Assessment of the Quality of Cervical Cancer Prevention Services in Southwest Nigeria: A Cross-Sectional Study Using Donabedian’s Quality Framework

Abstract

Introduction

Cervical Cancer (CC) is the second leading cause of cancer-related deaths among women in Nigeria, after breast cancer. However, there is a significant gap in evaluating prevention services due to the absence of organized and sustained programs. Immediate action is essential to address this critical issue.

Objective

The study assessed the quality of CC prevention services (CCPS) in selected Southwest Nigerian states using Donabedian’s quality framework.

Methods

The study employed a cross-sectional descriptive research design, selecting 24 Secondary Health Facilities (SHFs) and 72 reproductive-aged women (aged 30-49) from two states to evaluate the quality of CCPS. Based on the median score and interquartile range, the Donabedian quality framework categorizes CCPS as high, moderate, or poor. A paired independent t-test was conducted to compare the quality of existing CCPS in the two states.

Results

The study found that 42% of selected healthcare facilities in Osun State and 34% in Lagos State offer CCPS. The facilities have basic screening materials, with Visual Inspection with Acetic Acid (VIA) being the most used. The availability of materials resources in facilities varied based on the type of CCPS. The median score ranged from 124 to 185, with 54% of facilities rated good quality, 8.3% moderate, and 37.5% poor. However, there was no significant difference in CCPS quality between the two states at t = −1.96, P = 0.062.

Conclusion

Quality assessment of CCPS is crucial for providing effective and equitable healthcare. Donabedian’s framework enables systematic evaluation of the services’ structural, procedural, and outcome aspects. Addressing gaps and enhancing the quality of CCPS can effectively reduce the burden of CC.

Introduction

Cervical Cancer (CC) poses one of the gravest threats to women’s lives, holding significant public health importance. Globally, it ranks as the fourth most frequently diagnosed cancer and the fourth leading cause of cancer-related deaths in women, with an estimated 660 000 new cases in 2022. ¹ Approximately 94% of the 350 000 deaths attributed to CC occurred in low- and middle-income countries. Nearly 90% of CC deaths each year are among women living in these regions. However, many high-income countries have successfully implemented comprehensive CC prevention and control measures, dramatically reducing incidence and mortality from the disease.^1–3

In contrast, in Nigeria, CC is the second most prevalent cancer after breast cancer and is the most common cancer among women aged 15-44. Current estimates suggest that each year, 12 075 women are diagnosed with CC, and 7968 die from the disease.^3,4 CC is primarily attributed to high-risk persistent Human Papillomavirus (HPV) infection, a common sexually transmitted infection that, if left untreated, causes 95% of CCs.

Documented evidence^5–10 indicates that CC prevention services (CCPS) include a variety of interventions: HPV vaccination, organized screening programs, treatment of precancerous lesions, and health awareness and education aimed at reducing the incidence and impact of CC. These services must be tailored to the specific context of a country’s resources, healthcare infrastructure, and population needs. While high-income countries utilize advanced technologies and well-established healthcare systems in CC prevention strategies, low- and middle-income countries (LMICs) can make significant progress through innovative, cost-effective approaches and robust community engagement. Both contexts can learn from each other to enhance the effectiveness of CC prevention efforts globally. It is essential to evaluate existing CCPS and their quality to determine the need and potential for enhancement and the health system’s capacity to address CC more effectively. The goal is to improve the quality of CC prevention services and enhance health outcomes for women in the region.

Methods

Recruitment and Sampling

The study employed a cross-sectional descriptive research design. This study was conducted from April 2018 to June 2019 in two states of southwestern Nigeria, Lagos and Osun, and purposive sampling was adopted. It was conducted in government-approved public and private secondary health facilities (SHFs) that provide CCPS. Out of the six states, the two states (Osun and Lagos) were purposively selected based on the feasibility study. In addition, the criteria for choosing these states were based on the status of CC (CC) prevention. Lagos State is at the frontline in CC prevention, and there is a scale-up program on CC prevention in the state. Similar studies have been conducted in Ogun and Oyo States, but there is a dearth of information on the topic of interest in Osun State.

