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. 2025 Jun 16;52(4):265–280. doi: 10.1188/25.ONF.265-280

Cervical Cancer Screening Among Women in Malawi: An Integrative Literature Review

Jasintha Mtengezo 1,✉, Haeok Lee 1, Mercy Dokiso Chirwa 1
PMCID: PMC12169352  PMID: 40577578

Abstract

PROBLEM IDENTIFICATION

In Malawi, the cervical cancer death rate is eight times that of the global rate. Cervical cancer is preventable by vaccination, screening, and early treatment. The purpose of this study was to identify the prevalence of cervical cancer screening and factors associated with screening uptake among women in Malawi using Whittemore and Knafl’s integrative methodologic review framework.

LITERATURE SEARCH

A comprehensive literature search was conducted in MEDLINE®, Scopus®, Academic Search Complete, CINAHL®, and Google Scholar™ databases.

DATA EVALUATION

12 studies met the inclusion criteria, and quality was assessed using the Mixed-Methods Appraisal Tool, version 2018. Themes were categorized within the situation-specific theory components.

SYNTHESIS

The screening rate ranged from 1.74% to 47%. Access to healthcare services factors and individual, sociocultural, and sociodemographic factors were associated with screening uptake.

IMPLICATIONS FOR RESEARCH

The identified gaps in cervical cancer prevention in Malawi can serve as evidence to develop nursing intervention strategies to promote screening and treatment uptake in the country.

Keywords: cervical cancer, screening, barriers, facilitators, Malawi

Cervical cancer remains a global health problem, with an estimated 662,000 new cases and 348,874 deaths worldwide in 2022 (Ferlay et al., 2024; World Health Organization [WHO], 2024). Cervical cancer is a preventable disease, and it is the fourth most common cancer in women worldwide (WHO, 2024). The disease burden is greatest in resource-limited countries, where about 94% of cervical cancer deaths occur because of inequities in access to cervical cancer management services (Ferlay et al., 2024; Jedy-Agba et al., 2020; WHO, 2024). Malawi is a low-income country with a high burden of cervical cancer, where the age-standardized mortality rate is 54.1 of 100,000 per year (Ferlay et al., 2024).

Most cervical cancers are caused by human papillomavirus (HPV), for which a vaccine is available (WHO, 2021). The primary prevention strategy is administering the HPV vaccine to girls aged 9–14 years before they are sexually active, and the secondary target is vaccinating boys and older females when feasible and affordable (WHO, 2024). However, despite the low price of the HPV vaccine, because of the tier-pricing agreement in low-income countries, the HPV vaccine is still too expensive and additional resources are required to build a cold chain system to deliver the vaccine to targeted recipients. Most low-income countries are experiencing delays in scaling HPV vaccination programs for girls. In addition, the HPV vaccine has not yet been introduced to boys in Malawi (Catalan Institute of Oncology and International Agency for Research on Cancer Information Centre on HPV and Cancer, 2023). Most sexually active people who are infected with HPV do not have symptoms and their immune system clears it (WHO, 2021). If HPV is not cleared, it causes the growth of abnormal cancer cells (WHO, 2021). The risk factors for cancer progression include HPV type, HIV infection, presence of other sexually transmitted infections, number of births, use of hormone contraceptives, age at first pregnancy, and smoking (Bruni et al., 2023; International Center for AIDS Care and Treatment Program, 2022; Stelzle et al., 2021; UNAIDS, 2016). It takes 15–20 years for abnormal cells to become cancer, making cervical cancer a good target for screening and early detection (WHO, 2024). Cervical cancer screening (CCS) is recommended for women aged older than 30 years. The WHO (2021) set a target to eliminate cervical cancer by 2030, suggesting that 70% of women should be screened by age 45 years and that precancerous lesions should be treated early. Cervical cancer can be cured if diagnosed and treated at an early stage of the disease (WHO, 2021).

The screening tests for cervical cancer include Papanicolaou (Pap) testing, HPV DNA testing, and visual inspection with acetic acid (VIA) (WHO, 2021). WHO (2021) guidelines promote HPV DNA testing rather than VIA or cytology in screening and treatment approaches. In Malawi, pilot studies have indicated that HPV self-sample collection may be the preferred choice for women (Akanda et al., 2022; Chinula et al., 2022; Esber et al., 2017; Hood et al., 2020; Kim, 2022; F. Lee et al., 2021; Poli et al., 2020; Tang et al., 2023). However, HPV DNA testing has not yet been rolled out in the country. As a result, VIA remains the most recommended screening approach in the country because it is economical and easy to perform by clinicians and nurses. The Malawi government has been implementing a VIA-based “screen and treat” Cervical Cancer Control Program (CECAP) since 2004 (Ministry of Health and Population, 2019).

CECAP in Malawi comprises an organized set of nursing activities including advocacy and resource mobilization, public awareness and demand creation for cervical cancer prevention and control activities, and research aimed at preventing and reducing morbidity and mortality from cervical cancer (Ministry of Health and Population, 2019). Since the introduction of CECAP in Malawi, screening sites have increased from 104 in 2013 to 316 in 2020, which has increased the screening uptake from 12% in 2013 to 26% in 2020; worrisomely, it is still lower than the WHO’s 70% screening target (Ministry of Health, 2022). The challenges faced by CECAP at a national level include an inadequate number of CCS and treatment sites, lack of community awareness, inadequate funding, and a poorly coordinated referral system (Ministry of Health, 2022).

Literature Review

In 2016, Msyamboza et al. conducted a five-year (2011–2015) retrospective cohort study to evaluate VIA uptake and challenges of cryotherapy services using the national CECAP database, and reported increased screening sites from 75 to 130 and an increased CCS rate from 9.3% to 26.5%. The study database included only women who visited the health facilities; therefore, the results cannot be generalized. In addition, the screening rates included initial and subsequent visits, which means that the same women may have been screened more than once, making the prevalence rate unclear. The study also reported challenges in implementing the program in the country, which included lack of cryotherapy machines, gas stock-outs, and a shortage of trained and active VIA and cryotherapy service providers (Msyamboza et al., 2016). The challenges that women face in accessing VIA and cryotherapy services in the country were not reported.

