Worldwide Issues
Back >
Proposed Cervical Cancer Screening Project in Malawi, Africa
Below is information on a cervical cancer project for Malawi, Africa. Contact the National Cervical Cancer Coalition (NCCC) with any questions you may have.
Screening and Treatment of Cervical Cancer in Malawi
Project Location
Mulanje District, Malawi
Program Summary
Cervical cancer is the third most prevalent cancer in the world and is the most common cancer in women in sub-Saharan Africa. It is nearly always fatal if women are not treated. Because it takes, on average, ten years for abnormal cells to develop into invasive cancer, most women in developed nations receive the necessary attention and treatment to prevent this too-common cancer. However, women in poor nations of sub-Saharan Africa such as Malawi are not aware of and do not have access to even the most basic, effective, low-cost treatment methods which prevent cells from progressing into invasive, and often fatal, cancer.
According to Malawi cancer statistics, cervical cancer is the most common cancer in Malawi and accounts for nearly 80% of female cancer. Only 15% of women seek help in early, treatable stages. Most Malawian women do not know about cervical cancer as a disease and many are not even aware what the cervix is. And, given that Malawi currently only has one pathologist, and the country’s only cytologist died not long ago, basic programs that could identify and prevent cervical cancer, i.e., pap smears, are nearly impossible to implement. Women in Malawi are dying needlessly, at great costs to the individual, the family, and society.
Project HOPE is proposing a screening and treatment cervical cancer program in one of the Malawi’s most underserved areas, the rural Mulanje District. This pilot program will focus on education – informing women and men about cervical cancer and the need for screening and treatment; training – training physicians and nurses of Malawi’s Colleges of Medicine and Nursing as trainers-of-trainers of physicians, medical students, nurses, and midwives in the screening and treatment of women; promotion – reaching women through family planning and STD (sexually-transmitted diseases) clinics, during other health contacts (e.g., antenatal visits), and encouraging them to send sisters and mothers for cervical screening and treatment services; and treatment – using low-cost, highly effective, non-invasive methods that can be managed by non-physician providers.
After the conclusion of this three-year program, the Malawi Ministry of Health (MOH) will have the capability to replicate this major public health program in other parts of Malawi to save the lives of thousands of women and reduce much potential suffering. As a result, women will be more knowledgeable about their reproductive health and how to maintain it, and be better able to care for their families and remain economically active. The program will also contribute to improved cancer treatment in southern Africa, and will help in developing new approaches for other low-resource countries.
Project HOPE has collaborated with the Malawi MOH to provide primary health programs since 1989. HOPE’s work has contributed to a significant expansion of health promotion and preventive services for mothers, young women and children, and have strengthened the public and private sector in nine districts of Malawi.
Background
Conditions in Malawi
A former dictatorship, Malawi is now a strongly democratic country – and one where Christian and Moslem religions have great influence. With a per capita income of $170, however, Malawi is also among the poorest countries in the world. Its health system to date has focused on basic primary care and health promotion, predominantly for its most vulnerable groups: women and children. Despite these priorities, women are still inordinately affected by limited reproductive health services and lack of knowledge about reproduction.
Malawi suffers from some of the world’s highest maternal morbidity and fertility rates. In HOPE’s targeted districts of Mulanje and Blantyre, the rates far exceed the national levels. This situation is mainly due to poverty, rapid population growth, limited productive assets and weak institutional structures. Limited health services are also a major contributing factor to poverty. Inadequate nutrition, a high fertility rate, and high rates of STD and HIV infection contribute particularly to the poor health status of women of reproductive age. Both HIV and STDs are closely related to the development of cervical cancer.
Cancer in Malawi
Recently, the Malawi government identified cancer as one of the major health problems in the country. The Malawi National Cancer Committee in turn identified cancer of the cervix as the most common form of cancer affecting individuals in Malawi. The prevalence of cervical cancer is particularly high in Malawi because of the presence of many of the aforementioned risk factors (e.g., the human papilloma virus, a sexually transmitted disease; HIV; poor nutritional status; and certain hormonal factors).
