Before Malawi gained independence in 1964, it was colonized under Great Britain as a British protectorate called Nyasaland in 1907. In the 1950s, neighboring Rhodesia and Northern Rhodesia, now Zimbabwe and Zambia, respectively, had a much larger European population that was in favor of merging the three nations into one. Nyasaland resisted this union due to the higher proportion of Europeans in the other nations that would overshadow Nyasaland’s indigenous leadership. Despite resistance, the nations were joined in 1953, but after backlash from Africans in Northern Rhodesia and Nyasaland, all three nations were granted independence from Britain in 1963. After it gained independence Malawi was one of the poorest countries in the world. Civil war in neighboring Mozambique and periods of drought further challenged the country’s economic growth. In 2006, the country was pardoned from its structural adjustment loans which resulted in slight economic growth but with a heavily agriculture-dependent economy and loss of workers from HIV/AIDS, economic growth was reduced (The Commonwealth, 2019)
Cervical cancer is the most common form of cancer amongst women in Malawi, affecting 40% of the country’s female population. With 84% of the country’s population living in rural areas, accurate surveillance of the disease is difficult, but the International Agency for Research on Cancer’s (IARC) GLOBOCAN program reports an incidence rate of 75.9 individuals for every 100,000 individuals and the Malawi Cancer Registry reports a cervical cancer mortality rate of 49.8 individuals for every 100,000 individuals. Both the incidence and mortality rate of cervical cancer in Malawi is the highest across the globe. Furthermore, the five-year survival rate of the disease in Malawi is only 2.9% compared to 26.5% in Zimbabwe, and 68% in United States (Rudd et al. 2017). Other health metrics indicative of Malawi’s healthcare status is the maternal mortality rate of 684 per 100,000 live births and the infant mortality rate of 38.5 per 1,000 live births. Comparatively, the U.S. the maternal mortality rate is 18 per 100,000 live births and infant mortality rate is 5.9 per 1000 live births (Center for Disease Control, 2016).
Malawi has a three-tier healthcare system. The primary tier consists of community health centers and maternity units. The secondary tier consists of district hospitals which receive referrals from the primary tier community hospitals and provide more specialized services including diagnostic and laboratory testing. The tertiary tier provides highly specialized services for certain diseases. Healthcare is delivered through both the public and private sectors, with private sector non-governmental organizations providing many services at the primary level (African Health Observatory, 2018). The country is divided into twenty-nine districts, with each district having at least one district-level hospital. The government of Malawi provides free cervical cancer screening to all women (African Health Observatory, 2018).
A primary contributor to the high cervical cancer prevalence is the high rate of HIV/AIDS throughout the country. In Malawi, 11.7% of women between the ages of 15-49 are diagnosed with HIV and 25.4% of HIV-positive women were diagnosed with cervical cancer between 2007 and 2010 (UNAIDS, 2017 & Msyamboza et al., 2012). The immunosuppression caused by HIV makes HIV-positive women two to twenty-two times more likely to be infected by Human Papilloma Virus (HPV), leading to higher rates of pre-cancer and cancer at younger ages (De Vuyst et al., 2008). As of 2014, Malawi has been able to provide antiretroviral treatment (ART) to 66% of the country’s HIV-positive population, and 77% of those individuals remain living with HIV one year after beginning ART. (UNAIDS, 2017). Despite the increase in accessibility to ART since 2004, the incidence of AIDS-defining cancers, including cervical cancer, has continued to rise (Msyamboza et al., 2012).
In the 1980s, the Ministry of Health-Reproductive Health Directorate (MoH-RHD) and its partners established a cervical cancer prevention and control plan and in 2004, implemented a cervical cancer screening program with the use of low-cost Visual Inspection with Acetic Acid (VIA) (Maseko et al., 2015). As of 2014, over 100 health centers throughout Malawi offered VIA. However, as only 59,217 women were screened, 44% of women with cervical cancer may have been missed by the country’s screening program (Msyamboza et al., 2012).
Challenges to cervical cancer prevention in Malawi arise from a lack of clear and concrete policy regarding screening and vaccination. The National Sexual and Reproductive Health and Rights (SRHR) Policy of Malawi was created in 2009 to create a “framework for affordable, accessible, and acceptable sexual and reproductive health services” to ensure that men and women had fair access to their SRHR rights. Information regarding cervical cancer is included in the section on “reproductive cancer policy,” but does not specify the age at which a woman should be screened for cervical cancer nor does it state how often she should be screened. While the SRHR states that cervical cancer screening should be integrated into the primary health care tier, it does not specify the type of screening test that should be used or which health professionals should administer those tests. Additionally, it does not include HPV vaccination in its prevention guidelines (Maseko et al., 2015).
