Open access peer-reviewed chapter
Characteristics of participants.
Abstract
Cervical cancer (CC) is a significant public health issue in Mozambique, being the most common malignancy among women. This study explores the perceptions of patients, partners, and family members regarding the diagnosis and treatment of CC at the Central Hospital of Maputo. Methods: A qualitative research study was conducted at the Central Hospital of Maputo, involving 18 participants (6 women with CC, 6 partners, and 6 family members). Data were collected through semi-structured interviews and analyzed using thematic analysis. Women exhibited limited awareness of CC and HPV, while partners acknowledged the diagnosis but had a poor understanding of the disease. Family support was generally positive; however, emotional distress and changes in marital relationships were noted. It is essential to implement public health policies focused on educational initiatives regarding CC, involving patients, partners, and family members, as well as to promote preventive campaigns about HPV and the use of condoms.
Keywords
- cervical cancer
- patient perceptions
- HPV awareness
- qualitative research
- family support
1. Introduction
Cervical cancer (CC) is recognized as a significant global public health problem, being particularly prevalent in developing countries. According to Globocan [1], CC ranks fourth among the most frequent types of cancer among women, with approximately 530 thousand new cases and 265 thousand deaths per year. The reality is alarming, especially in Africa, where the mortality rate is 23 per 100,000 women [2]. Mozambique stands out in this scenario, with CC accounting for about a third of cancer cases among women, partly due to the high prevalence of Human Papillomavirus (HPV) infection [3, 4]. HPV, which can not only cause cervical cancer but also affect male sexual health, has a high spread among the young population, with significant infection rates reported among young women aged 20 to 30 years [5].
Early detection of CC is a crucial aspect to minimize the mortality associated with the disease. Although there are effective screening methods, such as cervical cytology (Pap smear), late diagnosis is still a worrying reality, with about 80% of cases being inoperable at the time of diagnosis [6]. A study by Lorenzoni et al. [7] points out that cervical cancer represents the most common malignant neoplasm among women in central hospitals in Mozambique. The situation is aggravated by the lack of knowledge about the routes of HPV transmission by men, who play a key role not only in the spread of the virus but also in women’s reproductive health [8].
In addition to the clinical aspects, the emotional impact of a cancer diagnosis is profound and multiform, affecting not only patients but also their partners and families. Trombini et al. [9] describe the diagnosis period as a time of intense emotional charge, where feelings of fear, dread, and depression are frequently reported. Family and partner support, in turn, is essential in the treatment and recovery phases. Salci and Marcon [10] emphasize that emotional, social, and financial support is vital to overcome the difficulties imposed by the disease.
This study aims to investigate the perception of cancer patients and their partners and family members in relation to the diagnosis and treatment of CC at the Maputo Central Hospital, one of the main health referral centers in Mozambique. Through this research, it is expected to better understand attitudes and knowledge about the disease, as well as the psychological and social impact that CC generates in families. The identification of these aspects can contribute to the development of more effective support and intervention strategies, providing an approach that not only treats the disease but also considers the integral well-being of women and their support network.
2. Methodology
This is a descriptive exploratory study, with a qualitative approach, through which we sought to know in depth the universe of meanings and attitudes of women with cancer and their partners and family members in relation to the diagnosis and treatment of CC at the Maputo Central Hospital. Data collection was carried out during the months of September to November 2022 in the oncology ward of Maputo Central Hospital, which usually admits patients with CC. It is a quaternary level hospital, of national reference, located in the center of Maputo city with the following geographical limitations (north – AV. Agostinho Neto; south – AV. Eduardo Mondlane; to this – AV. Tomás Nduda; and to the west – AV. Salvador Allende).
Data collection began after the women, their partners, and family members were informed of the importance and purpose of the research by signing the Informed Consent Form (ICF). Semi-structured interviews were used as a technique to capture data, and the interviews were recorded and transcribed in full after the participants’ consent using the MP4 player as an instrument. An interview script was prepared with the following guiding questions: What are the perceptions of cancer patients, their partners, and family members in relation to the diagnosis and treatment of cervical cancer in the oncology service of the Maputo Central Hospital. This instrument included sociodemographic data for women, their partners, and family members, in which the participants had the opportunity to discuss the theme, addressing aspects such as knowledge about the mode of transmission and attitudes of women, their partners, and family members toward the diagnosis and treatment of CC (See Appendix).
Through convenience sampling, defined by the criterion of data saturation and recurrence of information, but taking into account those that were not repetitive, the total size of research subjects to be interviewed was composed of 18 participants, 6 women with CC, 6 partners of women diagnosed with CC, and 6 family members.