Awareness is also a factor in the high rate of cervical cancer, especially for women of reproductive age. Malawian women, who are experiencing many of the cervical cancer risk factors, have virtually no access to education, screening, or treatment. In fact, most Malawian women know little about their own reproductive organs and reproductive health problems – even most health providers are not aware that cervical cancer is the most common cancer in Malawi. Cultural factors, which condone that men have multiple partners and which give women little power to negotiate safe sex, place even lower-risk, monogamous women at risk for the disease.
Project Description
Although Project HOPE has been involved in health services benefiting women in Malawi for 10 years, it became apparent that cervical cancer had not been addressed comprehensively by any group in Malawi. Following discussions with key personnel from the Ministry of Health, Colleges of Medicine and Nursing, and the Malawi National Cancer Committee, it was determined that there was a strong interest in developing a low-cost and effective screening and treatment program for Malawian woman who are at high risk of developing the disease, but who have virtually no access to education, screening, and treatment. The target area is located in the district of Mulanje.
Fortunately, cervical cancer is a highly treatable condition with a large window of opportunity, since it takes about ten years on the average for moderate to severe pre-cancerous cells to develop into invasive cancer. In developed countries, most women have access to pap smears that detect abnormal cells and then receive treatment as needed. This has reduced mortality from cervical cancer by as much as 90%. Unfortunately, pap smears are often not a good alternative in countries like Malawi where there is only one pathologist for the entire nation. Additionally, in neighboring African countries, it has been found that many women are lost to follow-up, from the time of screening to obtaining the test results and receiving a referral for treatment.
Because the pap smear method of screening and treatment cannot be applied to Malawi, Project HOPE and key Malawian health institutions have developed a program that combines low-cost early detection with immediate treatment that can be managed by non-physician providers (e.g. nurses). Non-physician providers can detect abnormal cells using Visual Inspection, with a light source and simple magnifying device. Then, by staining the cervix with acetic acid and employing cryotherapy (freezing of abnormal cells detected) treatment to prevent invasive cervical cancer can begin during the same visit.
According to a study by the World Bank (A New Agenda for Women’s Health and Nutrition, 1994), cryotherapy is about 80-90% effective, has minimal side effects, and can be implemented at a relatively low cost with no electricity. Other studies have confirmed the effectiveness and benefits of this method.
Strategy
- 1. Assess the needs, knowledge, attitudes, and practices of women and health providers. To involve beneficiaries most effectively in this project, focus groups will be held at the onset of the project to learn more about women’s knowledge of their reproductive system, STDs, cervical cancer, and the relationship between STDs and cervical cancer, as well as women’s willingness to participate in screening and treatment services. This information will be used to guide project design and the development of education materials, curricula, and education strategies.
2. Train providers in cost-effective screening, treatment, and counseling. The MOH operates 47 health centers in the targeted area (23 centers in Mulanje, 2 mission hospitals, 6 private health centers, 16 health centers on agricultural estates). Health centers are staffed predominantly by nurses and medical assistants. There are approximately 150 nurses in the district of Mulanje, most of them enrolled nurse-midwives, and about 70 provide family planning services. The project will train about 80% of the nurses, as well as some nurse-midwives serving poor urban women in the neighboring urban district of Blantyre in health centers operated by the College of Medicine of the University of Malawi.
3. Develop individual and mass education/promotion approaches. The health promotion efforts will be directed to particularly draw women from the rural and less accessible areas -- radio, print materials, local drama clubs -- to be screened at least once in their life time. Women will gain a better understanding of their reproductive health needs and options available to them.
4. Establish accessible, low-cost, effective screening and treatment services. This project will significantly increase access to all women, since the screening and treatment services will be provided by the MOH at no cost.
