Cervical cancer screening coverage and its related knowledge in southern Malawi

Cervical cancer is the fourth most common cancer among women worldwide for both incidence and mortality [1, 2], and approximately 90% of cervical cancer deaths occur in low- and middle-income countries [3]. Cervical cancer is particularly devastating to individuals, communities and countries as it is a painful cancer that affects women during childbearing and economically active years [4‐6].

Cervical cancer is largely a preventable disease; primary prevention and control strategies including human papillomavirus (HPV) vaccination and early detection and treatment of precancerous lesions have contributed to the reduction in disease and mortality burden in many high-income settings with strong health and social systems [2, 7‐9]. Cervical cancer mortality has thus become one indicator for functioning and equity of a health care system and has been considered a “a disease of the poor” [3].

Malawi has the highest mortality related to cervical cancer, with 51.5 deaths/100,000/year. This is twice the rate in Eastern Africa (28.6/100,000/year) and seven times the global rate (7.3/100,000/year) [10]. Only surpassed by Swaziland, Malawi has the second highest cervical cancer age-standardized incidence rate in the world (67.9/100,000/year). This compares to a global cervical cancer age-standardized incidence rate of 13.3/100,000/year, and to that of Eastern Africa, the region with the highest cervical cancer incidence rates, with 40.1.7/100,000/year [6, 10, 11].

The high prevalence of Human Immunodeficiency Virus (HIV) among women 15-49 years overall [12, 13] in addition to HPV infection, harboured by around 4.8% of the women in Malawi [14‐19], puts Malawian women at higher risk of cervical cancer [20‐22].

Health services in Malawi are provided by public, private for profit and private not for profit sectors. Its health system is organized at four levels: community, primary, secondary and tertiary. These different levels are linked to each other through an established referral system. Malawi’s health care services, however, experience shortages of essential medical products and technologies and health care financing remains a challenge [23]. In 2016, the Malawi Ministry of Health (MoH) developed the National Cervical Cancer Control Strategy outlining comprehensive interventions to mitigate the burden of cervical cancer [24]. Within this ‘Cervical Cancer Control Programme‘ the country adopted the single visit “screen and treat” approach, using visual inspection with acetic acid (VIA) followed by cryotherapy or thermo-coagulation at primary health facility level and with several referral hospitals offering diagnostic and curative cancer services. Cervical cancer screening is mentioned in the ‘Essential Health Plan’, and public health facilities provide services for free. There is, however, a need for scaling-up VIA screening services in health facilities and increasing resources, such as better infrastructure and human resources, for cervical cancer screening [6]. Current recommendations for VIA screening in Malawi are that women 25-49 years are screened once every 3 - 5 years, with yearly screening among HIV positive women. A national target of 80% screening coverage has been set for women aged 25-49 years being screened with VIA for the first time within the last 12-months [24]. Cervical cancer screening coverage increased from 9% in 2011 to 26.5% in 2015 nationwide [25]. According to the Health Sector Joint Annual Review Meeting held by the Directorate of Reproductive Health Services in the MoH on 21 September 2021, only 34% of eligible women were screened for cervical cancer between July 2020 and June 2021. Today cervical cancer screening coverage remains well below the target.

Studies on knowledge and awareness of cancer cervical screening carried out in Malawi and surrounding countries showed a consistent mix of screening barriers: little knowledge on symptoms or signs of the disease, lack of information of the screening programme and limited access to screening and treatment [18, 26‐34].

Médecins Sans Frontières France (MSF) has been operational in Malawi since 1986 and involved in HIV care since 1997. In 2018, in partnership with the MoH, MSF set up a comprehensive cervical cancer program in Blantyre City, as a model for urban areas, and Chiradzulu District, as a model for rural areas, both situated in the South of the country. By following the “screen and treat” approach the cancer screening component includes health-facility based information sessions and VIA. Immediately after testing, VIA positive patients are offered treatment using thermal ablation in the same health facility by qualified health personnel in Blantyre City and Chiradzulu District. Precancer lesions not treatable by thermal ablation and suspected cancer are referred to a higher level care facility for further diagnosis and treatment. All screen and treat steps are backed up with quality controls. This population-based survey aimed to estimate cervical cancer screening coverage in a representative sample of eligible women in Blantyre City and Chiradzulu District, and to understand why women were or were not screened in order to support the MoH improve cervical cancer screening uptake in the different areas.

Overall, despite relatively high knowledge of cervical cancer, cervical cancer screening coverage in Blantyre City and Chiradzulu District remained well below the national goal of 80%. Coverage was highest in Blantyre with almost every second eligible women screened, compared to slightly more than every third women screened in Chiradzulu with supported CC screening services and only every fourth women in Chiradzulu without supported CC screening services. Few women in our survey were screened more than once. This suggests that screening programs continue to reach women with cervical cancer screening for the first time, and that there remains a rather long way to go to reach routine cervical cancer screening among eligible women.

The few surveys that have been published on cervical cancer screening coverage in Malawi and other African countries were in areas with low coverage where no more than a quarter of the survey population had been screened, with the exception of Cameroon where almost half of the survey population had been screened [30, 37‐41]. Our survey therefore provides an important contribution to this topic.