In 2020, Pittalis et al. conducted a systematic review to examine factors influencing breast screening and CCS delivery in Malawi for studies published between 2015 and 2018. The factors hindering screening service delivery in Malawi were reported at patient, health facility, and healthcare system levels. The study did not report the CCS rate. Since 2020, the Government of the Republic of Malawi’s Ministry of Health has made great developments in cervical cancer prevention and control, such as the advent of the GeneXpert® machine for HPV testing for CCS and the scaling up of the VIA screening program to all districts in the country.

In 2022, Bruni et al. conducted a worldwide systematic review to identify CCS coverage for 194 WHO member states and 8 associated countries and reported a global 36% lifetime screening rate, 84% in high-income countries, 27% in low- and middle-income countries, 15% in sub-Saharan Africa (SSA), and 15% in Malawi. Studies have shown disparities in screening coverage in developing and developed countries, between and within regions, and within countries although they share some of the challenges like lack of infrastructure, resources, trained personnel, monitoring and evaluation, and funding (Bruni et al., 2023; McFarland et al., 2016; Pierz et al., 2020; Pittalis et al., 2020; Uchendu et al., 2021). More than 80% of cervical cancer cases in SSA are detected at a later stage because of low knowledge and awareness regarding cervical cancer and screening, cultural and religious beliefs, and limited access to screening services (Ayeni et al., 2023; Burt et al., 2021; Cubie & Campbell, 2020; Kamaraju et al., 2020; Mtengezo et al., 2022). Reviewing and identifying country-specific barriers to screening uptake are critical to effectively address the disease burden in each country.

The Screening and Nursing Impact in Malawi

In the literature reviewed, no studies addressed the CCS rate and barriers and facilitators to screening uptake from women’s perspectives in Malawi. Therefore, the purpose of this integrative review was to identify and report the prevalence rate of CCS and barriers and facilitators to CCS uptake among women in Malawi through analysis of the published literature. The results will be used to guide the restructuring of nursing intervention strategies that address access to healthcare services and individual, sociocultural, and sociodemographic factors to promote cervical cancer prevention behaviors and meet the WHO’s (2021) 70% screening target. Nurses in the country are pivotal to all CCS activities, and their positive impact in preventing cancer and contributing to early diagnoses is worth noting.

Conceptual Framework

The situation-specific theory (SST) (see Figure 1) was used as a culturally specific health behavior conceptual framework to understand barriers and facilitators that influence CCS behavior among women in Malawi (H. Lee et al., 2021; Mtengezo et al., 2022). The framework considers the uniqueness of a woman’s decision regarding CCS, which is influenced by access to healthcare services and individual, sociocultural, and sociodemographic factors (H. Lee et al., 2021; Mtengezo et al., 2022). The CCS rate is defined as the screening prevalence rate at a particular point in time or during a specified period using VIA, a Pap test, or HPV DNA. Access to healthcare services refers to the ability to obtain cervical cancer management services (H. Lee et al., 2021; Mtengezo et al., 2022); individual factors are personal aspects of women, including attitudes, knowledge, and skills, that influence screening uptake decisions (Mtengezo et al., 2022); sociocultural factors are societal and cultural aspects that influence women’s screening uptake decisions (H. Lee et al., 2021; Mtengezo et al., 2022); and sociodemographic factors are external factors that cannot be controlled but influence healthcare decisions and outcomes (Mtengezo et al., 2022). The SST framework guided data extraction, analysis, results presentation, and discussion.

FIGURE 1.

FIGURE 1

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Situation-Specific Theory Framework: Factors Influencing Cervical Cancer Screening Among Women in Malawi

Methods

The study used Whittemore and Knafl’s (2005) integrative methodologic review framework including problem identification, review purpose, literature search, data evaluation, data analysis, and presentation.

Literature Search

A comprehensive search using appropriate MeSH (Medical Subject Headings) terms in one database at a time was conducted in MEDLINE®, Scopus®, Academic Search Complete, CINAHL®, and Google Scholar™ databases using specified MeSH terms. Additional modifications to search terms including synonyms were applied to the search engine. The search terms included ([“cervical cancer”] [“cervical cancer screen*”]) AND (“rate” OR “VIA” OR “Pap smear” OR “HPV Self-test” OR “GeneXpert test” OR “utilization” OR “uptake”) OR (“barriers” OR “facilitators” OR “motivating” OR “obstacles” OR “challenges” OR “experience” OR “enablers” OR “hindrance”) AND (“Malawi” OR “Africa” OR “sub-Saharan Africa”). Additional articles were retrieved through hand searching citations and reference tracking.

Inclusion and Exclusion Criteria

Quantitative and qualitative full-text studies published in English were included if they reported either the prevalence of CCS uptake or barriers or facilitators to CCS among women in Malawi. There was no restriction to the publication date. Studies were excluded if they were not conducted in Malawi or if they were multicountry studies and did not separately report data for Malawi. Literature reviews, commentaries, protocols, and expert opinions were also excluded. The selection process and the sequence of flow of the search and study selection strategies followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and is presented in Figure 2 (Page et al., 2021).

FIGURE 2.

