RESUMO
We conducted a cluster randomized trial of two models for integrating HPV self-collection into family-planning (FP) services at 16 health facilities in Malawi between March 2020-December 2021. Model 1 involved providing only clinic-based HPV self-collection, whereas Model 2 included both clinic-based and community-based HPV self-collection. An endline household survey was performed in sampled villages and households between October-December 2021 in the catchment areas of the health facilities. We analyzed 7664 surveys from 400 villages. Participants from Model 2 areas were more likely to have ever undergone cervical cancer screening (CCS) than participants from Model 1 areas, after adjusting for district, facility location (urban versus rural), and facility size (hospital versus health center) (adjusted odds ratio = 1.73; 95% CI: 1.29, 2.33). Among participants who had ever undergone CCS, participants from Model 2 were more likely to report having undergone HPV self-collection than participants from Model 1 (50.5% versus 22.8%, p = 0.023). Participants from Model 2 were more likely to be using modern FP (adjusted odds ratio = 1.01; 95% CI: 1.41, 1.98) than Model 1 participants. The integration of FP and HPV self-collection in both the clinic and community increases CCS and modern FP uptake more than integration at the clinic-level alone.
RESUMO
BACKGROUND: To identify and to assess factors enhancing or hindering the delivery of breast and cervical cancer screening services in Malawi with regard to accessibility, uptake, acceptability and effectiveness. METHODS: Systematic review of published scientific evidence. A search of six bibliographic databases and grey literature was executed to identify relevant studies conducted in Malawi in the English language, with no time or study design restrictions. Data extraction was conducted in Excel and evidence synthesis followed a thematic analysis approach to identify and compare emerging themes. RESULTS: One hundred and one unique records were retrieved and 6 studies were selected for final inclusion in the review. Multiple factors affect breast and cervical cancer service delivery in Malawi, operating at three interlinked levels. At the patient level, lack of knowledge and awareness of the disease, location, poor screening environment and perceived quality of care may act as deterrent to participation in screening; at the health facility level, services are affected by the availability of resources and delivery modalities; and at the healthcare system level, inadequate funding and staffing (distribution, supervision, retention), and lack of appropriate monitoring and guidelines may have a negative impact on services. Convenience of screening, in terms of accessibility (location, opening times) and integration with other health services (e.g. reproductive or HIV services), was found to have a positive effect on service uptake. Building awareness of cancer and related services, and offering quality screening (dedicated room, privacy, staff professionalism etc.) are significant determinants of patient satisfaction. CONCLUSIONS: Capitalising on these lessons is essential to strengthen breast and cervical cancer service delivery in Malawi, to increase early detection and to improve survival of women affected by the disease.
