Empowering early detection: a pioneering breast health training course for healthcare workers in Malawi

Abstract

This paper shares our experiences and key lessons learnt from the development and implementation of a pioneering breast health training course for healthcare workers in Malawi, with a strong emphasis on early breast cancer diagnosis. In response to the rising burden of breast cancer and limited healthcare infrastructure, the course was designed to bridge the critical gap in early detection and diagnosis among local healthcare providers. The initiative was a collaborative effort involving Malawian health authorities, specialist clinicians, sectoral experts and civil society organisations, enabling us to create a curriculum specifically tailored to the local context. The course aimed to equip healthcare workers—from clinicians to nurses—with the essential knowledge and practical skills necessary for early detection, including clinical breast examinations. By enhancing their ability to identify suspicious cases at an earlier, more treatable stage, we sought to improve overall patient outcomes. Training was delivered through a blend of theoretical learning and hands-on clinical practice, ensuring that participants gained both knowledge and practical experience. In this paper, we highlight the challenges we faced, such as varying levels of healthcare expertise, and share the lessons learnt, including the importance of context-specific content, hands-on training and integrating breast healthcare with other services. The initiative has shown promising results in improving participants’ knowledge and skills. This paper aims to offer valuable insights for other regions seeking to implement similar programmes, emphasising the critical role of early diagnosis in reducing breast cancer mortality.

SUMMARY BOX.

• Early detection of breast cancer is critical to improving survival rates, yet healthcare workers in low-resource settings, like Malawi, often lack the specialised training necessary for accurate identification of suspicious lesions and timely diagnosis, contributing to high mortality rates.

• This paper provides valuable insights into how design, testing and national scale-up of a locally tailored, hands-on breast health training course for healthcare workers can significantly enhance early detection skills, empowering providers to identify breast cancer at more treatable stages.

• By highlighting the effectiveness of targeted training programmes, this initiative could drive policy changes that integrate breast health education into national healthcare systems, ultimately improving early detection and reducing breast cancer mortality in sub-Saharan Africa.

Introduction

Breast cancer is the most frequently diagnosed cancer in women in low- and middle-income countries (LMICs) and the second most frequent cause of cancer-related death.^{1 2} In sub-Saharan Africa (SSA), a staggering three women in every hundred lose their lives to breast cancer annually.^{3 4} Breast cancer does not need to be a death sentence, but socioeconomic, geographical and cultural barriers to accessing timely diagnosis and treatment often lead to stark disparities in morbidity and mortality rates between and within countries.⁵,⁸

Malawi is a poignant example of these challenges. Breast cancer is the second most common cancer among women (and third most common for both sexes),² with extremely low survival rates following diagnosis.³ The average survival time after diagnosis is just 5.6 months, and only 9.5% of patients survive beyond 18 months.³ Incidence rates are expected to exceed cervical cancer in SSA by 2030.^{1 9} Despite these concerning statistics, healthcare system inefficiencies hinder Malawi’s ability to tackle the issue.¹⁰

Several factors contribute to this. On the demand side, women, particularly those in rural areas, face numerous barriers to seeking care. These include societal expectations, such as the need for spousal approval, fear of a cancer diagnosis¹¹ and concerns over potential social stigma, including the risk of being abandoned by partners or losing employment.¹² Furthermore, for women to seek care, they must first recognise the significance of symptoms, which may not appear until the disease is advanced.^{13 14} On the supply side, service provision is hindered by limited availability of trained healthcare providers, shortages of equipment, stock-outs of essential supplies and lack of supervision and control standards.¹¹¹⁵,¹⁷

As a result, many women present to health facilities with advanced-stage breast cancer, if at all.^{3 18 19} Consequent delays in obtaining a diagnosis and initiating treatment^{18 20} lead to poor clinical outcomes and higher costs for the public health system, directly impacting women’s health and survival.

This situation underscores the urgent need for targeted public health action, and the Malawi Ministry of Health (MoH) has called for better coordination of efforts and resources to identify a locally relevant and feasible strategy for delivering more responsive and effective breast cancer care in the country.¹⁰ Addressing these challenges effectively will be critical to improving survival outcomes and reducing the healthcare burden in Malawi and other LMICs facing similar obstacles.

The Akazi project

In response to this call for action, in 2019 the Akazi project was launched with the objective to strengthen breast cancer services in Malawi through the co-development of targeted interventions with national and local stakeholders. After undertaking a national assessment (publication forthcoming), the project identified key gaps in breast cancer care and built the evidence base for more effective planning and investments. One of the priority intervention areas identified was the need to facilitate the ‘downstaging’ of breast cancer through early detection of symptomatic cases at the primary care level.