Malawi’s cervical cancer screening program has not been able to adequately screen a significant amount of the population because of both barriers for women in accessing the services and inadequate healthcare infrastructure, personnel, and supplies. In 2015 a study was conducted to assess the challenges faced by the health system for cervical cancer prevention. Researchers surveyed forty-one service providers from twenty-one health facilities across fourteen of the country’s twenty-nine health districts. It was found that out of twenty-one health facilities, only seven provided screening and treatment of cervical cancer and only six were open for screening Monday-Friday. The remaining centers were either open only once or twice a week. On average, ten women were screened at each clinic per day, and the most common reason reported for the low screening rate was a lack of awareness in the community regarding the availability of VIA. Another primary contributor to the low screening rate is a lack of trained health care providers and an imbalanced distribution of providers with more in urban areas than in rural areas. There is also a lack of district-level supervision of provider screenings due to transportation costs. Out of the surveyed health facilities, fifty-two percent reported running out of stock of one or more pharmaceutical products for VIA for a week’s time throughout the year. While most facilities had the necessary material and equipment for VIA, only approximately one-third of the facilities, had the materials necessary for cervical biopsy and cryotherapy. With transportation from rural areas being a major barrier towards cervical cancer treatment, lack of immediate removal of cervical neoplasms after VIA can be detrimental (Maseko et al., 2015).
Cervical cancer risk is higher in women who have given birth to three or more children. In Malawi, large families are culturally valued and thus the average birth rate for women in Malawi is 4.57 (World Bank, 2017). As of 2016, 44% of married women over the age of 20, 26% of married girls under 20, and 50% of unmarried sexually active adolescent girls utilized contraceptives (World Bank, 2016). However, in a largely male-dominated society, many women abstain from contraception due to a largely cultural practice of males making family decisions. Therefore, gender inequity plays a major role in limiting accessibility to contraception (RIPPLE Africa, 2019).
Another risk factor for cervical cancer is pregnancy before the age of seventeen, with individuals giving birth before seventeen being twice as likely to be diagnosed with cervical cancer than individuals giving birth at 25 or older. In Malawi, 9% of girls are married before the age of 15 and 42% of girls are married before the age of 18. 31.7% of girls have their first child between the ages of 18 and 22 (African Institute for Development Policy, 2017). Therefore, early childbirth is contributing to the prevalence of cervical cancer in the country.
A study conducted at the tertiary health facility in Blantyre, Queen Elizabeth Central Hospital (QECH), found that on average women waited forty-two weeks between onset of symptoms and an appointment at QECH. Nineteen of these weeks were spent waiting after a referral from a district hospital or health center. Contrastingly, in the United Kingdom, all patients with suspected cancer are required to be seen by a specialist in two weeks. The study found that a contributing factor to the delay in symptom onset and visiting a health center or hospital was consultations with traditional or herbalist healers (Rudd et al., 2017). There is a common misperception among many women that cervical cancer is incurable and therefore many women seek care from herbalists first to alleviate their symptoms before seeking hospital care when symptoms worsen. In Malawi, it is common for most villages to have at least on traditional healer (TH). In rural areas, 80% of Malawians initially consult traditional healers about ailments due to the lower cost of herbal remedies and proximity (Truter, 2007). Due to the trust that many women place in traditional healers, integrating traditional healers into cervical cancer prevention is pivotal.
The southern region was selected for this intervention as 52% of all cancer incidence in Malawi is from this region. Additionally, 18% of the southern region is infected with HIV/AIDS as opposed to 10% and 8% of the central and northern regions, respectively (Msyamboza et al., 2012). With HIV/AIDS as a major risk factor for cervical cancer, this intervention will first focus in the southern region and then potentially expand to the central and northern regions. This intervention will occur more specifically in Balaka, Malawi, a southern rural district, eighty-nine kilometers from Blantyre. Blantyre is the second-largest city in Malawi and functions as the industrial and commercial capital of Malawi. One of the four central, or tertiary tier, healthcare facilities in Malawi is located in Blantyre. Balaka contains one district, or secondary tier healthcare facility, and seven health centers, or primary healthcare facilities.
This intervention aims to integrate traditional healers into cervical cancer prevention to reduce the time spent between initial symptom appearance and treatment in women with suspected cervical cancer. It also aims to sensitize community members on the importance of cervical cancer screening and HPV vaccination. Currently, there is no clear delineation of the age and frequency of cervical cancer screening necessary in the national SRHR. This intervention will communicate these important factors to the general public. It also aims to increase the capacity of primary healthcare facilities to accurately conduct cervical cancer screening and HPV vaccination through increased trained personnel, resources, and oversight. Lastly, the intervention will specifically focus on targeting cervical cancer screening in HIV-positive individuals who are at a significantly higher risk for cervical cancer, by training ART staff in VIA.
The personnel required for this intervention include a multidisciplinary team of gynecologists, community health workers, gynecological nurses, and medical students. The model of this intervention will function through “mirror organizations” whereby the David Geffen School of Medicine (DGSOM) team will partner with an identically composed University of Malawi College of Medicine (UMCOM) team. Integrating local partnership into the model is essential to understanding the local moral world within which the project will be functioning. Understanding cultural and traditional beliefs will be pivotal to creating an acceptable intervention to reduce cervical cancer rates.