FIGURE 2

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PRISMA Flow Diagram for Selection of Studies: Cervical Cancer Screening Uptake and Associated Factors in Malawi

PRISMA—Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Data Evaluation

Two researchers conducted critical appraisal independently to determine whether the studies were appropriate to be included in the review. Any discrepancies or disagreements were resolved in an open discussion between the two reviewers. Unresolved disagreements were resolved by consulting a third independent researcher. Quality appraisal was conducted using the Mixed-Methods Appraisal Tool, version 18.0 (Hong et al., 2018). The Mixed-Methods Appraisal Tool was modified by a group of content experts in an e-Delphi study, and the items were retained if they had an agreement score of 0.8 (Hong et al., 2019). The Mixed-Methods Appraisal Tool was suitable for this study because it can assess multiple study designs. It can be used to appraise the methodologic quality of quantitative descriptive studies, qualitative research, randomized controlled trials, nonrandomized studies, and mixed-methods studies with specific designated design questions (Hong et al., 2018). The appraisal tool checklists have “yes,” “no,” and “cannot tell” options to determine the validity and quality of each study. Calculation of an overall score from the ratings of each criterion is discouraged. In critiquing, the researchers posed several of the stipulated questions to seek more information about the strength and limitation of the methodologic quality of each study rather than providing a simple “yes” or “no” answer. No study was excluded based on quality assessment results; rather, the methodologic rigor that each study contributed was considered and discussed in the report.

Data Analysis

Data were extracted and summarized in a Microsoft Excel spreadsheet, which included the author, year of publication, setting, theory, study design, purpose, population, sample size and sampling method, data collection and analysis method, variable measure, major findings, strengths, and limitations. The emerging themes were organized according to the SST components (H. Lee et al., 2021; Mtengezo et al., 2022).

Results

Characteristics of the Studies

The search for CCS uptake, barriers, and facilitators yielded 1,240 articles, and only 12 studies met the inclusion criteria (see Table 1). Of the 12 studies, 9 used a quantitative design (Chirwa, 2022; Chosamata et al., 2015; Gerstl et al., 2022; Mkandawire et al., 2020; Mpachika-Mfipa et al., 2022, 2023; Msyamboza et al., 2016; Mtengezo et al., 2022; Talama et al., 2020) and 3 used a qualitative design (Bula et al., 2022; Moucheraud et al., 2020, 2022). Of the nine quantitative studies, six used a cross-sectional design (Chosamata et al., 2015; Gerstl et al., 2022; Mkandawire et al., 2020; Mpachika-Mfipa et al., 2022, 2023; Mtengezo et al., 2022) and three used a retrospective design (Chirwa, 2022; Msyamboza et al., 2016; Talama et al., 2020). The sample sizes in the quantitative studies varied from 749 to 145,000 participants, and the samples consisted of women aged 18–62 years. Most quantitative studies used adapted tools that were pilot tested before use (Gerstl et al., 2022; Mpachika-Mfipa et al., 2022, 2023; Mtengezo et al., 2022; Talama et al., 2020). Two studies reported a Cronbach’s alpha of 0.88 (Mtengezo et al., 2022) and 0.65 (Chosamata et al., 2015).

TABLE 1.

Summary of Reviewed Studies (N = 12)

Study Setting, Design, Sample, Purpose, and Framework Main Findings and Situation-Specific Theory Association Limitations and Strengths
Bula et al., 2022 Rural qualitative sub-study of 17 women to explore perceptions of and motivations for screening

  • ■ Access to healthcare services factors included the source of information as radio, friends, and family planning clinics; individual factors included limited knowledge specific to cancer and attitude (misconceptions of CCS that it was painful and uncomfortable, fear of diagnosis and treatment, stigma of a positive screen result; motivation: desire to know health status, screening available in the community, peer encouragement; an understanding of screening as a prevention and cancer as a deadly disease like AIDS); and sociocultural factors included myths in the community (healthcare provider collecting blood or vaginal discharge to sell/satanic rituals).

  • ■ Limitation: included views of only women who participated in the community-based CCS program in a rural setting
Chirwa, 2022 Rural and urban retrospective cohort study using random sampling of 7,826 women that examined socioeconomic inequality in CCS uptake

  • ■ Ever screened: 13%

  • ■ Sociodemographic factors included inequalities such as the following: lower CCS rates in rural areas (AOR = 0.075, 95% CI [0.059, 0.09], p = 0.01) than in urban areas (AOR = 0.195, 95% CI [0.162, 0.228], p < 0.001); lower CCS rates in women with no education, women who had a lower income, and women who were aged younger than 24 years; and those who had an HIV test were more likely to undergo CCS (OR = 2.48, 95% CI [1.71, 3.6]).

  • ■ Limitations: used household survey data; no control over the variables corrected
Chosamata et al., 2015 Rural and urban cross-sectional study of 257 women aged 30–45 years that examined prevalence and determinants to use of CCS services

  • ■ Ever been screened: 13.2%

  • ■ Reasons for not being screened were related to individual factors, including knowledge (lack of knowledge [33.5%], having heard of CCS [OR = 17.7], higher level of knowledge [OR = 7.37]) and attitude (lack of interest [39.7%], no reason [19.8%]) and sociodemographic factors, including older age (OR = 7.05), having more than 1 sexual partner (OR = 3.24), and use of oral contraceptives (OR = 2.6).

  • ■ Cronbach’s alpha = 0.654

  • ■ Limitation: nonprobability sampling
Gerstl et al., 2022 Rural and urban cross-sectional study of 1,850 women aged 25–49 years that examined screening coverage and why women had not been screened; health belief model; 2% opted out of the study.

  • ■ Screening uptake was as follows: those who had never been screened (33.7%), those in urban areas (40.2%), and those who had support (38.9%) and did not have support (25.4%). Access to healthcare services factors included referral to a health facility (49.9%), individual factors included knowledge (95.6% had some knowledge about CC, 34.4% had knowledge about CC symptoms) and attitude (51% believed to be at risk for CC), and sociodemographic factors included older age and literacy; education, income, and HIV status; lack of time (26%); and lack of motivation (18.3%).

  • ■ Limitations: used different sampling methods in targeted sites; no baseline data available to compare the results
Mkandawire et al., 2020 Urban cross-sectional study of 196 women who were HIV positive and aged older than 18 years that investigated the knowledge of CC, CCS rate, and predictive factors; health belief model

  • ■ Ever been screened: 47%

  • ■ Access to healthcare services factors included getting information from health facilities, and individual factors included knowledge (98% had heard of CC, 57% knew at least 1 sign/symptom of CC).