For data analysis, the theme of content analysis proposed by Bardin was used. For the purpose of understanding and preserving the confidentiality of the women’s identity, their partners and family members were identified by the letters “EN” added to the sequential number of the interviews.
The research project was approved by the Institutional Committee of Bioethics for Health of the Higher Institute of Health Sciences - ISCISA (CIBS - ISCISA) under number TFCSPID20/19 and respected the principles of the Declaration of Helsinki that establish the criteria for research involving human beings. All the information obtained during this study was handled confidentially by the researcher responsible for the study.
3. Results and discussion
3.1 Sociodemographic characteristics of the participants
The study involved interviews with six women diagnosed with cervical cancer (CC), six partners, and an equal number of family members, all of whom were admitted to the Oncology service at Maputo Central Hospital. Among the women, half were over 40 years old; all were employed in the informal sector, and five identified as evangelical Christians. Two women had completed primary education, two had completed secondary education, and two had attained higher education (Table 1).
| Variables | Features | Women | Partners | Family |
|---|---|---|---|---|
| Acts | 30–39 years | 3 | 0 | 6 |
| 40–49 | 3 | 6 | 0 | |
| Education level | Primary | 2 | 0 | 0 |
| Secondary | 2 | 1 | 1 | |
| Academic | 2 | 5 | 5 | |
| Profession | Formal | 0 | 1 | 3 |
| Informal | 6 | 5 | 3 | |
| Religion | Catholic | 1 | 1 | 1 |
| Evangelical | 5 | 3 | 5 | |
| No | 0 | 2 | 0 | |
Table 1.
These findings are consistent with research conducted by Dejeane Barro and Regina Lopes [11], which noted that the incidence of cervical cancer is rare in women under 30 years of age, peaking between the ages of 45 and 50. Additionally, a study by Allanda Santos et al. [12] highlighted that HPV infections tend to regress spontaneously in women under 30, whereas persistent infections are more commonly observed in older women. Moreover, Allanda Santos et al. [12] indicated that limited access to health information may be correlated with low educational attainment, potentially resulting in delayed health-seeking behavior and subsequently late CC screening.
The partners of the women interviewed ranged in age from 40 to 50 years. Five partners had completed high school and were employed in the informal sector, and three identified as evangelical Christians. Family members were all under 40 years old; five had completed high school and identified as evangelical Christians (Table 1).
3.2 Women’s knowledge about cervical Cancer
All interviewed women reported having heard about cervical cancer at some point in their lives, although most lacked detailed knowledge about the disease. These findings align with the research conducted by Santos et al. [13], which indicated that 45% of women surveyed had heard of cervical cancer but could not articulate its specifics.
Knowledge of cervical cancer is essential for women to prevent this pathology through early screening. When asked about their understanding of cervical cancer, the majority of women (five out of six) demonstrated some awareness of the disease. Allan Santos et al. [13] noted similar findings, suggesting that knowledge about cervical cancer is generally low among women due to inadequate information and deficiencies in educational programs that promote effective health actions. These conclusions are consistent with those of Allan Santos et al. [13], who found that many women approached health facilities primarily for symptomatic concerns rather than for preventive measures.
Responses from participants included:
Concerning the transmission mode, all interviewed women expressed a lack of understanding regarding how cervical cancer is transmitted. Al-Naggar et al. [14] reported that over 50% of participants in their study were unaware of HPV transmission methods.
All participants reported that they neither smoked nor consumed alcoholic beverages. However, they exhibited uncertainty and fear regarding how they contracted cervical cancer.
Luciana Buosis [15] noted that tobacco can exacerbate HPV-infected tissues’ susceptibility to mutations while reducing Langerhans cells, which play a critical role in the immune response. Research by Sang-Soo Seo et al. [16] demonstrated that women who consume alcohol while being exposed to tobacco have a higher risk of persistent HPV infection, while those not exposed to these substances have a lower risk. Therefore, the participants’ denial of smoking and alcohol use may indicate an attempt to dissociate from socially stigmatized risk factors.
3.3 Sexual and reproductive health
The average age for the onset of sexual activity among participants was 18 years. Allan Dantas dos Santos et al. [13] similarly found that the average age of sexual debut among their interviewees was approximately 17.8 years, corroborating our findings. Early initiation of sexual activity (prior to age 18) is associated with an increased risk of cervical cancer due to greater exposure to carcinogenic agents [17].