In this intervention, we recognize the need for a bottom-up approach in integrating THs into cervical cancer prevention. Modeled after an intervention integrating THs into HIV care and testing, this intervention will create a partnership between the district hospital in Balaka and the International Traditional Healers Association in Blantyre (Gqaleni et al., 2011). A TH would be selected as the district coordinator for Balaka, and would then select and recruit other THs across the district to be trained. The training workshops would be led by a joint team of nurses from the Mbera Community Health Centre, a governmental primary care facility, nurses from the David Geffen School of Medicine, and the district TH. THs that volunteer to participate in the training would learn how to identify the common symptoms of cervical cancer, which include vaginal discharge, pelvic and back pain, and bleeding between periods. THs would be trained to direct women who experienced these symptoms immediately to primary or secondary health facilities, allowing women to access screening and treatment earlier.
This intervention will also focus on community sensitization of cervical cancer. It will attempt to communicate more immediate prevention factors of cervical cancer such as HPV vaccination and cervical cancer screening in addition to more distal prevention practices. These will include increasing awareness as to how multiple childbirths, early pregnancy, and HIV infection increase the risk of cervical cancer. As males play a large role in decision-making and family planning, it will be imperative to sensitize males as well. As THs have a strong cultural and moral value amongst Malawians, their involvement in the sensitization campaign will create a more formative impact. Therefore, the District TH will also recruit a coalition of THs from villages in Balaka to attend cervical cancer prevention education training. This training will be led by the District TH. After the District TH is trained by public health educators from the University of Malawi. The sub-district THs will be provided training materials such as visual and informative posters to lead training sensitization workshops in their respective villages. They will be advised to garner male and female family members to attend the workshops by hosting them after religious services, in which both males and females are often present. A commonly cited barrier to cervical cancer screening is a lack of awareness as to the necessary age to start screening and how frequently women should be screened thereafter. Therefore, this sensitization campaign will involve publicizing the translated motto of “Get screened for cervical cancer between 21 and 29, every 3 years, and between 30 and 65 every 5 years”. Malawi has led a strong campaign against HIV/AIDS through a similar manner, and therefore we hope to bring the same level of awareness to cervical cancer. The message will be publicized through posters throughout the busiest parts of the district as well as through the local radio station.
As of January of 2019, the Malawian government, in conjunction with the World Health Organization announced a campaign for free HPV vaccinations in all public and private schools, health clinics, and hospitals throughout the country (Magombo-Mano, 2019). With the HPV vaccination available, it will be imperative that the community is aware of its importance. Therefore, the intervention’s sensitization campaign will specifically target fathers and husbands, often the decision-makers in the family, to encourage them to vaccinate their female family members. In order to do so, public health workers and medical professionals from both the Mbera Community Health Centre, DGSOM team, and UMCOM team will facilitate health fairs in villages throughout the Balaka district. These health fairs will provide information about the HPV vaccination as well as ease of access to the vaccination. As the vaccination requires two doses, the health fair will return after six months to administer the second dose.
This intervention will also work to increase the capacity of primary health facilities to provide screening and treatment through VIA by increasing trained personnel. As previously mentioned, most facilities are only able to offer screening one to two days a week with approximately ten individuals screened per day. Additionally, only seven of twenty-one facilities provided both screening and treatment. With transportation as a major barrier to healthcare for Malawian women, this intervention will seek to make screening and treatment available at all seven community health centers in Balaka. VIA can be conducted by paramedical workers, midwives, nurses, and clinicians. As midwives and nurses make up the primary healthcare force in primary care centers, this intervention will train more of these professionals to perform VIA. A joint team of medical professionals from the UMCOM and DGSOM will conduct this training, to ensure that local leadership is spearheading the intervention. Additionally, materials needed for the immediate treatment of neoplasms, such as cryotherapy machines and NO2 cylinders will be provided to each of seven primary centers to ensure that treatment is not further prolonged for the many individuals who cannot easily travel to alternate centers.
Lastly, this intervention will focus on addressing a population heavily affected by cervical cancer, which is the HIV-positive population. With HIV as a major risk factor for cervical cancer, this intervention will focus on training ART providers in Balaka’s HIV clinics in VIA. While formerly ART could only be provided by hospitals since 2004 ART delivery was moved to community health centers to increase access for more people (Jahn et al., 2015). In Balaka, HIV prevalence is 16% in women (Balaka District Health Office, 2014). Therefore, this intervention will train medical assistants and nurses in HIV clinics to offer VIA and to educate patients on their risk for cervical cancer. The joint team of medical professionals from UMCOM and DGSOM will conduct these training sessions.
This multifaceted approach will be used to address the biosocial factors that contribute to the high prevalence of cervical cancer in Malawi. By emphasizing local partnership as a key facet of this project, the intervention seeks to work from the grassroots level.