effective service delivery. There are many private healthcare providers in the country – most of them concentrated in urban areas – who are better equipped to serve the people in the country. However, private health care comes at a cost that many Nepalis may not be able to afford. Given the country’s poor economy and the minimal income of many households, people have to prioritize their spending, which often does not include preventive health care. People visit health care centers often only when symptoms become unbearable, which in the case of cervical cancer means that the cancer has spread to the uterus. This means women are spending a fortune on treatment services instead of having screening tests that could have diagnosed the problem much earlier and saved them money.
Clearly, there are many factors that have proven to be barriers to HPV and cervical cancer screening in Nepal. Factors include lack of awareness, social stigma and poor infrastructure that is unable to provide adequate services to those who need it most. In such cases, a self-sampling method of HPV testing could prove useful, provided such a service could be provided to women at a price that does not scare them away from testing. My research on the feasibility of self-sampling for HPV testing in Kathmandu found that there is a dire need for increased awareness of HPV screening and access to alternative testing routes among Nepali women. In the urban context of Kathmandu, where internet access is the highest in the country, an online self-sampling pathway has the potential to address this need and remove some of the current barriers to testing, such as stigma.
The article by Swastika Shrestha and colleagues was published by SRHM in December 2020 and is available here:
Reference:
Gyenwali, D., Pariyar, J. and Onta, SR, 2013. Factors associated with late diagnosis of cervical cancer in Nepal. Asian Pacific Journal of Cancer Prevention, 14(7), pp. 4373-4377.
Please note that blog posts are not peer-reviewed and do not necessarily reflect the views of SRHM as an organization.