Most participants reported having between two and five children, a reflection of societal values where larger families are often perceived as a sign of prosperity. These findings align with a systematic review by Tekalegn Yohannes et al. [18], which indicated an elevated risk of cervical cancer among women with multiple pregnancies.
Participants were also questioned about their number of sexual partners in lifetime: two indicated they had only one sexual partner, one reported seven, and three reported three sexual partners. Studies suggest that women with more than two sexual partners face a five-fold increase in the incidence of cervical HPV lesions [19].
Sakshi Basoya and Ashish Anjankar [20] posited that the use of condoms during sexual intercourse is a primary preventative measure against cervical cancer by mitigating HPV infection risks. While all women reported using condoms at the onset of sexual activity, they eventually discontinued their use due to trust in their partners.
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Sexually transmitted infections (STIs) are recognized as contributing factors to cervical cancer development [21]. All interviewed women acknowledged having had STIs in the past, which were treated at local health facilities. One participant reported never using a contraceptive method, while the others cited using Depo-Provera or oral contraceptive pills. Oral contraceptive use may influence HPV genome transcription, as noted by Adriane Cristina Bovo et al. [22].
3.4 Women’s attitudes toward the diagnosis and treatment of cervical cancer
Most participants expressed feelings of anguish, despair, fear, and melancholy. Similar results have been reported in studies conducted by Dinah Kassaman et al. [23] and Patience Asante et al. [24], which find that many women not only experienced fear and despair but also harbored doubts about the effectiveness of available treatments.
Upon receiving a diagnosis of CC, patients described the experience as arduous, marked by feelings of sadness and dread, as well as fear of death and an existential questioning of their circumstances. As one participant articulated,
Another shared,
A third participant noted,
Regarding challenges encountered during treatment, all women reported that they were managing well overall. However, two participants mentioned experiencing symptoms such as diarrhea, mucositis, myalgias, and anemia. It was also observed that some women experienced a decline in self-esteem attributed to physical weakness as well as other factors. Research has indicated that chemotherapy can lead to various physiological changes, with common side effects including hair loss, anxiety, nausea, vomiting, anemia, fatigue, and digestive disturbances [25, 26].
All participants unanimously expressed appreciation for the support they received from their families, including their partners, and they conveyed satisfaction with this support. According to Emma Ream et al. [27], family support during such challenging times is paramount, as it assists individuals in making decisions to persevere with treatment despite its side effects and the associated challenges.
3.5 Partners’ knowledge about cervical cancer
Understanding the experiences of the partners of women with CC is critical, as they play a fundamental role in providing care and support during challenging health crises [28]. Partners were queried about their knowledge of their partner’s cancer diagnosis. Most men recognized that their partners had cancer but could not specify the type, with only one correctly identifying it as cervical cancer. This aligns with findings by Charity Binka [28], which highlighted men’s limited awareness of their partners’ cervical cancer diagnoses.
Responses included:
Partners’ awareness of cervical cancer transmission paths was also assessed. Unprotected sexual activity is recognized as a primary transmission pathway for cervical cancer [29]; however, all partners interviewed could not specify these routes, despite numerous public health campaigns by the Mozambique Ministry of Health.
Similar findings were observed by Hae Kim et al. [30], who noted that none of the 12 men interviewed could identify cervical cancer transmission routes. Likewise, Pedro Pedreira et al. [8] reported that men held misconceptions surrounding cervical cancer and were largely uninformed regarding transmission pathways.
Responses from men included:
3.6 Support from partners at diagnosis of cervical cancer
It is crucial for men to accompany their partners to health units, as a cervical cancer diagnosis presents significant challenges in the couple’s marital life. When asked, all partners stated that they were not present when their partners received their cervical cancer diagnosis. Many were busy with work or family responsibilities. This finding supports previous research demonstrating that many men fail to accompany their partners to health appointments due to various obstacles, including time constraints, hostility from healthcare professionals, transportation issues, and uncertainty regarding how to provide support following a diagnosis [31, 32, 33].
Statements from participants included:
3.7 Partner support following cervical cancer diagnosis
Although all men stated they were not present at the time of diagnosis, they reported actively participating in their partners’ treatment process. All indicated helping to acquire medications, providing transportation for hospital visits, and seeking blood donors. These findings echo those of Charity Binka et al. [28], in Ghana, where many men reported providing financial, material, social, and emotional support to their partners.
