Cervical cancer screening during the COVID-19 pandemic: meanings of the experiences of Primary Health Care nursesAbstract
To understand how nurses perceive the performance of cervical cancer screening activities in Primary Health Care in the city of Rio de Janeiro, in the context of the COVID-19 pandemic, and to discuss their experiences in view of the concept of comprehensive health care.
Methods: Qualitative, exploratory, and descriptive study conducted from April to July 2021. Semi-structured interviews were used to obtain data and, as a research technique, Thematic Content Analysis, according to Bardin, was used to study the testimonies.
Results: Categories constructed: Decreased presence of users in health services; The COVID-19 pandemic has compromised the scheduling of cervical cytology tests.
Final considerations: The COVID-19 pandemic generated a health crisis that exposed the weaknesses of the services, such as gaps in the follow-up of users of the National Program to Combat Cervical Cancer, compromising the longitudinality and comprehensiveness of health care. The focus on Primary Health Care is relevant in building resilient teams that respond to emergency demands and minimize damage related to essential activities, such as discontinuing cervical cancer screening.
Keywords:
Cervical Cancer; COVID-19 Pandemic; Nurse; Primary Health Care; Integrality in Health
Resumo
Objetivos: Compreender como os(as) enfermeiros(as) significam a realização das atividades de rastreio do câncer do colo do útero na Atenção Primária à Saúde no município do Rio de Janeiro, no contexto da pandemia de Covid-19, e discutir suas experiências à luz do conceito de integralidade em saúde.
Métodos: Estudo qualitativo, exploratório e descritivo realizado de abril a julho de 2021. Foram utilizadas entrevistas semiestruturadas para obtenção dos dados e, como técnica de investigação, a Análise de Conteúdo Temática, de acordo com Bardin, para o estudo dos depoimentos.
Resultados: Categorias construídas: Diminuição da presença dos usuários nos serviços de saúde; e A pandemia de Covid-19 comprometeu o agendamento do exame citopatológico do colo do útero.
Considerações finais: A pandemia de Covid-19 gerou uma crise sanitária que expôs as fragilidades dos serviços, como as lacunas no seguimento de usuárias do Programa Nacional de Combate ao Câncer de Colo Uterino, com prejuízo da longitudinalidade e da integralidade do cuidado em saúde. É relevante a centralidade na Atenção Primária à Saúde, na construção de equipes resilientes que respondam às demandas emergenciais e minimizem danos relacionados às atividades essenciais, como a descontinuidade no rastreamento do câncer do colo do útero.
Palavras-chave:
Câncer do Colo do Útero; Pandemia da Covid-19; Enfermeiro; Atenção Primária à Saúde; Integralidade em saúde
Introduction
Cervical cancer (CC) occurs through an invasive process, resulting from intraepithelial neoplastic changes often associated with infection by the human papillomavirus (HPV). It is a chronic condition that takes an average of 10 to 20 years to develop and goes through preclinical (benign) phases characterized by premalignant or precancerous lesions that can be treated and cured (Machado; Souza; Gonçalves, 2017).
CC is considered a public health problem due to its high mortality rate among women of different ages (WHO, 2019). In 2018, there were approximately 570,000 new cases of CC and around 311,000 deaths; more than 85% of these deaths occurred in low- and middle-income countries (WHO, 2019). The high mortality rate from this disease worldwide is 6.9 per 100,000 inhabitants in the same period and could be reduced through effective screening and treatment programs. Screening at least 80% of the target population, combined with early diagnosis and treatment of abnormal cases, makes it possible to reduce the incidence of invasive cervical cancer by 60-90% (WHO, 2019).
In Brazil, the estimated incidence of CC for 2023 was 17,010, with a rate of 13.25% per 100,000 women (INCA, 2022). CC ranks third in primary incidence and mortality from cancer in women in the country, behind breast and colorectal cancer, excluding cases of non-melanoma skin cancer (Brazil, 2016). Among all types of cancer, it has one of the highest potentials for prevention and cure when diagnosed early. Its incidence is among women aged 30 and over, with a progressive increase in risk and generally reaching its peak between the ages of 50 and 60 (INCA, 2021).
Barriers related to women presenting for the exam late, as well as inaccessible diagnosis and treatment, are recurrent (WHO, 2019), even though the cytopathological exam for CC screening is known as a highly efficient method for the early detection of precursor lesions of invasive cancer and has a low cost. One of the main points related to this situation is the difficulty of users to access the preventive exam and the organization of the Family Health Strategy (ESF) services. This can compromise the participation of the target group of the National Program to Combat Cervical Cancer (PNCCCU) in actions for the promotion, prevention and early detection of CC (Andrade et al., 2017).