  • ■ Limitations: targeted 1 antiretroviral therapy clinic; views of women who were HIV negative unknown
Moucheraud et al., 2020 Theory-informed qualitative study of 60 women aged 18–62 years that explored perceptions and experiences with CC disease and screening; multilevel health outcome framework

  • ■ Access to healthcare services included encouragement from a friend, a campaign announcement, and the availability of screening services in the community; individual factors included knowledge (cancer is very dangerous, it kills, and it is ruining the lives of many people in Malawi; exposure to information; and risk factors [uncircumcised men, male hygiene, multiple partners, use of vaginal herbs]) and attitude (beliefs and rumors [never can have children again], fear of divorce if positive for human papillomavirus, acknowledgment of being at risk if HIV positive, knowledge of CC status, feelings of being at risk [having signs and symptoms, partner infidelity, family history of CC]); and sociocultural factors included husband approval and a period of abstinence.

  • ■ Limitations: used secondary data, no control on the variables

  • ■ Strength: evaluated the successes and challenges of implementing screening services in the country
Moucheraud et al., 2022 Qualitative study of 47 women aged older than 18 years that explored experiences in a “screen and treat” program; multilevel health outcome framework

  • ■ Access to healthcare services factors included challenges such as equipment stock-outs and service availability, as well as women who were sent back and felt discouraged; individual factors included knowledge (knew the general concept of screening; counseling and education using pictorial tools was helpful and informative, and corrected some misconceptions concerning CCS) and attitude (screening process was painless contrary to the rumors; attitude of healthcare providers); and sociocultural factors included seeking husband’s approval to access CCS and comfort talking with female providers.

  • ■ Limitation: included women from only 3 health facilities offering “screen and treat” services at HIV treatment sites
Mpachika-Mfipa et al., 2022 Semiurban and rural cross-sectional study of 482 women aged 18–49 years using multistage random sampling that examined sociodemographic determinants of CCS uptake; behavioral model of health services use; 4% opted out of the study.

  • ■ Ever been screened: 13.1%

  • ■ Sociodemographic factors included age groups: Those aged 25–35 years and 36–49 years were 2.63 and 3.9 times more likely to undergo screening than those aged 18–24 years (AOR = 2.63, 95% CI [1.3, 5.31]; AOR = 3.9, 95% CI [1.62, 9.38]); religion: Christians were 2.77 times more likely to undergo screening than Muslims (AOR = 2.77, 95% CI [1.23, 6.22]); ethnicity: those of Chewa ethnicity were 71% less likely to undergo screening than those of Yao ethnicity (AOR = 0.29, 95% CI [0.09, 0.95]); and residence: Those in semiurban areas were 2.57 times more likely to undergo CCS than those in villages (AOR = 2.57, 95% CI [1.19, 5.55]).

  • ■ Limitations: conducted at health facilities; views of women who did not visit the health facility unknown

  • ■ Strength: rigorous sampling from all zones
Mpachika-Mfipa et al., 2023 Semiurban and rural cross-sectional study of 482 women aged 18–49 years using multistage random sampling that examined factors associated with CCS uptake; behavioral model of health services use

  • ■ Ever been screened 13.1%

  • ■ 27.3% of women were HIV positive, and 8.5% of women were HIV negative; access to healthcare services factors included those who had heard from health facilities versus those who had heard from the radio, family/friends, and other sources (31.2% versus 16.7%; 9.3%; 16.7%) and those recommended by a healthcare provider versus others (19.6% versus 4.7%); individual factors included knowledge (have heard of CC versus have not heard [23% versus 1.4%], high knowledge level of CC signs/symptoms versus low knowledge level [66.7% versus 19.8%]) and attitude (had positive beliefs of CCS versus negative beliefs [19.2% versus 4.9%]); sociocultural factors included willingness to be screened by a male healthcare provider versus not (14.4% versus 4.7%); and sociodemographic factors included HIV status.

  • ■ Limitations: conducted at health facilities; views of women who did not visit the health facility unknown
Msyamboza et al., 2016 Rural and urban (national level) retrospective cohort study of 145,015 women aged older than 29 years that evaluated CCS uptake and challenges of screening services

  • ■ Ever been screened: 9.3% in 2011, 13.2% in 2012, 11.7% in 2013, 20.8% in 2014, and 26.5% in 2015

  • ■ Access to healthcare services factors included faulty/broken cryotherapy machine and gas stock-outs, lack of cryotherapy machines in facilities, 1 Papanicolaou test at a public site countrywide, and a shortage of trained and active visual inspection with acetic acid and cryotherapy service providers; 43.3% of eligible candidates received cryotherapy.

  • ■ Limitations: used secondary data, no control on the variables

  • ■ Strength: evaluated the successes and challenges of implementing screening services in the country
Mtengezo et al., 2022 Rural and urban cross-sectional study of 291 women aged 18–60 years who were HIV positive that used cluster stratified random sampling and convenience sampling to examine the CCS status and factors affecting screening status; situation-specific theory

  • ■ Ever been screened: 32.9%; after HIV diagnosis: 27.8%

  • ■ Access to healthcare services factors included 49% who had a shortage of healthcare providers, 47.1% who had no money for transportation, 32.4% who had to travel a long distance to screening sites, 23.8% who did not know where to go, and 23.3% who had a long waiting time; individual factors included knowledge level (AOR = 1.11, 95% CI [1.03, 1.2]) and attitude (for those who were not screened, 31.4% thought they were not sick) (AOR = 1.43, 95% CI [1.04, 1.97]); sociocultural factors included social support networks (AOR = 6.8, 95% CI [1.41, 32.76]); and sociodemographic factors included employment (AOR = 6.37, 95% CI [1.32, 30.8]).