Objectives
Local capacity will be developed in the Colleges of Medicine and Nursing to provide training to women’s health providers in the education counseling, screening, and treatment of women in the early stages of cervical cancer.
Women in the target area will be better informed about cervical cancer and sexually transmitted diseases, and their reproductive system, and be able to participate freely in life-saving screening and treatment programs. Men will also be educated to assist in the acceptance of this new program.
A model cervical cancer education, screening and early treatment program will be functioning in the rural district of Mulanje and select sites in the neighboring urban Blantyre and will be replicated by the Ministry of Health throughout the nation.
Sustainability
The project addresses sustainability on four levels:
At the national/policy level, the objective is the development of a national commitment to cervical cancer screening and treatment services, with MOH resources being specifically allocated to this issue.
At the pre/in-service education level, the objective is increased knowledge and skills of practicing MCH nurses and medical and nursing students about cervical cancer screening and treatment, through trained faculty from the University of Malawi Colleges of Medicine and Nursing.
At the health facility level, the objective is to provide cervical cancer screening and treatment at least once to every woman 30 years or older, through the specialized training of service providers.
At the community level, the objective is increased demand for cervical cancer screening and treatment services among women over age 30, with women empowered through education to self-initiate these demands.
Beneficiary Population
Women and their families are the primary beneficiaries of this project. Approximately 360,000 women of reproductive age in the districts of Mulanje and Blantyre will benefit from this program. Within this population, specific groups targeted include:
Women, ages 30-50 who attend STD and Family Planning clinics in the districts of Mulanje and Blantyre for cervical cancer screening and treatment, as well as for reproductive health education and counseling
Referred sisters, mothers, and other female relatives, seeking cervical cancer screening and treatment services.
In the long run, numerous other women throughout Malawi will benefit from the newly trained providers and from the improved capability of the MOH to provide a high-impact, much-needed public health program. And, although not directly targeted to receive treatment, the female health providers trained in this program (about 85 total) will benefit from receiving training in a new technical skill, improving their education, and strengthening their counseling skills.
Monitoring & Evaluation
The two major groups of beneficiaries of this program—women and health providers—will participate in the monitoring and evaluation of the program.
Women from within the targeted population will provide information about the knowledge, attitudes and practices relating to cervical cancer at the onset of the project and again at the project’s end to assist in the evaluating the project impact. Women will be asked to review education materials and strategies that will be developed and implemented, and provide feedback about the acceptability of education and promotion activities, such as community theater. In addition, exit interviews will be conducted with women who have received the project’s cervical cancer services, to monitor the quality of care and counseling given by the newly-trained providers.
Health Providers. The project steering committee, consisting of representatives of the health professionals from the College of Medicine, College of Nursing, and the Ministry of Health will participate in monitoring the progress of this project in quarterly meetings, using information collected by the project health information system and information provided by project staff. In addition, representatives of the same institution will provide members to the final evaluation team.
Evaluating the Project Impact
To determine impact, we will conduct a qualitative final participatory evaluation with representatives from the Ministry of Health (local levels), College of Medicine, College of Nursing, and women beneficiaries. This evaluation will also review project outputs (e.g., number of trainers-of-trainers and health providers trained; materials and curricula developed; number of mass education activities implemented [e.g., number of radio broadcasts, number of theater presentations, etc.]). A final workshop meeting will share the lessons-learned from this project with the central Ministry of Health, to prepare the Ministry for replication in other districts of Malawi.
Roles & Responsibilities
For this program, Project HOPE will be responsible for:
- Overall program design
- Coordination with all partners
- Selection and guidance of qualified consultants
- Implementation of survey and qualitative research of beneficiary and provider knowledge, attitudes, and practices
- Coordination and supervision of all training
- Supervision and quality assurance of services provided at the local level
- Program evaluation
- Documentation of lessons-learned and implementation of a lessons-learned workshop for the central Ministry of Health
- Accountability of funding and finances
Contact the National Cervical Cancer Coalition (NCCC) to find out how you may be able to help with this project.