Responses included:
3.8 Implications of cervical cancer on marital life
All partners reported that cervical cancer led to a cessation of sexual activity due to the pain experienced by women during intercourse. Changes in the couple’s daily routine were noted, particularly concerning the time that women spent receiving treatment. Statements from participants included:
These findings align with results from Suelem Magalhães [34], in Brazil, where 90% of women with cervical cancer reported negative effects on their marital life. Furthermore, many men indicated that their sexual lives had changed due to their partner’s health condition [28, 35]. Leucorrhea with an unpleasant odor, a common symptom of cervical cancer, has also contributed to the reduction of sexual contact between couples [28].
3.9 Extramarital relationships
In the Mozambican context, where polygamy [36, 37], is culturally “accepted,” maintaining regular sexual activity is vital for marital stability. Due to their partner’s health condition, most men reported having other sexual partners, and all but one acknowledged not using condoms in these extramarital relationships. Such behaviors increase the risk of HPV transmission and subsequent cases of cervical cancer.
Statements from participants included:
Parallel findings were reported by Charity Binka et al. [28], where men acknowledged engaging in extramarital relationships due to their partner’s illness. Men’s sexual behaviors, characterized by multiple partners and a lack of condom use, pose additional health risks to women, as they may facilitate HPV transmission [38]. Unprotected sex and having multiple sexual partners are recognized risk factors for cervical cancer [19].
3.10 Family perspectives
According to Dwi Kurniasih et al. [39], knowledge about cervical cancer and its progression can significantly enhance the support provided by families to patients. Family members were queried about their familiarity with cervical cancer. Most participants reported having heard of the disease but demonstrated limited understanding of its specifics. For some, cervical cancer was perceived as a “wound in the uterus,” while others regarded it as a form of bleeding.
These findings are consistent with research conducted by Zintle Gwavu et al. [40] and Allan Santos et al. [13], where many interviewees could not articulate the nature of cervical cancer but had heard of it.
Responses included:
3.11 Knowledge of family members regarding the causes of cervical cancer
Half of the family members interviewed were unable to identify causes of cervical cancer, while the other half attributed it to sexual contact and/or sexually transmitted infections. Human Papillomavirus (HPV) is the primary risk factor for precursors of cervical cancer [41, 42]. None of the family members interviewed could accurately specify its causes.
Responses included:
3.12 Knowledge of family members regarding transmission routes of cervical cancer
Family members offered divergent opinions regarding transmission pathways. Some linked transmission with poor genital care or hygiene, while others mentioned sexual intercourse or expressed uncertainty.
Responses included:
The divergent opinions among family members regarding the transmission pathways of cervical cancer reveal gaps in knowledge, particularly around the understanding of HPV.
The reference to hygiene as a potential risk factor could reflect broader socio-cultural misconceptions about women’s health, where cleanliness is wrongly associated with cancer prevention. The health education interventions that clarify the nature of HPV transmission can help to demystify these beliefs and shift the focus toward evidence-based preventive measures such as vaccination and regular Pap tests [43].
3.13 Attitudes of family members toward the diagnosis
According to Livia Urtiga et al. [44], family support is crucial for ensuring that patients with cervical cancer can navigate their diagnosis in a secure and calm environment. Family members expressed feelings of pain, fear, and despair upon hearing about their loved one’s diagnosis while simultaneously conveying hope and faith in their recovery. Their religious beliefs provided significant emotional support during this challenging time [44].
Responses included:
3.14 Attitudes of family members toward treatment
Family support is crucial for cervical cancer patients to maintain hope and commitment to treatment [39, 45, 46]. Family members affirmed that they provided social, economic, spiritual, and emotional support. These findings corroborate studies highlighting the significance of family encouragement in enabling patients to face treatment challenges.
Responses included:
Despite encountering various side effects from chemotherapy, such as mood swings, nausea, and lack of appetite, family members reported offering necessary assistance, including medications for nausea and emotional support.
Responses included:
4. Conclusion
Cervical cancer poses a significant public health challenge in developing countries such as Mozambique, predominantly affecting women from lower socioeconomic backgrounds. The limited awareness of cervical cancer among women, along with their family members, underscores the urgent need for enhanced educational initiatives regarding the importance of early screening.
This study indicates that women with cervical cancer, along with their partners and families, displayed limited knowledge regarding the disease. This necessitates governmental and partner engagement in comprehensive educational programs focused on primary prevention and awareness, especially in schools and community settings.
Upon receiving a cervical cancer diagnosis, women and their families often experience feelings of anguish, fear, and self-doubt. Psychosocial support is essential for navigating these difficult experiences. Despite potentially adverse reactions to chemotherapy, the women reported receiving emotional, spiritual, financial, and social support from their partners and families. Family and community support systems play pivotal roles in helping cervical cancer patients approach their diagnosis with hope and resilience.
