Uptake and safety of community‐based “screen‐and‐treat” with thermal ablation preventive therapy for cervical cancer prevention in rural Lilongwe, Malawi

Bula³

et al. 2021

BMJ Open

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IntroductionCervical cancer is the leading cause of cancer deaths among women in Malawi, but preventable through screening. Malawi primarily uses visual inspection with acetic acid (VIA) for screening, however, a follow-up for positive screening results remains a major barrier, in rural areas. We interviewed women who underwent a community-based screen-and-treat campaign that offered same-day treatment with thermocoagulation, a heat-based ablative procedure for VIA-positive lesions, to understand the barriers in accessing post-treatment follow-up and the role of male partners in contributing to, or overcoming these barriers.MethodsWe conducted in-depths interviews with 17 women recruited in a pilot study that evaluated the safety and acceptability of community-based screen-and-treat programme using VIA and thermocoagulation for cervical cancer prevention in rural Lilongwe, Malawi. Ten of the women interviewed presented for post-treatment follow-up at the healthcare facility and seven did not. The interviews were analysed for thematic content surrounding barriers for attending for follow-up and role of male partners in screening.ResultsTransportation was identified as a major barrier to post-thermocoagulation follow-up appointment, given long distances to the healthcare facility. Male partners were perceived as both a barrier for some, that is, not supportive of 6-week post-thermocoagulation abstinence recommendation, and as an important source of support for others, that is, encouraging follow-up attendance, providing emotional support to maintaining post-treatment abstinence and as a resource in overcoming transportation barriers. Regardless, the majority of women desired more male partner involvement in cervical cancer screening.ConclusionDespite access to same-day treatment, long travel distances to health facilities for post-treatment follow-up visits remained a major barrier for women in rural Lilongwe. Male partners were identified both as a barrier to, and an important source of support for accessing and completing the screen-and-treat programme. To successfully eliminate cervical cancer in Malawi, it is imperative to understand the day-to-day barriers women face in accessing preventative care.

Section: Methodsmentioning

confidence: 99%

Barriers to follow-up after an abnormal cervical cancer screening result and the role of male partners: a qualitative study

Chapola¹,

Bula³

et al. 2021

BMJ Open

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“…A community-based cervical cancer screen-and-treat pilot program with VIA and thermocoagulation was implemented by UNC Project-Malawi between July-August 2017 in 4 villages in rural Lilongwe, Malawi. The recruitment and screening protocols are detailed elsewhere [15]. In brief, we first met with the local traditional leaders to discuss the screening program.…”

Section: Study Setting and Participantsmentioning

confidence: 99%

“…On the screening day for each village, we arrived with our equipment and set up in predesignated areas. The study population comprised of women between 25 and 50 years of age who had never been diagnosed with cervical cancer [15]. We offered participants VIA screening and same-day thermocoagulation treatment for VIA positive lesions eligible for ablative therapy.…”

Section: Study Setting and Participantsmentioning

confidence: 99%

“…To overcome the barriers stated above, we implemented a pilot project in rural Malawi in 2017 to bring screen-and-treat utilizing VIA and thermocoagulation directly to the community [15]. Thermocoagulation is an alternative ablative therapy that can use battery, is more portable than cryotherapy, with efficacy and safety comparable to cryotherapy [16][17][18].…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Women’s experiences in a community-based screen-and-treat cervical cancer prevention program in rural Malawi: a qualitative study

Bula²,

Chapola³

et al. 2021

BMC Cancer

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Background Malawi has the world’s highest cervical cancer incidence and mortality due to high rate of HIV coupled with inadequate screening and treatment services. The country’s cervical cancer control program uses visual inspection with acetic acid (VIA) and cryotherapy, but screening is largely limited by poor access to facilities, high cost of cryotherapy gas, and high loss-to-follow-up. To overcome these limitations, we implemented a community-based screen-and-treat pilot program with VIA and thermocoagulation. Through a qualitative study, we explore the experiences of women who underwent this community-based pilot screening program. Methods We implemented our pilot program in rural Malawi and conducted an exploratory qualitative sub-study. We conducted in-depth interviews with women who were treated with thermocoagulation during the program. We used semi-structured interviews to explore screen-and-treat experience, acceptability of the program and attitudes towards self-sampling for HPV testing as an alternative screening method. Content analysis was conducted using NVIVO v12. Results Between July – August 2017, 408 participants eligible for screening underwent VIA screening. Thirty participants had VIA positive results, of whom 28 underwent same day thermocoagulation. We interviewed 17 of the 28 women who received thermocoagulation. Thematic saturation was reached at 17 interviews. All participants reported an overall positive experience with the community-based screen-and-treat program. Common themes were appreciation for bringing screening directly to their villages, surprise at the lack of discomfort, and the benefits of access to same day treatment immediately following abnormal screening. Negative experiences were rare and included discomfort during speculum exam, long duration of screening and challenges with complying with postprocedural abstinence. Most participants felt that utilizing self-collected HPV testing could be acceptable for screening in their community. Conclusions Our exploratory qualitative sub-study demonstrated that the community-based screen-and-treat with VIA and thermocoagulation was widely accepted. Participants valued the accessible, timely, and painless thermocoagulation treatment and reported minimal side effects. Future considerations for reaching rural women can include community-based follow-up, cervical cancer education for male partners and self-sampling for HPV testing.

“…Challenges identified included inability to sustain functional cryotherapy equipment for treatment and difficulty for women in predominantly rural communities to access the facilities where screening was offered [ 8 ]. To address these challenges, in 2017 we implemented a community-based screening pilot study utilizing thermal ablation (over cryotherapy) for same-day treatment of VIA-positive lesions in rural Lilongwe District, Malawi [ 19 ].…”

Section: Introductionmentioning

confidence: 99%

Perceptions of cervical cancer and motivation for screening among women in Rural Lilongwe, Malawi: A qualitative study

Bula¹,

Chapola³

et al. 2022

PLoS ONE

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Introduction Cervical cancer is the leading cause of cancer death among women in Malawi. Low awareness of cervical cancer and negative perceptions of screening can prevent women from participating in preventative strategies. We sought to explore perceptions and motivations for screening among women who participated in a cervical cancer screen-and-treat pilot study in rural Malawi. Materials and methods We conducted a qualitative sub-study of a community-based cervical cancer screen-and-treat pilot study in rural Lilongwe between July-August 2017. From October 2017-February 2018, 17 women who underwent screening using visual inspection with acetic acid (VIA) and same-day thermal ablation treatment were recruited at their 12-week follow-up visit post treatment to participate in this qualitative sub-study. Semi-structured interview guides that explored baseline knowledge of cervical cancer, perceptions, and motivation for screening were used for in-depth interviews (IDIs). IDIs were conducted in the local language, Chichewa, translated and transcribed to English. Data was analyzed using NVivo® V12.0. Results Findings included fatalistic views on cancer, but limited knowledge specific to cervical cancer. Misconceptions of cervical cancer screening were common; however, there was a unique understanding of screening as prevention (i.e., finding and treating early disease to prevent progression to worsening disease). This understanding appeared to stem from HIV prevention concepts known to the community. Motivations for screening included desire to know one’s health status, convenience of community-based screening, and peer encouragement. Conclusion Despite limited knowledge of cervical cancer and misconceptions of screening, the concept of screening for prevention, desire to know one’s health status, convenient access, and peers’ influence were motivators for participation in screening. Cervical cancer screen-and-treat programs in high HIV prevalence areas should consider utilizing language that parallels HIV prevention language to communicate the need for cervical cancer screening and treatment and utilize prevention concepts that may already be familiar to women living there.