Furthermore, a new obstacle arose with the advent of the infection caused by the novel coronavirus (SARS-CoV-2), characterized as a pandemic by the World Health Organization on March 11, 2020 (PAHO, 2020a). This event triggered the disorganization of Primary Health Care (PHC) due to the high demand for care arising from COVID-19 cases. A significant portion of health resources were reallocated, given the new scenario imposed by the pandemic, which greatly weakened health promotion and prevention activities, resulting in lack of care and precarious follow-up of users (Fernandes, 2020).
At the beginning of the COVID-19 pandemic, the National Cancer Institute (INCA) recommended postponing CC screening tests, emphasizing that cases with positive screening or symptomatic tests should be investigated and, if confirmed, treated (Brasil, 2020a). Health professionals were advised to discourage users from seeking health services for cancer screening, to postpone this process. However, during the pandemic, the epidemiological scenario and the response capacity of the local health network were considered to establish the resumption of CC screening (Brasil, 2020b).
The qualified CC screening must be in line with the perspective of comprehensive health, which has its meaning related to care as a value that dialogues with the right to health, the replacement of the focus on the disease with care for the person, the approach to the human being in its entirety with a focus on users, taking into account their life history and how they live, get sick and die (Mattos, 2009). Incidentally, the ESF, as a health care model in force in Brazil, seeks to combine comprehensive care practices with programmatic actions and the reorganization of care for spontaneous demand from the perspective of user-centered reception (Giovanella; Franco; Almeida, 2020).
To understand the meanings of nurses’ experiences regarding CC screening practices within the PHC in the city of Rio de Janeiro, this research was conducted on their daily activities in PNCCCU actions. It aimed to understand the meanings attributed by nurses to the performance of CC screening activities in PHC in the city of Rio de Janeiro and to discuss their experiences in view of the concept of comprehensive health.
Methods
This is a qualitative, exploratory and descriptive study, whose data were analyzed considering the theoretical framework on the concepts of comprehensive health care, based on the CC Control Policies in Brazil. Comprehensive health care is a value, and its different meanings have in common the broad identification of the needs of service users with a focus on the interface between preventive and care actions and the complexity of human beings (Mattos, 2009).
The research setting consists of the Family Health units in the planning area 1.0, in the central region of Rio de Janeiro city. The units that presented the highest and lowest indicators of cytopathological test results for detecting CC were selected, according to the parameter of the Cervical Cytopathological Test Ratio, according to the indicator of the Undersecretariat for Health Promotion, Primary Care and Health Surveillance (SUBPAV).
The study involved 19 nurses who worked in care activities. Initially, the sample comprised 24 nurses; two were on maternity leave and met the exclusion criteria established for the study. Of the remaining nurses, 19 agreed to participate in the study and three refused. The inclusion criteria were having at least two years of experience in monitoring users in the ESF and agreeing to participate in the study. The exclusion criteria were being away from work during the entire data collection stage or withdrawing from the study for some reason.
Initially, the managers of the selected health units were contacted by email and, later, in person, so that the nurse with experience in PHC could explain the study and arrange the nurses’ participation as interviewees.
This meeting was the first step, a movement to familiarize themselves with the research field. The nurses were contacted by telephone or in person to be informed about the research aims and to negotiate the scheduling of the interviews. Due to the COVID-19 pandemic, the researcher had to return to some health units more than once to schedule and conduct the interview. The routine of the health units where the interviews took place was respected, so the professional was well received.
Data production took place from the end of March to late July 2021, and to access each of the participants, a semi-structured interview with a script of questions was chosen as the data collection technique. The service itself was the place for the interviews, which were previously scheduled, in a restricted area, to ensure confidentiality of the statements, and were recorded on an MP4 electronic device to maintain total fidelity to the statements, with an average duration of thirty minutes. A previously trained researcher conducted the interview, introduced herself to the interviewee, explained the objectives and ethical aspects, and obtained the interviewee’s consent.
To ensure the anonymity of the participants, the code “E” referring to the nurse was used, followed by an ordinal number, which varied from 1 to 19. The statements from the interviews were then transcribed in full. An individual script was used to guide the interviews, addressing aspects of the professionals’ practices in tracking CC.
The sufficiency of the data was determined by the criterion of empirical data saturation, when answers were repeated without new arguments on the questions formulated, and the perception that the data collected would no longer contribute to their consolidation, so the interviews ended. Secondary data were collected through access to the websites of the Ministry of Health and the City Hall of Rio de Janeiro (SUBPAV).
After the interviews were fully transcribed, the material was analyzed using the Thematic Content Analysis research technique, according to Bardin (2011), including procedures of pre-analysis, exploration of the material, data processing, inference and interpretation. The analysis categories were processed in line with the scientific production on the topic and the researchers' viewpoint, resulting in an understanding of the internal logic of the community under study.
