A Call to Modify the Approach to Increasing Cervical Cancer Awareness in Sub-Saharan Africa
Michelle S. Williams
The University of Alabama at Birmingham, AL, USA
The cervical cancer mortality rate in Sub-Saharan African countries is nearly three times the global cervical cancer mortality rate, yet most women in these countries are unaware of this fact. Following the success of the United States President’s Emergency Plan for AIDS Relief (PEPFAR), former U.S. President George W. Bush started the Pink Ribbon Red Ribbon initiative in 2011 to fight cervical cancer and breast cancer in Sub-Saharan African countries. He recently returned to Zambia to fortify his efforts in what he calls the “War on Women’s Cancers” by celebrating the expansion of the Pink Ribbon Red Ribbon program to Botswana, a neighboring country in Southern Africa. Public and private organizations have pledged more than $75 million to support Pink Ribbon Red Ribbons’ initiatives. As a result, some public health organizations have created attention-grabbing campaigns aimed at increasing awareness of the impact of cervical cancer in Sub-Saharan Africa.
However, I personally believe that the approach that some organizations are taking to increase cervical cancer awareness may be causing more harm than good. Many women living in countries in Sub-Saharan Africa have stigmatizing beliefs about cervical cancer that act as psychological barriers to screening. These beliefs may cause women to erroneously underestimate their risk for developing cervical cancer. For example, Jhpiego, a nonprofit organization, has produced health promotion material with the statement “She is living with HIV but dying of cervical cancer.” Statements like this compound the stigma associated with cervical cancer and HIV/AIDS. Data from one of my studies have shown that stigmatizing beliefs about cervical cancer, such as only promiscuous women and women who cheat on their husbands get cervical cancer, are common in Ghana (Williams & Amoateng, 2012). It is a fact that women who have HIV also have an increased risk for developing cervical cancer. However, data indicate that cervical cancer is the leading cause of cancer death among women in Sub-Saharan African countries, including countries in which the prevalence of HIV is relatively low.
No woman should have to die because of cervical cancer. Cervical cancer is highly preventable and easily treatable when precancerous and cancerous lesions are detected early. Public health researchers and health care providers have been working to develop cervical cancer screening tools that can be used in low resource areas that lack the infrastructure that is necessary to support cytology-based Pap testing. Screening tools such as visual inspection with acetic acid (VIA), requires few resources and has proven to be effective at detecting precancerous and cancerous cervical lesions in women living in developing countries. VIA is also highly effective because healthcare providers can treat low-grade cervical lesions immediately with cryotherapy (See & Treat), rather than risk losing track of women by having to schedule appointments for follow-up treatments like colposcopy. Yet, despite the effectiveness of VIA and the availability of the Pap test in large urban hospitals, the promotion of regular cervical cancer screenings in Sub-Saharan African countries is rare.
For example, my research involving women in Kumasi, Ghana, revealed that most participants, including highly educated women, had never heard of HPV, and were relatively unaware of cervical cancer and the need for preventive cervical cancer screenings. I believe that health promotion campaigns regarding cervical cancer should focus on increasing awareness among all African women, not just those who have HIV. It is imperative that public health organizations become aware of the stigma associated with cervical cancer. Cervical cancer awareness campaigns should reflect the fact that HPV is the most common sexually transmitted infection and far more women in developing countries are infected with HPV than HIV (Bruni et al., 2010; Schiffman, Castle, Jeronimo, Rodriguez, & Wacholder, 2007).
In addition, a culturally sensitive approach should be used when public health professionals develop health promotion campaigns in African countries. The PEN-3 model, developed by Dr. Collins Airhihenbuwa (2008), is a culturally sensitive theoretical framework for developing culturally relevant health promotion interventions. Using a culturally sensitive approach, the PEN-3 prompts researchers to assess the specific factors that impact health behaviors. According to this theory, the lack of frame of reference for preventive health services, cultural beliefs regarding gender concordance between patients and healthcare providers, the dominating role of men in women’s health care behaviors, and the cost of screening are the most important issues that need to be addressed in cervical cancer awareness interventions in African countries. Funds from organizations that aim to reduce the incidence of cervical cancer in Sub-Saharan Africa would be more effectively spent on educating youth about the importance of preventive care versus sick care, and increasing the uptake of the HPV vaccine among girls and boys. Funding should also go towards training women to become gynecologists, primary care providers, oncologists, and nurses. Additionally, it is important to build infrastructure for high quality screenings and follow-up care, and to offset the costs of such screening , so that women can access cervical cancer screenings for little to no cost.
I am glad that a “war on women’s cancers” has been declared in Sub-Saharan African countries. I applaud the efforts of the public health organizations that have taken on the challenge of increasing awareness of cervical cancer in response to the call for action. However, I firmly believe that cervical cancer awareness campaigns based on a culturally sensitive approach would be more effective than what is currently being used. With the anticipated increase in the incidence of cancer in developing countries (Bray, Jemal, Grey, Ferlay, & Forman, 2012), now is the time to decrease the stigma associated with cervical cancer and increase the promotion of the regular use of tools for the prevention and early detection of cervical cancer.
About the Author
Michelle S. Williams
Michelle is a doctoral student at the University of Alabama at Birmingham and she is also completing a graduate certificate in global health. She is a Fulbright Alumni Ambassador and a former NIH MHIRT Scholar. She is passionate about reducing cancer disparities in the US and in Sub-Saharan Africa
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Bray, F., Jemal, A., Grey, N., Ferlay, J., & Forman, D. (2012). Global cancer transitions according to the Human Development Index (2008-2030): a population-based study. Lancet Oncology, 13(8), 790-801.
Bruni, L., Diaz, M., Castellsague, X., Ferrer, E., Bosch, F. X., & de Sanjose, S. (2010). Cervical human papillomavirus prevalence in 5 continents: meta-analysis of 1 million women with normal cytological findings. Journal of Infectious Disease, 202(12), 1789-1799.
Schiffman, M., Castle, P. E., Jeronimo, J., Rodriguez, A. C., & Wacholder, S. (2007). Human papillomavirus and cervical cancer. Lancet, 370(9590), 890-907.
Williams, M., & Amoateng, P. (2012). Knowledge and beliefs about cervical cancer screening among men in Kumasi, Ghana. Ghana Medical Journal, In Press.