  • ■ Cronbach’s alpha: 0.88

  • ■ Limitations: targeted women who were HIV positive in support groups who were exposed to health information; views of women who were HIV negative and who were not in support groups unknown
Talama et al., 2020 Rural retrospective study of 749 women who were HIV positive that measured the impact of a quality improvement project; Plan-Do-Study-Act model

  • ■ Screening rate: at baseline (1.74%) and after (73%); 85.3% received the screening test for the first time; access to healthcare services factors included integrating CCS into routine HIV care, mentorship and training of all healthcare providers, provision of resources and CC health talks, consistent community engagement, and monitoring and evaluation.

  • ■ Limitations: used secondary data (reports and registers); no control over the data; targeted only 1 clinic in a rural setting
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AOR—adjusted odds ratio; CC—cervical cancer; CCS—cervical cancer screening; CI—confidence interval; OR—odds ratio

The qualitative studies used individual in-depth interviews and/or focus group discussions (Bula et al., 2022; Moucheraud et al., 2020, 2022). The sample sizes ranged from 17 to 60 participants. Data were analyzed using thematic analysis (Moucheraud et al., 2020, 2022) and content analysis (Bula et al., 2022).

The models and frameworks that guided the studies include the health belief model (Gerstl et al., 2022; Mkandawire et al., 2020; Mpachika-Mfipa et al., 2022, 2023), SST (Mtengezo et al., 2022), multilevel health outcome (Moucheraud et al., 2020, 2022), and Plan-Do-Study-Act quality improvement model (Talama et al., 2020). Some studies used a convenience sampling method (Bula et al., 2022; Moucheraud et al., 2020, 2022; Mpachika-Mfipa et al., 2023).

CCS Rate

CCS rates were reported in nine quantitative studies (see Table 2), ranging from 1.74% to 47% (Chirwa, 2022; Chosamata et al., 2015; Gerstl et al., 2022; Mkandawire et al., 2020; Mpachika-Mfipa et al., 2022, 2023; Msyamboza et al., 2016; Mtengezo et al., 2022; Talama et al., 2020). Five of nine studies reported a screening rate of 13% (Chirwa, 2022; Chosamata et al., 2015; Mpachika-Mfipa et al., 2022, 2023; Msyamboza et al., 2016). In a cross-sectional study that included women who were HIV positive, HIV negative, and of unknown status, the CCS rates were 27.3% in women who were HIV positive and 8.5% in women who were HIV negative (Mpachika-Mfipa et al., 2023). The screening rate was obtained by participant self-report (Chosamata et al., 2015; Mpachika-Mfipa et al., 2022), a combination of self-report and verification of the women’s health passport (i.e., health record) (Gerstl et al., 2022; Mtengezo et al., 2022), or a record review from the health facility registries (Msyamboza et al., 2016; Talama et al., 2020). Only one study reported the screening test used, and 97.9% of participants were screened using VIA and 2.1% were screened using VIA and Pap tests (Mtengezo et al., 2022).

TABLE 2.

Prevalence of Cervical Cancer Screening Uptake in Malawi

Study Sample Screening Rate Measure
N %
Chirwa, 2022 7,826 13 Malawi Population HIV Impact Assessment household survey, 2015
Chosamata et al., 2015 257 13 Self-report
Gerstl et al., 2022 1,850 34 Self-report
Mkandawire et al., 2020 196 47 Self-report
Mpachika-Mfipa et al., 2022, 2023a 482 13 Self-report
Msyamboza et al., 2016 b 2011: 164,145; 2012: 169,350; 2013: 174,735; 2014: 180,306; 2015: 186,069 2011: 9; 2012: 13; 2013: 12; 2014: 21; 2015: 27 National Cervical Cancer Control Program database, 2011–2015
Mtengezo et al., 2022 291 who were HIV positive 33 Self-report and health passport record review
Talama et al., 2020 749 2 Ministry of Health cervical cancer register
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a

Study year of both studies was 2022.

b

Study years were 2011, 2012, 2013, 2014, and 2015.

Barriers and Facilitators to CCS Uptake

The barriers and facilitators to CCS uptake from studies were identified, analyzed, and organized based on the SST components in Figure 3, which include access to healthcare services and individual, sociocultural, and sociodemographic factors (Mtengezo et al., 2022).

FIGURE 3.

FIGURE 3

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Summary of the Barriers and Facilitators of Cervical Cancer Screening Uptake

Sociodemographic Factors

The sociodemographic characteristics associated with screening uptake include age, education, employment, religion, ethnicity, residence/location, wealth/income, time, having more than one sexual partner, use of oral contraceptives, HIV status, and being tested for HIV (Chirwa, 2022; Chosamata et al., 2015; Gerstl et al., 2022; Moucheraud et al., 2020; Mpachika-Mfipa et al., 2022, 2023; Mtengezo et al., 2022). Most studies categorized age into groups as follows: 18–24 years, 25–35 years, and 36–49 years (Chosamata et al., 2015; Gerstl et al., 2022; Mpachika-Mfipa et al., 2022). Increased odds of screening were reported in women aged older than 29 years compared to women aged younger than 29 years (Chirwa, 2022; Chosamata et al., 2015; Gerstl et al., 2022; Mpachika-Mfipa et al., 2022, 2023).

Residence/location was categorized as rural and urban or semiurban and villages (Chirwa, 2022; Chosamata et al., 2015; Gerstl et al., 2022; Moucher-aud et al., 2020; Mpachika-Mfipa et al., 2022, 2023; Mtengezo et al., 2022). Women who lived in semiurban areas were 2.57 times more likely to undergo CCS than those who lived in villages (adjusted odds ratio = 2.57, 95% confidence interval [1.19, 5.55]). The unavailability of screening services in rural areas was reported as the greatest challenge to CCS uptake (Bula et al., 2022; Moucheraud et al., 2020, 2022).