Sampling and Sample Size

Health Facilities and Nurses

Twenty-four SHFs (14 in Lagos and 10 in Osun) were purposively selected based on their provision of CCPS. In addition, 19 trained registered nurses (9 in Osun and 10 in Lagos) who fulfilled the inclusion criterion of at least two years of experience providing CCPS were included. These nurses served as key informants to explore their roles and insights regarding CCPS delivery.

Selection of Reproductive-Age Women

Two categories of reproductive-age women participated in the study: those who utilized CCPS in selected SHFs and those in selected communities engaged in the Focus group Discussions (FGDs). A purposive sampling technique was used for the first category; the total number of screened women per facility over the past year was summed, and the mean was calculated. A quota sample of three women per secondary health facility was selected, employing a non-random quota sampling technique to recruit 72 participants to ensure a representative demographic sample, including age and socioeconomic status variables.

For the second category, random sampling was employed to select two communities (public and private) from the representative SHF providing CCPS in each state. Communities without the selected secondary health facilities within their domain were not eligible. There were two homogeneous groups (ages 30-39 and 40-49) per community, and four FGDs were conducted in each state to enhance the qualitative aspect of the study, providing diverse insights into user experiences. Participants were recruited through purposive sampling. Eligibility criteria included: (1) women residing in the selected communities with either a public or private SFH providing CCPS, (2) ages between 30 and 49, and (3) whether they have used CCPS or not.

Inclusion and Exclusion Criteria

Inclusion Criteria

1. Women aged 30-49 years residing in communities served by selected SHF.

2. Women who had either utilized or not utilized CCPS.

3. Registered nurses with at least two years of experience in SHF providing CCPS.

4. Government-approved public and private SHF providing CCPS in Lagos and Osun States.

Exclusion Criteria

1. Communities without selected SHF in their domain.

2. Women who did not fall within the age range of 30-49 years or were not residents of selected communities.

3. Nurses with less than two years of experience in providing CCPS.

Data Collection

Data were collected using the Donabedian Quality Framework, which evaluates the quality of healthcare services through structure, process, and outcome dimensions. Three instruments were employed for this purpose. The Facility Assessment Tool (FAT) assessed human and material resources, including the types and availability of CCPS methods, using a 34-item scale. The Non-Participant Observation Client-Provider Checklist (NPOCPC), adapted from the West Midland Cervical Screening Quality Assurance tool, evaluated service delivery and infection control across 21 items. The SERVQUAL questionnaire assessed perceived service quality across five dimensions: tangibles, reliability, responsiveness, assurance, and empathy. The instruments demonstrated strong validity (CVI of 0.86) and reliability (inter-rater reliability ≥0.92).

Data Analysis

Quantitative data were analyzed descriptively, summarizing categorical variables as frequencies and percentages and continuous variables as means and standard deviations. Scores from the structure, process, and outcome components were aggregated, with a total attainable score of 205. CCPS quality was categorized as poor (<149.5), moderate (=149.5), or good (>149.5) based on the median threshold. Comparative analysis between Lagos and Osun states was performed using paired independent t-tests, while boxplots illustrated data distribution and variability. Qualitative data from FGDs were analyzed thematically, providing insights into women’s experiences with CCPS. This analysis enriched the quantitative findings, offering a comprehensive understanding of CCPS delivery and utilization.

Ethical Statement

Ethical Approval

The Institute of Public Health at Obafemi Awolowo University, Ile-Ife, Osun State, approved the study (IPH/OAU/12/590). Various ministries of health and hospital management boards gave permission to collect data, and respondents gave consent. All patient details have been fully de-identified to ensure confidentiality and compliance with ethical research standards. No information is included that could allow the identification of any individual participant.

While the study’s purposive sampling approach may limit the generalizability of findings, integrating multiple data collection methods strengthened the robustness of the results. Triangulation of data sources, including observational tools and FGDs, minimized potential biases and ensured a holistic evaluation of CCPS quality. The reporting of this study conforms to the STROBE guidelines. ¹¹

Results

The demographic table summarizes the distribution of participants by age group, marital status, religion, ethnicity, education level, employment status, and income range. A significant proportion of participants were self-employed, between the ages of 30 and 34, and identified as Yoruba. The observed age range for HPV vaccination was 12 to 24 years (Table 1).

Table 1.

