Cervical Cancer in Sexual and Reproductive Health

Cervical cancer is the fourth most common cancer among women worldwide. However, the problem disproportionately affects women in developing countries and ranks as either the first or second most common cancer. (Pimple S,2016)

Human papillomavirus (HPV), especially type 16 and 18 a sexually transmitted infection (STI), is a causal factor for virtually all cases of invasive cervical cancer (ICC). Overall, women that engage in sex at an early age can subsequently become pregnant at an early age, and have a large number of children, which are factors that have been associated with an increased risk of HPV infection and ICC. (J. Ferlay 2013)

Evidence suggests that these early sexual and reproductive health (SRH) factors, low social economic status and immune deficiency is associated with a greater risk of HPV infection and cervical cancer development because of the biological predisposition of the immature cervix and cervical trauma experienced during delivery of birth. In addition, a women's risk may also be heavily dependent on the "high-risk" sexual behaviour of the male partner rather than their own sexual behaviour. This is particular among lifetime sexually monogamous women, since men in general, report more lifetime numbers of sexual partners than women. (A.N. Burchell, and K. Wellings 2006)

Therefore, to achieve the primary objective of cancer prevention reproductive health issues including HPV vaccination, regular cervical cancer screening and contraception use should not be overlooked.Cervical cancer risk is associated with increased sexual activity. Initiatives to encourage later commencement of sex and limiting the number of sexual partners would have a favourable impact on risk of cancer of the cervix and other sexually transmitted infections (Diane Cooper, 2007).

There has been overwhelming evidence that connects cervical cancer to early sexual debut. It is important to have young people educated and have access to Social Behavioural Change and Communication (SBCC) and sexual and reproductive health rights (SRHR). This will ensure that they know how to go about STI prevention and use of contraception. 

Cervical cancer remains a major cause of morbidity and mortality among women in resource constrained settings due to low access to cancer screening and vaccination (Bingham A, 2003). Studies show that those who come from low social economic status have high risk acquisition of HPV earlier and more frequent than those who are from high social economic status. 

Citing the Tanzania Demographic Health Survey (TDHS) of 2015-16, the survey states that: Both women and men in rural areas are more likely to marry earlier than their urban counterparts. This is because the latter has more access to SRHR at such a young age, more opportunities to engage fellow young people and other youth friendly services as well as peer educators and make informed choice.

Early diagnosis consists of 3 steps that must be integrated and provided in a timely fashion of which awareness and accessing care, clinical evaluation, diagnosis and staging and access to treatment that is saying in other words access to SRHR.

Ivony Issack Kamala, Nurse and Midwife who is the Manager - Medical and Technical Service at Uzazi na Malezi Bora Tanzania (UMATI) – a Member Association of IPPF Africa Region shares with us about the UMATI Cervical Screening project in Tanzania:

Question 1: Tell us about the recent Cervical Screening Project in Tango, Tanzania

Answer:The cervical cancer screening project in Tanga is incorporated as integrated health services provided during outreach in Tanga city under the Cluster model/Cluster Plus; it being a Public – Private - People - Partnership (4Ps) for demand creation and integrated service delivery. In this model, we aim at providing services integrated service delivery to 5 multisectoral facilities identified within 20km radius engaged in formal agreement to provide outreach and subsidized facility-based services. 

Question 2: What do you consider as the successes/achievement of the project?

Answer: The successes/ achievements of the project have been:

1. Reaching 1,626 women with Cervical Cancer screening services in just one month. Educating the population has been a great achievement too. We have had women come from great distances referring their peers and sharing stories of how well we have helped them. We share information with the community through community healthcare workers (CHW) and community-based distributors (CBD). They have been sensitizing our people and referring them to health facilities. After this, our field officer follows up the clients with easy.  By use of informative tools, they capture an extensive amount of data that is linked to a great feedback system. One thing we learnt from this is that, women need better access to family planning services and more men need easier access to education on family planning.

Health providers and the great outreach team have strategies to incorporate integrated health services i.e. voluntary counseling and testing (VCT), visual inspection using acetic acid (VIA), sexually transmitted infections (STI) and FP services all in one service provision outreach basket.

2. On job training/mentorship to the service providers during outreaches at Static facilities. We had two teams in the project headed by UMATI service providers of which one happens to a certified National Trainers on FP and another competent in VIA. These two teams each had a preceptor, a trainee and 1 or 2 CHW depending on their availabilities. The team leaders (UMATI Service providers were constant), preceptors were interchanging as well as trainees who were service providers at host outreach facility. After this leg of outreach, we are looking into certifying the service providers who were competent in their service provision. So, the ongoing on job mentorship ensures sustainable health service provision even long after UMATI moves on from Tanga outreach cluster model.

Question 3: What challenges that you experienced during the implementation period?

Answer: The challenges were mostly lack of education, sometimes women being reluctant to attend these services due to fear of the unknown. They have not experienced VIA before they do not know what it is but after they were educated, and they experience we got more clients.

Another challenge was the culture and tradition of Tanga area in Tanzania. Most of our clients were communities that culture and religion tend to keep a woman at home and has to follow her man. This is so serious that men themselves go shopping for women to the market.  This robs the woman of the opportunity to get our services. Even getting counselling is a challenge. The service providers sometimes have to follow these women to their homes to counsel them. Eventually when the women come to the health facility they would spend less time accessing the cancer screening services. 

Also, the issue of distance in which clients would travel a long distance to the facility hence the service providers were to be efficient in-service integration.

The biggest challenge yet was the controversial political statements which had vague translation to the communities in Tanzania. The early days after the statements went out, there was a decline in uptake of FP services but after incorporation of VIA then we saw the slow but steady increase of demand for the integrated services. 

HOW TO PREVENT CERVICAL CANCER

It is not easy to avoid HPV in low-income setting due to the prevalence of risk factors such as early marriage, poor access to VIA services, inability to access HPV vaccination and et cetera. Hence, it is advisable to adhere to the following: 

1. Have at least one faithful partner or use condom/barrier method of FP. 
2. Cervical screening – for women of reproductive age around 35 years of age and should be done at least every 3 years. And women between 50-64 should have at least a check 5 yearly.
3. Avoid use of cigarettes which increase susceptibility to HPV
4. Do not douche with substances such as honey, cotton, perfumes and other cologne scents, chocolate or peanut butter. 
5. Avoid basic douching agents because the vagina is naturally acidic in nature, basic douching agents neutralize the vaginal condition hence, leave the area susceptible to infections and lower the immunity. Gardasil vaccine started to be used in Tanzania, to prevent HPV infection which causes cervical cancer for young girls aged 14-26 years and services.