Two studies reported a low screening rate in women with no education (Chirwa, 2022; Gerstl et al., 2022). Education accounted for more than 95% of the socioeconomic inequality in CCS uptake (Chirwa, 2022). Women who had higher income or who were employed were more likely to undergo CCS services than women who had lower income or who were unemployed (Chosamata et al., 2015; Gerstl et al., 2022; Mpachika-Mfipa et al., 2022; Mtengezo et al., 2022). Studies revealed that women who were HIV positive, had had more sexual partners, or used oral contraceptives were more likely to undergo screening than women who were HIV negative and who had only one sexual partner (Chosamata et al., 2015; Gerstl et al., 2022; Moucheraud et al., 2020; Mpachika-Mfipa et al., 2022). Other studies found that age, education, religion, ethnic group, location/residence (urban, semiurban, rural, village, trading center), wealth/income, and time did not influence screening uptake (Gerstl et al., 2022; Mtengezo et al., 2022).

Individual Factors

Individual factors included knowledge and attitude (Bula et al., 2022; Gerstl et al., 2022; Mkandawire et al., 2020; Moucheraud et al., 2020, 2022; Mpachika-Mfipa et al., 2023; Mtengezo et al., 2022; Talama et al., 2020). Knowledge and attitude were measured with either predefined, close-ended questions answered with “yes,” “no,” and “do not know” responses (Mpachika-Mfipa et al., 2023; Mtengezo et al., 2022) and/or with open-ended questions (Mkandawire et al., 2020). Knowledge was measured by a number of items related to awareness of cervical cancer disease, signs and symptoms, risk factors, and prevention measures (Bula et al., 2022; Chosamata et al., 2015; Gerstl et al., 2022; Mkandawire et al., 2020; Moucheraud et al., 2020, 2022; Mpachika-Mfipa et al., 2023; Mtengezo et al., 2022). The screening rate was higher in women who had heard of cervical cancer (23%) versus those who had not (1.4%) (Mpachika-Mfipa et al., 2023). Counseling using pictorial tools during health education talks, exposure to information, and corrected misconception regarding CCS (Moucheraud et al., 2022) motivated women to undergo screening (Bula et al., 2022). In a study that used close-ended questions, 98% of participants had heard of cervical cancer but only 57% were able to identify at least one sign/symptom of the disease (Mkandawire et al., 2020).

Attitude was defined by women’s perceptions, beliefs, feelings, and fears regarding screening (Bula et al., 2022; Moucheraud et al., 2020, 2022; Mpachika-Mfipa et al., 2023; Mtengezo et al., 2022). Attitude was independently associated with CCS uptake (odds ratio = 6.8, 95% confidence interval [1.41, 2.76]) (Mtengezo et al., 2022). Some women reported myths and misconceptions about the screening procedure, including that it was painful, which prevented them from undergoing screening (Bula et al., 2022; Moucheraud et al., 2022). Some women reported that they were surprised that the screening procedure was painless, and this motivated them to get screened (Bula et al., 2022; Moucheraud et al., 2020, 2022). Women who had a positive experience with VIA were willing to undergo screening again and to recommend the screening to others (Bula et al., 2022). Women perceived cancer as a serious disease and felt themselves to be at risk for reasons such as they had signs and symptoms of the disease, an unfaithful partner, and a family history of cervical cancer; therefore, they wanted to undergo screening to know their health status (Bula et al., 2022; Moucheraud et al., 2020).

Some women feared a positive screening result and treatment (Bula et al., 2022). The stigma of having a positive result was compared to having HIV/AIDS because cancer is also a deadly disease (Bula et al., 2022). Some women feared the attitude of healthcare providers who were disrespectful when talking to them about genitalia when accessing CCS services (Moucheraud et al., 2022). Some women believed that they were HIV negative, which meant that they were not at risk for developing cancer, and lacked motivation to undergo screening (Bula et al., 2022; Gerstl et al., 2022; Moucheraud et al., 2020; Mpachika-Mfipa et al., 2023).

Access to Healthcare Services

Access to healthcare services was measured by items related to availability of equipment and resources, screening sites and trained healthcare providers, waiting time, distance to screening sites, transportation cost, gender of the healthcare provider, and sources of information about cervical cancer (Bula et al., 2022; Chosamata et al., 2015; Gerstl et al., 2022; Mkandawire et al., 2020; Moucheraud et al., 2020, 2022; Mpachika-Mfipa et al., 2023; Msyamboza et al., 2016; Mtengezo et al., 2022). Women who received recommendation for screening from a healthcare provider had increased screening rates compared to those who received recommendation from others (19.6% versus 4.7%) (Mpachika-Mfipa et al., 2023).

High screening rate (1.74% versus 73%) was reported in a pre- and post-test study by Talama et al. (2020) that integrated services, provided resources/support to strengthen gaps in the system, and engaged communities. Women reported that conducting VIA in a nonclinic community setting increased CCS because women could access the services easily, it was convenient and available within the community, and it was affordable (Bula et al., 2022; Moucheraud et al., 2020). Bula et al. (2022) reported that women were motivated with same-day treatment and felt that the services were adequate and accommodating.

The women reported unavailability or inadequate resources as a great challenge, which included longer waiting times, few service providers, and unavailability of services in facilities. In addition, it was reported that some women were not screened the day they visited the clinic, which discouraged them to seek screening again when healthy but to receive screening if they had signs and symptoms of the disease (Moucheraud et al., 2022; Msyamboza et al., 2016). Mtengezo et al. (2022) reported that 32.4% of the women walked long distances to screening sites and 23.8% did not know where to undergo screening.

Sociocultural Factors

Sociocultural factors included beliefs, myths, spouse approval, gender of the healthcare provider, and encouragement from significant others (Bula et al., 2022; Moucheraud et al., 2020; Mpachika-Mfipa et al., 2023; Mtengezo et al., 2022). A higher screening rate was reported in women who were willing to be screened by a male healthcare provider than those who were unwilling (14.4% versus 4.7%) (Mpachika-Mfipa et al., 2023). Some women were unwilling to be screened by male healthcare providers because of religious beliefs or embarrassment (Moucheraud et al., 2020, 2022).