Respondents’ Demographic Characteristics.

Variable	Frequency (n = 72)%
Age (years) 32.2 ± 27.9
30-39	44 (66.1)
40-49	28 (38.9)
Marital status
Single	11(15.3)
Married	48 (66.7)
Divorced	6 (8.3)
Widowed	7 (9.7)
Religion
Christianity	42 (58.4)
Islam	25 (34.7)
Traditional	5 (6.9)
Ethnicity
Yoruba	42 (58.3)
Ibo	23 (31.9)
Hausa	4 (5.6)
Others	3 (4.2)
Education
None	15 (20.8)
Primary	19 (26.4)
Secondary	26 (36.1)
Tertiary	12 (16.7)
Occupation
Civil servant	20 (27.8)
Self-employed	32 (66.1)
Student	4 (5.6)
Not employed	16(22.2)
Monthly income
<10 000	17 (23.6)
10 000–30 000	20 (27.8)
30 000–50 000	22 (30.5)
50 000 & above	13 (18.1)

Distribution of Secondary Health Facilities Providing CCPS Across Various Dimensions

Figure 1 illustrates the demographic characteristics of secondary health facilities that provide CCPS across various dimensions, including geographical location, state, and ownership type. Many facilities (58%) are found in peri-urban areas, while fewer are in rural (29%) and urban (13%) areas. By state, 58% of the facilities are in Lagos, and 42% are in Osun. The distribution is evenly divided in ownership, with 50% public and 50% private facilities. These findings underscore the uneven distribution of facilities, with a notable concentration in peri-urban areas and Lagos State, highlighting potential disparities in access to CCPS between urban and rural populations (Figure 1).

Figure 1.

Demographic Distribution of Secondary Health Facilities Providing CCPS. This figure shows Health Facilities’ Geographical and Ownership Patterns in the Lagos and Osun States.

Available CCPS Methods in Secondary Health Facilities (SHFs) in Selected States

Figure 2 shows the available methods of CCPS in the SHFs in selected states, and the majority (78.9%) of the personnel are trained service providers. The highest proportion of service available in the surveyed facilities was the availability of CC screening using the visual inspection methods, 85.7 and 70% in the two states, respectively, followed by treatment services (71.4%) in Lagos State and 40% in Osun State. A good percentage (71.4%) of the SFH in Lagos State has facilities for treating pre-cancerous lesions, and less than average percent provides (40%) treatment of CCPS in Osun State. HPV vaccinations are the least available in the two states, with 10% of HPV DNA testing available in Osun State. The SHFs followed the three-dose HPV vaccination schedule recommended by WHO, and it is an out-of-pocket expense. The DNA method used is the polymerase chain reaction (PCR)-based testing (Figure 2).

Figure 2.

Availability of CC Prevention Methods in SHFs. This Figure Compares the Prevalence of Screening, Treatment, and Vaccination Services Across Lagos and Osun States. LBC: Liquid-Based Cytology; VIA: Visual Inspection With Acetic Acid; VILLI: Visual Inspection With Lugol’s Iodine.

Boxplot and Pattern in the Range of Scores of the Quality of CCPS

The Boxplots and Whisker plot shows the distribution pattern in the range of scores of the quality of CCPS. As reflected in Figure 3, the middle value in the second half of the data set (Q3) is −163.5, and the middle value in the first half of the data set (Q1) is −141 with a mean score of 151.96 ± 15.54. The Interquartile range (IQR) −22.5, being equal to the difference between upper and lower quartiles, measures the statistical dispersion (variability) in the scores of the quality of CCPS in selected Secondary Health Facilities (SHF). This revealed that the distribution pattern is symmetric to the right and positively skewed. The boxplots visualize the median (line in the box), and the data sets’ approximate quartiles (whiskers) are in the upper quantiles. This denotes that the SHF in the upper hinge has a good quality of CCPS, while the lower hinges show the SHF with poor quality of CCPS at the cutout point (median value) of 149.5 (Figure 3).

Figure 3.

Boxplot Analysis of Quality Scores for CCPS. This Figure Depicts the Variability and Skewness in Quality Scores Among SHFs, Highlighting Disparities in Service Quality.