The research was submitted to the Ethics and Research Committees of the Anna Nery School of Nursing/São Francisco de Assis Teaching Hospital/Federal University of Rio de Janeiro and the Municipal Health Secretariat of Rio de Janeiro. The content of the Free and Informed Consent Form (FICF) adhered to the requirements of Resolution No. 466, dated December 12, 2012, from the National Health Council (CNS), and was approved under opinions 34626620.2.0000.5238 and 34626620.2.3001.5279, respectively. The FICF was presented to the research participants after outlining the objectives and significance of voluntary participation. After reviewing the document, two copies were signed, one of which was given to the interviewee.1
Results and Discussion
The interviewees had the following social characteristics: 94.73% were female and 5.27% were male; 58% were between 30 and 99 years old, 26% were between 20 and 29 years old, 11% were between 50 and 59 years old, and 5% were between 40 and 49 years old. Regarding education, 54% of the professionals had a specialization or residency in Family Health, and 46% had other specializations or residencies not focused on family health. Regarding the time of experience in the ESF, 34% of the professionals had between 2 and 4 years of experience, 60% had between 5 and 10 years of experience, and 6% had been working in the ESF for 10 years or more.
Based on the information in the nurses’ statements, two empirical categories formed the analytical dimensions for this group.
Category 1 - Decreased presence of users in health services
From the interviewees’ perspective in this investigation, the COVID-19 pandemic was a peculiar circumstance and period that often implied weaknesses in the care of those under their responsibility. At the time, the population avoided attending the health service and the teams focused their assistance on certain priority groups, such as pregnant women and on the treatment of tuberculosis, which made it impossible to fully serve the users linked to the Cervical Cancer Care Line, as can be seen in the reports below:
I think the weaknesses at this time would be the pandemic, the issue of patients, at this time, avoiding coming to the health unit due to coronavirus contamination issues. I think that, in principle, from my point of view, the weaknesses would be only these. Nurse 4
There is the issue of lockdown, of strikes and it ends up that preventive care is not a priority line of care, right, so sometimes it is left as a second option. [...] but in this time of pandemic, we have lost a bit with that, right, but we do the active search [...]. Nurse 5
[...] It's really bad that the patient who came for a routine exam isn't coming, right? This is a guideline for us to focus more on providing care at this time in priority cases (pregnant women, children under 1 year old, and patients undergoing tuberculosis treatment, for example), right, who really need care. So, a silent CCU won't reach me, so this has become very deficient, so I believe that in the future, this will generate an increase in CCU. I think that if a study is done based on these 2 years of inactivity, right, during the pandemic, it won't be good at all. [...] With the pandemic, we haven't been able to monitor these lines of care in a better way, [...] Nurse 13
We've already had to cancel at least 3 times the entire scheduled preventive appointments due to the increase in COVID-19 cases. [...] and then the coverage [of the exam] during this period, for example, until today probably did not reach the target [...] and the services, as they have stopped at least twice, their return is overwhelming and, then we are only left with attending to the demands, some scheduled services, trying to advance surveillance, screening and everything else that encompasses our competences [...]. Nurse 7
Regarding the decrease in the population’s attendance at the ESF during the COVID-19 pandemic, a study by Silva et al. (2020) showed results like our research findings towards the alignment with the recommendations of the Ministry of Health for the basic network, that is, avoiding the movement of people in services to contain the transmission of the virus in the territory.
With the decreased number of users in the health service, it is essential to create other possibilities and modalities of care, such as community construction strategies for managing actions. In this case, care networks with multiple care technologies prioritizing comprehensive care and greater resolution of PHC must be considered in crisis such as the COVID-19 pandemic.
Regarding the construction of practices of new forms of social action, in which comprehensiveness can be achieved, Machado, Pinheiro and Guizardi tell us that:
We believe that the comprehensive way of knowing how to do things, based on the search for new forms of care, with respect to the different existing “world conceptions”, is an alternative for the construction of a comprehensive health policy in tune with the expectations of the Brazilian population. (Machado; Pinheiro; Guizardi, 2006, p. 74).
Regarding the observations of the interviewees on the cytopathological examination of the cervix being linked to the line of care, which was put on the back burner and was not considered a priority during the COVID-19 pandemic, an investigation by Santana, Medeiros and Monken (2022) showed divergent results. It was found that the response to PHC demands was ensured by adjusting the ESF work process. It is worth noting that institutional efforts towards such adjustments are strategic, since the loss of care for specific groups can worsen the clinical situation of users.
The development of technologies in PHC, such as applications to facilitate communication with the population about the prevention of COVID-19, can enable the implementation of specific actions to combat the transmission of COVID-19 and favor the reorganization of health services. For Alves, Salomé and Miranda (2022), the developed COVID-19 application can help teams better organize assistance in fighting the pandemic in their territory.