Some women received CCS after recommendation from spouses/partners, daughters, friends, peers, HIV support groups, and healthcare providers (Bula et al., 2022; Moucheraud et al., 2022). One study indicated that women opted out of the studies promoting screening because they wanted to discuss it with their partner first (Moucheraud et al., 2022). Two studies reported that women were unwilling to be screened because of myths and community beliefs such as healthcare workers collecting blood or vaginal discharge to sell to foreigners for satanic rituals and not being able to bear children again (Bula et al., 2022; Moucheraud et al., 2020). Studies indicated that women were motivated to undergo screening after getting some information from media, door-to-door educational talks, and community gatherings (churches and funerals) (Bula et al., 2022; Moucheraud et al., 2020).

Discussion

The study aimed to determine the CCS rate and barriers and facilitators to CCS uptake among women in Malawi. The screening uptake ranged from 1.74% to 47%, and a 13% screening rate was reported in four studies (Chirwa, 2022; Chosamata et al., 2015; Mpachika-Mfipa et al., 2022; Msyamboza et al., 2016). The 13% screening rate is in line with the screening coverage rate reported in the Ministry of Health’s (2022) National Cervical Cancer Strategic Plan 2022–2026 and not very far from the 15% reported in a worldwide systematic review (Bruni et al., 2022). The CCS rate is below the 70% by 2030 screening target set by the WHO (2021). This is a worrisome situation because Malawi has high disease burden contributing to a high death rate, which is eight times that of the global rate (Ferlay et al., 2024). The CCS uptake was influenced by access to healthcare services and individual, sociocultural, and sociodemographic factors.

There were mixed findings regarding the association of sociodemographic factors and CCS uptake. Some studies found that screening uptake was associated with age, residence, education level, employment, HIV status, number of sexual partners, and use of oral contraceptives (Chirwa, 2022; Chosamata et al., 2015; Gerstl et al., 2022; Mpachika-Mfipa et al., 2022, 2023; Mtengezo et al., 2022). Some systematic reviews conducted in SSA and among Arab women in the United States reported higher rates of screening uptake in women who were married, had higher education and income, and were HIV positive (Abboud et al., 2017; McFarland et al., 2016; Uchendu et al., 2021; Yimer et al., 2021). Because the effects of the sociodemographic factors are inconsistent across the studies, their effect on healthcare decisions and quality-of-life outcomes presents an opportunity for additional studies based on country-specific definitions and categorization.

Conflicting findings emerged regarding women’s knowledge about cervical cancer and screening. A higher screening rate was reported in women who had heard about cervical cancer (23%) versus those who had not (1.4%) (Mpachika-Mfipa et al., 2023). This concurs with reviews conducted in low- and middle-income countries that noted that the lack of knowledge and awareness of cervical cancer and screening was the most frequent barrier at the individual level (Abboud et al., 2017; McFarland et al., 2016; Petersen et al., 2022; Pierz et al., 2020; Pittalis et al., 2020). This could be improved by nurses and other healthcare workers providing public health education and media campaigns (Uchendu et al., 2021). An intervention study in Nigeria by Chigbu et al. (2017) found that providing house-to-house health education significantly increased screening uptake from 3.2% to 67.6% before and after the intervention. In Malawi, some of the challenges faced by CECAP at a national level were lack of community awareness and inadequate funding (Ministry of Health, 2022). An increased screening uptake from 1.74% to 73% in the country was associated with the provision of structured health education talks, service integration, training of healthcare providers, community engagement, and resources (Gerstl et al., 2022; Talama et al., 2020). Developing structured, low-cost health education intervention strategies that women can access to correct misconceptions and eventually promote CCS uptake is critical.

In addition, knowledge was measured by different tools related to awareness about cervical cancer, risk factors, signs and symptoms, screening, and prevention. Almost all quantitative studies used adapted instruments that were pilot tested in Malawian context for cultural relevance, but only two studies reported a Cronbach’s alpha (0.65 and 0.88), signifying high reliability (Chosamata et al., 2015; Mtengezo et al., 2022). Women’s knowledge level differed in studies that used close-ended questions with predefined “yes,” “no,” and “do not know” responses (Mpachika-Mfipa et al., 2023; Mtengezo et al., 2022) compared to those that used open-ended questions (Mkandawire et al., 2020). A study that used close-ended questions reported that 98% of the participants had heard of cervical cancer but only 57% were able to identify one sign/symptom of the disease (Mkandawire et al., 2020). Those that used close-ended questions with predefined “yes,” “no,” and “do not know” responses could have been easily limited by participants ticking responses even if they had no knowledge about the answers. Open-ended questions require participants to formulate their own responses, which may have made it difficult for participants to answer. This points to the need to use standardized, culturally sensitive measurement tools in the country.

Women also reported that they feared pain during the screening procedure, disease diagnosis, and treatment (Bula et al., 2022; Moucheraud et al., 2020, 2022). This concurs with reviews conducted in low- and middle-income countries in which women perceived that the test was painful and feared receiving positive screening results; they believed that if someone was diagnosed with cancer, it was terminal (Ali et al., 2017; Marques et al., 2023; McFarland et al., 2016; Petersen et al., 2022). Of note, the review also found that exposure to information and counseling using health education talks and pictorial tools, including videos and flyers, corrected misconceptions and consequently increased the desire to undergo screening (Bula et al., 2022; Moucheraud et al., 2022).