Table 2 presents a comparison of existing CCPS per state based on the level of ownership. This table compares the structural, process, and outcome components of CCPS between public and private facilities and the states of Lagos and Osun. It revealed a relationship at a significant level of P ≤ 0.05 in the outcome at state. Additionally, there is a significant difference in the structure, process, and quality of CCPS based on the level of ownership (Table 2).

Table 2.

Comparison of the Quality of Existing CCPS per State Based on the Level of Ownership.

	Mean	SD	T	P value
States
Structure
Osun	37.30	14.75	−1.59	0.124
Lagos	44.50	7.035
Process
Osun	44.60	5.18	−1.57	0.129
Lagos	47.21	2.91
Outcome
Osun	63.10	2.60	0.39	0.039
Lagos	65.21	2.11
Quality of CCPS
Osun	145.02	19.55	−1.96
Lagos	156.91	9.94		0.062
Based on level of ownership
Structure
Public	35.0	7.92		0.002
Private	48.0	10.45	−3.43
Process
Public	44.33	4.37	−2.31	0.030
Private	47.91	3.08
Outcome
Public	64.08	2.38	−4.79	0.637
Private	64.58	2.71
Quality of CCPS
Public	143.41	12.42	−3.18
Private	160.50	13.84		0.004

Discussion

This study’s findings provide vital insights into the quality of CCPS in Southwest Nigeria, evaluated using Donabedian’s Quality Framework. The study revealed significant disparities in the quality of CCPS based on facility ownership and geographic location. Private facilities demonstrated higher structural and process quality than public facilities, with better infrastructure, equipment, and adherence to clinical protocols. However, outcome scores were comparable, indicating the potential for improvement in client-perceived service quality across both facilities.

Private facilities in peri-urban areas, such as Alimosho and Agege, demonstrate higher structural and process quality, aligning with the findings of Akinyemiju et al ¹² Conversely, public facilities, which are more evenly distributed across urban, peri-urban, and rural regions, face significant resource challenges, especially in rural settings. These disparities highlight Aniebue and Aniebue’s ¹³ call for equitable healthcare investments to ensure quality service delivery in underserved areas. Moreover, the availability of CCPS varies significantly between Lagos and Osun states, where trained service providers make up 78.9% of personnel, reflecting global trends prioritizing skilled healthcare workers. Visual inspection methods (VIA/VILI) are commonly found in facilities in Lagos and Osun and are consistent with international trends advocating for cost-effective screening options. Nonetheless, there are considerable disparities in treatment services, with greater availability in Lagos compared to Osun, showcasing infrastructural inequities that align with earlier findings from Ezechi et al ¹⁴ The absence of pap smears in Lagos and Osun within SHFs is concerning, given its global recognition as an effective secondary prevention method. Possible explanations include resource limitations, such as inadequate laboratory infrastructure or supplies for cytological analysis and a lack of trained personnel.

Additionally, VIA/VILI may be prioritized due to its simplicity, cost-effectiveness, and ease of implementation in low-resource environments. However, integrating pap smears alongside VIA/VILI could enhance diagnostic accuracy and improve existing screening methods. The availability of visual inspection methods (VIA and VILLI) as the primary screening tools underscores their practicality and cost-effectiveness in low-resource settings. However, the limited availability of pap smear testing in Lagos and Osun states highlights infrastructural gaps, as this method remains a globally recognized standard for CC screening. Moreover, treatment services and HPV vaccination programs are more accessible in Lagos than in Osun, reflecting disparities in resource allocation and healthcare infrastructure. The absence of HPV DNA testing in Lagos, despite its urban setting, indicates a need for targeted investments to enhance diagnostic capabilities capacity. These findings underscore the need for strategic interventions to address gaps in the structure and process components of CCPS, particularly in public and rural facilities. Emphasizing equitable resource distribution, increasing trained personnel, and integrating advanced diagnostic methods are essential steps to improve service delivery. Significant disparities in treatment services were observed, with a higher availability in Lagos compared to Osun, revealing infrastructural inequities consistent with findings from Ezechi et al ¹⁴ Similar trends were noted for HPV vaccination programs, which are more accessible in Lagos, reflecting disparities in resource allocation and healthcare infrastructure. The lack of HPV DNA testing in Lagos, despite its urban setting, indicates the need for targeted investments to enhance diagnostic capacity. These findings underscore the necessity for strategic interventions to address gaps in the structure and process components of CCPS, particularly in public and rural facilities. Emphasizing equitable resource distribution, increasing trained personnel, and integrating advanced diagnostic methods are critical to improving service delivery and outcomes.

