A multi-level qualitative exploration of factors influencing breast and cervical cancer screening uptake in Nepal.

e13858 Background: The global cancer burden disproportionately impacts low- and middle-income countries. In Nepal, breast and cervical cancer are the two leading causes of cancer deaths in women. Yet, there is no national breast cancer screening program, and less than 10% of eligible women have undergone cervical cancer screening. This qualitative study aims to identify facilitators and barriers to breast and cervical cancer screening at individual, community, and health system levels. Methods: We conducted 60-90 minute face-to-face in-depth interviews (IDI) (n = 28) with community women 30-60 years of age (n = 12), female community health volunteers (FCHVs) (n = 4), health coordinators (n = 4), service providers (n = 5), and deputy mayors (n = 3) from four municipalities in central Nepal until data saturation was reached. To capture diverse perspectives, we interviewed both women who opted in and out of breast and/or cervical cancer screening. An in-depth interview guide based on the five domains of the Consolidated Framework for Implementation Research (CFIR) was developed and modified iteratively. Interviews were recorded and transcribed verbatim and analyzed using a hybrid deductive-inductive coding and qualitative thematic analysis approach. Results: Key facilitators identified by all participants included 1) awareness through female community health volunteers (FCHVs) and 2) government subsidies for cancer treatment and insurance coverage for referrals. From a community perspective, 3) peer-to-peer communication networks and 4) having specialized health workers conduct screenings were important. On a systems level, local government leaders expressed 5) strong political motivation for collaboration with NGOs and tertiary hospitals to facilitate increased specialist access and training, while health coordinators and providers noted that 6) using cost-effective, accessible screening methods (visual inspection with acetic acid, HPV-DNA self-sampling, and clinical breast examinations) with immediate treatment or follow-up imaging would improve the sustainability of local programs. Systems-level barriers included 1) limited health and human resource availability, 2) geographical barriers to follow-up care, and 3) inequitable access to screening for marginalized groups. On a community level, 4) cancer-related stigma and lack of family, social, and financial support, 5) cultural expectations for women to focus on household obligations, and 6) privacy concerns led women to avoid screening or delay seeking care until symptomatic. Conclusions: Participants emphasized tackling barriers such as stigma, geographical challenges, and cultural expectations for women, and bolstering facilitators like the extensive FCHV network and multi-sector partnerships. Our findings will guide the development of a community-driven breast and cervical cancer co-screening program.