Some studies reported that women opted out of the studies because they wanted to seek spouses’ approval before undergoing screening (Moucheraud et al., 2020, 2022; Mpachika-Mfipa et al., 2023). The finding is similar to findings in reviews conducted in Nigeria and the United States, which revealed that involvement of a partner or a trusted family member increased access to screening services (Luft et al., 2021; Uchendu et al., 2021). In some cultures, including Malawi’s, spouses are recognized as the decision-makers in their partner’s health; women have limited decision-making power for their own health and care, hindering their ability to seek timely services. Empowering women to make their own decisions and involving men to support CCS services are paramount. In addition, educating men about HPV and the role they play in transmitting the disease is critical for them to take responsibility for their health and that of their partners. This promotes a sense of shared responsibility in cervical cancer prevention strategies.

Women also felt uncomfortable with male healthcare providers performing the screening procedure because of religious beliefs and embarrassment over exposing genitalia when not sick (Moucheraud et al., 2022; Mpachika-Mfipa et al., 2022). The results of the studies conducted in low- and middle-income countries such as in SSA and Portugal concur with the finding that some religious beliefs discourage women from exposing their bodies to males (Marques et al., 2023; McFarland et al., 2016; Pierz et al., 2020; Uchendu et al., 2021). Cervical screening is viewed as a gender-sensitive procedure, which may influence screening uptake. Understanding sociocultural factors is important in designing acceptable cultural interventions to increase screening uptake. The preliminary studies in Malawi have reported that women preferred self-sample collection for HPV testing (Esber et al., 2017; Hood et al., 2020; Kim, 2022; F. Lee et al., 2021; Tang et al., 2023). However, the practical aspects of implementation require careful planning, adaptation, and additional research.

A shortage of qualified healthcare providers and resources, as well as poor staff–patient interaction, was noted in most health facilities (Moucheraud et al., 2022; Msyamboza et al., 2016; Mtengezo et al., 2022). Similarly, the reviews conducted in SSA and Arab countries indicated that few trained staff were committed to providing CCS and early treatment services in health facilities (Ali et al., 2017; Cubie & Campbell, 2020; McFarland et al., 2016; Pierz et al., 2020). If countries are advocating screening uptake, there should be adequate resources to meet the demand, including healthcare providers with positive attitudes. In Malawi, the challenges facing CECAP include an inadequate number of CCS and treatment sites and a poorly coordinated referral system (Ministry of Health, 2022). Lack of human, financial, and material resources and unavailability of CCS services could contribute to women’s delay in seeking screening services (Bruni et al., 2023; Chinula et al., 2022; Cubie & Campbell, 2020; McFarland et al., 2016; Ministry of Health and Population, 2019; Rudd et al., 2017). Nurses should advocate for increased access to screening services and lobby government and developmental partners to increase funding to promote community outreach programs, bring screening services closer to women, and promote increased screening uptake.

Strengths and Limitations

This was the first integrative review of empirical and theoretical studies conducted in Malawi. Few studies met the inclusion criterion of providing CCS. Some eligible studies may have been missed. The CCS rate was not calculated because of variations in sampling and measurement tools across the studies.

Implications for Nursing Practice and Research

Tailored community health education intervention strategies are needed to correct misconceptions regarding cervical cancer and screening to promote screening uptake. Nurses should increase health education messages about cervical cancer, risk factors, signs and symptoms, and screening uptake. In addition, research should evaluate the impact of various educational interventions on screening rates. Most studies reviewed are descriptive correlational studies that identified relationships between CCS and other predisposing variables that need to be tested with culturally sensitive intervention studies and standardized measures. Nurses should be knowledgeable about screening protocols, and training programs should ensure that healthcare providers, including nurses, are well equipped with knowledge and skills to effectively perform screening procedures. In addition, adequate human, material, and financial resources for cervical cancer prevention and control activities should be made available at all screening sites across the country. Through advocacy, education, and screening procedures, nurses can help mitigate the burden of cervical cancer and promote women’s health in the country.

Conclusion

This study was conducted to identify CCS rates and factors associated with screening uptake in Malawi. The CCS rate from a synthesis of literature ranged from 1.74% to 47%, which is below the 70% target set by the WHO. The challenges hindering cervical screening uptake are related to access to healthcare services and individual, sociocultural, and sociodemographic factors. Developing targeted culturally appropriate and sustainable intervention strategies to address the challenges and increase screening uptake among women in the country is critical. Multiple approaches to promote cervical cancer prevention behaviors should be considered: developing health education about cervical cancer prevention; boosting public awareness; promoting HPV vaccination for boys, girls, and people at higher risk for HPV; and improving access to CCS services. Improving the healthcare delivery system will address the financial and human resource challenges faced by CECAP in the country. The identified gaps in cervical cancer prevention in Malawi could serve as evidence to develop nursing interventions tailored to the local context to address the barriers and promote CCS uptake in the country. Malawi is experiencing delays in scaling the HPV vaccination program. Public and private sectors must work collaboratively to enhance the HPV vaccination program for girls and boys in the country.

KNOWLEDGE TRANSLATION.

  • ■ The reported cervical cancer screening rates in Malawi are below the 70% screening target set by the World Health Organization.

  • ■ The barriers and facilitators to screening uptake are related to access to healthcare services and individual, sociocultural, and sociodemographic factors.

  • ■ Identified challenges must be addressed by developing country-specific interventions, including training sufficient service providers, increasing screening sites with adequate resources, and providing culturally appropriate screening and treatment services.

Footnotes

The authors gratefully acknowledge Evelyn Acheson, PhD, MSN, RN, for editorial assistance, Blair Sibale, MSN, RN/M, for providing cervical cancer policy resources, and Agness Chimphangwi, MSN, RN/M, for her input on the cervical cancer screening literature in Malawi.

No financial relationships to disclose. Mention of specific products or opinions related to those products do not indicate or imply endorsement by the Oncology Nursing Society.

Mtengezo and Lee contributed to the conceptualization and design. Mtengezo completed the data collection. Mtengezo and Dokiso Chirwa provided the analysis. All authors contributed to the manuscript preparation.

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