The repercussions of cervical cancer extend to marital relationships, often resulting in reduced sexual activity and increases in extramarital relations among partners, contributing to heightened risks associated with HPV transmission. Without adequate protective measures, these patterns pose additional public health risks and underscore the need for comprehensive approaches to cervical cancer prevention and treatment.
A. Interview guide
Appendix 1: Interview guide for women
B.1 Participants’ background information
B.2 Age
Gender:
Educational Level:
Occupation:
Marital Status:
Number of Children (if applicable):
Have you ever heard of CC? If so, in your opinion what is CC?
Could you tell me how you knew you have CC? In your opinion, how does CC appear?
Do you consume any alcohol or tobacco?
How old were you when did you have your first sexual intercourse?
How many children do you have and how old did you have your first child?
I am now going to ask a sensitive question, but I would like you to answer me honestly. Could you tell me how many men you had sexual involvement with before the disease you have been diagnosed?
Did you always use condoms in your sexual relations? If not why?
Have you ever contracted a sexually transmitted disease? If so, how many times? Did you go to the health unit for treatment? Have you ever used oral contraceptive? For how long?
On the day you went to the health facility for cervical screening or consultation, did you go alone, or did someone accompany you?
At the time you received the diagnosis that you have CC, what was your reaction?
When you learned of the diagnosis, who was the first person who revealed your health condition? Why?
Have you revealed to your husband that you have CC? If not why? If so, what was your partner’s reaction?
In addition to your partner, have you revealed to other family members that you have CC? If so, what was the family’s reaction?
Could you tell me how the treatment is going? Is there any difficulty you face in relation to treatment? If so, which ones?
Regarding treatment, have you received any support/encouragement from your partner and your family? If so, which ones?
Are you satisfied with the support of your family and your partner? If yes or no, why?
Do you want to ask me any questions? Thank you very much for your time.
What recommendations would you make for improving awareness and education about cervical cancer in your community?
What additional support do you believe is necessary for women diagnosed with cervical cancer and their families?
Thank you for your time and insights today. Is there anything else you would like to add regarding your experiences with cervical cancer, or any questions you have for us?
Appendix 2: interview guide for (men) partners
C.1 Relationship context
How are you related to the woman diagnosed with cervical cancer? (e.g., partner, family member)
How long have you known the wife diagnosed with cervical cancer?
What do you understand about cervical cancer and its causes?
What are your thoughts on how cervical cancer is transmitted?
Have you had any conversations with the woman about her diagnosis? What was discussed?
Were you with your wife at the time the diagnosis was made? If not, why?
What was your reaction at that moment?
Could you tell me what implications this disease has brought to your married life?
What changes did this disease bring to the family?
Have you accompanied your wife at the time of treatment? If not why?
How did you feel when your partner was diagnosed with cervical cancer?
What kind of support do you believe you provided to her?
I am now going to ask a sensitive question, but I would like you to answer it truthfully. Do you have other sexual partners? If so, do you use condoms in these relationships?
What recommendations would you make for improving awareness and education about cervical cancer in your community?
What additional support do you believe is necessary for women diagnosed with cervical cancer and their families?
Thank you for your time and insights today. Is there anything else you would like to add regarding your experiences with cervical cancer, or any questions you have for us?
Thank you very much for your time
Appendix 3: interview guide for family members
D.1 Relationship context
How are you related to the woman diagnosed with cervical cancer? (e.g., partner, family member)
How long have you known the woman diagnosed with cervical cancer?
To begin with, I would like to know in your perception, what is cervical cancer?
In your opinion, what is the cause of CC?
What are the routes of transmission of CC?
When she revealed that she has CC in her family, how did you feel? What came to your mind? What was the reaction that the family had when they learned that she had this disease?
What changes did this disease bring to the family?
Have you/family joined her for any treatments? What has that experience been like?
How have you or family supported her during this process?
What are the difficulties she has faced to continue with the treatment? Can you explain whether these difficulties are related to the effects of the medication, or the type of work it does or some other reason? How has it overcome these difficulties?
How has your family dynamic changed since the diagnosis?
Are there any noticeable changes in the way you interact with the diagnosed woman?
What recommendations would you make for improving awareness and education about cervical cancer in your community?
What additional support do you believe is necessary for women diagnosed with cervical cancer and their families?
Thank you for your time and insights today. Is there anything else you would like to add regarding your experiences with cervical cancer, or any questions you have for us?
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