Furthermore, as Bruni et al ¹⁵ noted, the limited provision of HPV vaccination services in both states highlights ongoing global challenges in vaccine accessibility^. However, vaccination remains more accessible in urban areas, likely due to enhanced public health outreach or increased involvement from the private sector. In Osun, the limited availability of HPV vaccination in SHFs reflects uneven resource distribution or prioritization arising from varying policy decisions or funding models, thus emphasizing the need for standardized implementation strategies across states.

On the other hand, private facilities demonstrate a higher level of structural and process quality than their public counterparts, as evidenced by their greater mean scores. This aligns with findings from Okeke et al ¹⁶ and Adewole et al, ¹⁷ which attribute these differences to better management and funding in private settings. While outcome quality scores are comparable between private and public facilities, the overall quality of CCPS is significantly higher in private facilities than in public ones. Geographic disparities reveal that urban and peri-urban facilities deliver higher-quality services than their rural counterparts, highlighting Adefuye et al.’s ¹⁸ calls for enhanced rural healthcare infrastructure. The distribution of quality scores shows a positively skewed pattern, suggesting moderate variability and a median score serving as a benchmark for distinguishing high- and low-quality facilities. Facilities in the upper quartile demonstrate superior quality, while those in the lower quartile require targeted improvements. These findings align with Ezem’s ¹⁹ observations regarding variability in service quality, emphasizing the necessity for focused interventions to support facilities below the median benchmark.

Conclusion

The quality assessment of CCPS is crucial for providing effective and equitable healthcare. Donabedian’s framework enables the systematic evaluation of the structural, procedural, and outcome aspects of services. Although private facilities excel in structural and process quality, similar outcome scores across ownership types suggest that efforts should concentrate on enhancing the overall client experience. Addressing disparities in resource allocation and expanding access to comprehensive CCPS can significantly alleviate the burden of CC in Nigeria.

Implications for Policy and Practice

This study highlights critical implications for improving CCPS quality in Southwest Nigeria. Policymakers must prioritize training, infrastructure, and resource allocation investments to address disparities between private and public facilities and urban and rural areas. Expanding HPV vaccination programs and enhancing treatment service availability are essential for comprehensive CC prevention. Leveraging Donabedian’s Quality Framework, these findings underscore the need for strategic, equitable healthcare interventions that ensure all women, regardless of socioeconomic status or geographic location, have access to high-quality CCPS.

Limitations of the Study

Cross-Sectional Design

The study’s cross-sectional design presents a significant limitation, as it captures data at a single point. This restricts the ability to infer causality or observe changes over time. While the design effectively addressed the research objectives, its findings are limited to describing associations rather than establishing cause-and-effect relationships. Furthermore, the study was conducted in selected health facilities within Southwestern Nigeria, limiting the findings’ generalizability to other regions or populations.

Impact of Industrial Strikes

Prolonged industrial strikes in the two states where data collection occurred created significant challenges. These interruptions delayed the research timeline, requiring data collection to resume only after the strikes had ended. This delay may have influenced participant recruitment and responses, as some individuals enrolled during this period sought additional healthcare services or used the study to voice grievances about the healthcare system. These dynamics introduced unintended biases into the data.

Participant Incentives and Recruitment

While incentives played a crucial role in encouraging participation, they may have affected the sample’s representativeness. Individuals motivated by the incentives might differ systematically from those who would participate without such rewards. This potential selection bias could have impacted the study’s findings and applicability to broader populations.

Participant Familiarity with Research Context

Many participants were not familiar with health-related research of this nature. Several expressed confusion about the study’s purpose and the reasons for asking specific questions or video-recording interactions. Although efforts were made to explain the study’s objectives and address concerns comprehensively, this lack of familiarity may have affected participants’ engagement and willingness to provide detailed, candid responses. As a result, this unfamiliarity could have influenced the depth and quality of the data collected.