The COVID-19 pandemic, by interrupting scheduled care, ended up weakening the health actions developed by the care lines, with negative repercussions on the essential and derivative attributes of PHC, in line with the assumptions of Starfield (2002), especially regarding longitudinality, access and comprehensiveness.
Category 2 - The COVID-19 pandemic has compromised the scheduling of cervical cytology tests
Among the testimonies obtained, it is worth noting that the collection of material for the cytopathological examination of the cervix was one of the first practices to be suspended and that the respective schedule was restricted and blocked, as mentioned in the following narratives.
Now we are living in a very unique period, it is something we have never experienced before, I think this is one of the weaknesses because we have seen that we have lost several segments of health that we would have been able to handle before, for example, we have had reduced care. So, sometimes this monitoring of women's health is lost, the cytopathological exam as an activity that should not be suspended, right? So, I think this is a weakness, one of the main weaknesses we have now. Nurse 9
[...] because of what we are experiencing today, for example, I cannot collect the preventive tests that I would like for my patients, due to this pandemic issue, since we have to make choices about care [priority cases for care]. [...]. But, due to this situation we are in regarding the pandemic, we are not able to receive as much, I am super anxious. [...] In my team, we have reduced it a lot, we have practically stopped, unless we observe a case, for example, with a woman who has stopped menstruating, is in menopause and starts to have significant vaginal bleeding, so we have to keep a close eye on her, right? It could be endometrial cancer, for example. Nurse 10
[...] So, we don't have a shift or technical professional [for health education] [...]. I don't think so, especially with the pandemic, because preventive tests were one of the first things we stopped doing with the increase in COVID cases, right? It was one of the first procedures we stopped doing. Nurse 14
I think that after the pandemic, we don't have much time available in our schedule to do preventive tests, right, because now we must do swabs (COVID) here in the unit. Then we must do other vaccination activities and there is not much space in the schedule for the exam and, also during this pandemic, many women are not looking for it, it turns out that we are not able to do an efficient active search, to have much control over this, right? [...] Before the pandemic, sometimes the person in a free demand would comment on something and we would do it [Pap smear], but now it is a bit difficult even due to physical space, we had an office that is now exclusive for COVID care. It is more restricted now. Nurse 16
Regarding the COVID-19 pandemic, the proposed service reorganization focused on infection control, the purpose of which was to mitigate sustained transmission in the territory. Thus, the components of the work process of the ESF teams were directed to suspend general demand activities in PHC services, while maintaining care for priority demands, which proved to be a necessary strategy, since suspending care for these specific groups could increase the risk of worsening clinical conditions and, consequently, mortality from other causes (Giovanella et al., 2020).
However, the impact of the COVID-19 pandemic on the drop in the performance of cervical cytology tests was significant. Research by Oliveira et al. (2021) presented similar results to this study, demonstrating that, during the COVID-19 pandemic, the direction of managers, aiming at reorganizing the flow of care in PHC, often compromised access to diagnostic procedures specific to this level of care, such as the Pap smear. Eventually, the pandemic led to the suspension of different exams and procedures, due to the need to prioritize situations that required more speed in the context of a health crisis.
As a limitation of the study, it is worth noting that the results were produced from the perspective of nurses, which gives specificity to the findings. However, the reason for choosing these professionals was their significant participation in the PNCCCU.
Due to the COVID-19 pandemic, the routine of health teams had to change in different aspects; a new reality was imposed, with limitations never experienced before. In this sense, there was an impact on the development of this research, especially concerning fieldwork, since the professionals directly involved in the care provided to the population were not always available, and many were removed due to their health conditions, which implied social isolation.
Final considerations
In the context of ESF services, the COVID-19 pandemic caused a crisis that exposed the weaknesses of the services, such as gaps in the follow-up of PNCCCU users that, consequently, harmed the longitudinality and comprehensiveness of health care.
Based on the findings of this investigation, which revealed the perspective of PHC nurses in the city of Rio de Janeiro regarding the meanings they attributed to the practice of CC screening activities, we identified a loss of users' search for the Pap smear test in the context of the COVID-19 pandemic, since the population received guidance on social isolation and avoided being present at ESF services, which made it impossible to fully serve patients linked to the Cervical Cancer Care Line.
In addition, the scheduling of CC screening exams was compromised, which was one of the first practices suspended or restricted. Given the reorganization of services with less focus on preventing certain diseases, such as CC, there is concern about future effects, such as late diagnosis, increased comorbidities, and other long-term complications.
One must invest in studies to improve public policies to control CC and consider situations that deal with health emergencies. It is urgent to develop research that addresses innovation to organize healthcare in the territory and build resilient teams that respond to emergency demands. It is also paramount to highlight the importance of producing knowledge about strategies that minimize the effects of delays in the diagnosis and treatment of CC, as well as addressing the return of CC screening practices in the post-crisis period, with a focus on welcoming actions and health promotion, which were so compromised during the pandemic.
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