Knowledge of cervical cancer, risk factors, and possible prevention methods are present in the survey population. However, less than half of the women who have heard of cervical cancer screening have been screened. Likewise, only slightly more than one-third of women who said they believe they are at risk for cervical cancer have been screened. This suggests that knowledge of cervical cancer screening and awareness of being themselves at risk of cervical cancer are not the main barriers to screening in this population. Although the survey participants know that screening is important, and more than half thought they were personally at risk, it did not translate into action. Increasing knowledge about cervical cancer and screening alone is therefore not enough, practical actions that women can do to prevent cervical cancer should be clearly communicated. Information campaigns on cervical cancer risk and prevention possibilities must be reinforced, and specifically target women who have not yet accessed cervical cancer screening services.

These results are consistent with recent qualitative surveys, which showed high awareness but low uptake of cervical cancer screening not only in Malawi [34, 37, 42], and also in other African countries [27, 28, 38, 40, 43‐45]. The results are also in line with surveys carried out in Kenya, where higher screening rates were observed in women with higher levels of education in the highest income quintile and living in urban areas [41, 46].

Overall, almost all women reported knowledge of cervical cancer, and among those not screened, very few reported fear as a deterrent to screening, or that they would not be comfortable being screened by a man. In Blantyre City, an urban setting with better access to care the main reason for not being screened was lack of time, in Chiradzulu District with access to free and enhanced CC screening services the main reason was lack of information and in Chiradzulu without access to free and enhanced CC screening services the main reason was inconvenient location. While the predominant reasons for not being screened differed by strata, and can be addressed specifically in each setting, they were consistent in that the barriers were practical, mutable constructs that are amenable to intervention [34, 47]. They included supply-side barriers, (such as lack of time, and lack of access) which can be addressed by the health system, for example by extending hours of service provision, and accessibility of cervical cancer screening sites. In addition, demand-side barriers were important (such as lack of motivation and lack of information), which can be addressed by adapting and scaling up information campaigns. These results are internally consistent with the reasons women reported for screening, which for a majority was due to a recommendation in a health facility, indicating that cervical cancer screening was often an ‘add-on’ service that women receive when they are already seeking care for other services. The higher proportion of women with HIV among women screened in Chiradzulu District is also consistent with the understanding that women undergo cervical cancer screening while they are already in the health facility for other services.

Among all interviewed women who underwent cervical cancer screening in the past, less than 1% were VIA positive. This is a surprisingly low VIA positivity rate in light of previous studies, including a country wide study reporting 10% VIA positivity or suspected cancer [25], and a retrospective survey in Kamuzu Central Hospital in Lilongwe, Malawi, reporting almost one-third of HIV-positive women having either high-grade dysplasia or cervical cancer [48]. Considering the 13% prevalence of HIV in Malawi and the 5% prevalence of cervical HPV 16 or 18 infections among women in the general population in Eastern Africa [14], a higher proportion VIA positive would be expected. Further research should be envisaged to better understand the real prevalence of VIA positivity and precancer lesions in Malawi.

Although only slightly more than 2% of women refused to participate in the survey, this represented every ninth women in Blantyre compared to less than 1% in Chiradzulu. MSF is very well-known in Chiradzulu District, as it has been supporting the health system in the district for many years, whereas MSF’s interventions in Blantyre only started with the cervical cancer screening project in 2018. The urban Blantyre population may have had less time and therefore been less willing to participate in the survey, especially as there are many surveys carried out in this city.

Although spatial sampling is an appropriate sample design for urban areas, cluster sampling would have been feasible for Blantyre as the city includes many non-residential areas, such as arable lands, fields, industrial areas, wasteland and nature reserves; and the population is fairly concentrated in certain areas. As well, the use of geospatial sampling in Blantyre City might have led to over-representation of wealthier women in the survey since they usually live in larger homes with a higher chance to be included in the survey, which may have biased the screening coverage results. However, the distribution of socio-demographic characteristics among participants is similar to the 2015-2016 Malawi Demographic and Health Survey [12], and the differences in socio-demographic characteristics between Blantyre and Chiradzulu rather more likely reflect the differences that usually exist between urban and rural areas than a sampling bias.

Less than half of eligible women went for cervical cancer screening both in Blantyre City and in Chiradzulu District. These coverage results are slightly higher than previous surveys in Malawi, they are still much lower than the targeted cervical cancer screening rate of 80% for Malawi.

Most of the survey population had already heard about cervical cancer. Despite this knowledge, fewer than half of eligible women had been screened for cervical cancer. Reasons given for not attending screening are mutable concepts, such as lack of time, access, motivation and information, which are amenable to intervention. Most women who had been screened did so upon recommendation in a health facility, indicating not only that health care workers are successfully promoting screening to women already seeking care, and also that further efforts to inform and motivate women outside of the health facility on practical actions to prevent cervical cancer are necessary. Despite the low cervical cancer screening coverage, the positive reception amongst women who were screened, underscores this core part of cancer prevention as an important part of the way forward to reducing the burden of cervical cancer in Malawi. To significantly reduce mortality due to cervical cancer in Malawi requires a comprehensive health strategy that focuses on prevention, screening and treatment. Cervical cancer is not yet a disease of the past. Cervical cancer is a disease that can be prevented and treated; we know how, we now have to put it in place.