Barriers to and enablers of cervical cancer screening delivery in Eswatini

Background: In 2018, Eswatini had the highest age-standardised incidence of cervical cancer in the world. The key preventive approach in Eswatini involves cervical cancer screening, delivered through the Ministry of Health and collaborations with external non-governmental organisations. However, screening rates remain low due to delivery and uptake challenges. Limited research has focused on nurses’ perspectives regarding the barriers and enablers of screening delivery, leaving gaps in knowledge. This study employed the Micro-Meso-Macro framework to explore nurses' experiences and perceptions regarding barriers and enablers to delivering screening services in Eswatini. Methods: An interpretative qualitative design was employed. Twenty in-depth telephone interviews were conducted among 20 nurses from 20 healthcare clinics distributed across the four geographic regions of Eswatini. Data were analysed using an inductive thematic approach with constant comparison. Identified themes informed continuing data collection, and sampling continued until thematic saturation was achieved. Results: Results are presented under three identified themes: (1) Nurses experience limited leadership and engagement from the Eswatini Ministry of Health, (2) nurses face process, resource and/or capacity barriers, and (3) client-related barriers to equity of access to screening hinder nurses' efforts to provide cervical cancer screening services. Barriers to screening service delivery include gaps in nurses’ knowledge and skills, inadequate cooperation between the Ministry of Health and non-governmental organisation-employed nurses, shortages of staff and equipment, limited training, absence of record-keeping systems, poor coordination between clinics and regional hospitals, insufficient leadership and engagement from the Ministry of Health, and lack of feedback on service delivery. Enablers of cervical cancer screening included guidelines and standard operating procedures, supportive supervision, a triage system to guide clients to screening services, comprehensive training programs, and patient incentives to promote the uptake of screening services. Conclusions: This study identified multiple challenges in delivering cervical cancer screening services in Eswatini, spanning micro, meso, and macro levels. These challenges included nurses' lack of knowledge and skills, resource shortages, limited leadership, and dependence on NGO support. Addressing these barriers calls for a multifaceted approach, involving advocacy, better data management, supportive supervision, and educational initiatives to enhance screening services delivery.