‘Downstaging’ is the process of ensuring that women with early signs of breast cancer, such as a palpable tumour, are diagnosed sooner, improving their chances of successful treatment.²¹,²³ It requires prompt care-seeking by women when symptoms arise, healthcare providers able to recognise early symptoms and timely referral for tests and treatment.^{6 24} Downstaging breast cancer, through public awareness activities and training staff to undertake clinical breast examination (CBE) as an entrance point to early diagnosis, has been shown to improve survival in SSA.^{21 23 25}

To achieve this, the project formed a partnership with civil society, healthcare providers, experts, the MoH and district authorities to co-design a solution. The intervention had two components: (1) developing a training package for frontline health workers to improve diagnostic and referral capabilities; and (2) raising breast health awareness in rural communities to encourage early health-seeking behaviour. This paper focuses on the first component.

As mentioned, early breast cancer diagnosis depends on both patients and primary health providers recognising symptoms, but awareness is low in Malawi.¹⁰ With only two dedicated breast care clinics in a country of nearly 20 million people,²⁶ located in Lilongwe and Blantyre, most women rely on local health centres as their primary—often only—point of contact for health services. These centres are usually staffed by nurses and non-physician clinicians (eg, clinical officers and medical assistants), who are trained in general healthcare but often lack specialised knowledge and training in breast health and examinations such as CBE.²⁷

To address this gap, Akazi developed a new training course on breast health for primary care providers, tailored to the local context. The innovative aspect is that this is the first-ever dedicated course on breast health for frontline providers in Malawi. This manuscript shares our experience of piloting the course and assessing its impact on participants’ knowledge. As we look towards scaling up this initiative, the lessons learnt could offer valuable insights for other countries facing similar challenges in breast cancer care.

Designing a context-specific training programme

The project took a collaborative approach, bringing together key stakeholders like the MoH (Department for Non-Communicable Diseases), district authorities, sectoral experts, civil society (the Breast Cancer Care Foundation) and others. This was to ensure local ownership of the course, with these groups helping shape the initiative to meet national priorities and local needs. Two project working groups were set up: one at the national level to develop and test the breast health training manual for frontline care providers; and another at the local level to lead community awareness efforts.

The training content was developed in close collaboration with partners through regular meetings and shaped by insights from similar programmes in other settings,¹⁸²⁸,³⁰ as well as consultations with sectoral experts who deeply understand Malawi’s health system. The curriculum covered essential theoretical aspects of breast health, including breast anatomy and common pathologies, breast cancer risk factors and good patient communication practices. It also covered practical skills such as how to perform a CBE correctly—the preferred method for breast cancer early detection in low-resource settings like Malawi;^{16 31} how to distinguish benign/malignant lesions, and when and how to develop a referral plan.

The training was led by the core project team (including the co-authors) along with four clinicians from Queen Elizabeth Central Hospital (QECH) in Blantyre. These clinicians are consultant surgeons and registrars actively working at the QECH Breast Clinic, bringing specialised expertise in breast healthcare and clinical teaching. The training content and approach were reviewed by a broader group, including MoH and Blantyre District Health Office representatives. A facilitators’ workshop in February 2023 established roles and training modalities. The pilot course was held at a central location in QECH from 27 February to 1 March 2023, chosen for its status as a major teaching hospital with dedicated training facilities. 15 health workers from seven health centres across Blantyre District participated. This was an intensive 3-day course combining theory and practice. We selected providers who regularly interact with outpatients and can offer CBE during other visits, such as for family planning, maternal care or cervical cancer screening. This approach was to ensure service integration, optimise public health resources and maximise convenience for patients.¹⁰

Training material included lectures, simulation sessions, group discussions and hands-on practice on silicon models and real patients at the weekly breast clinic at QECH. Each participant had the chance to practise both on mannequins and actual patients, allowing them to reinforce their skills in a supervised, real-world setting.

Pilot testing

The frontline health workers who took part in the pilot included eight nurses/midwives and seven non-physician clinicians. Their average age was 34, ranging from 24 to 46, with a fairly equal mix of men (8) and women (7). Most of the participants had either a certificate (6) or a diploma (8), with one having a Bachelor of Science degree. While 12 participants had some prior knowledge of breast cancer from various sources like school, medical books and the internet, and 5 were familiar with CBE, none had received formal training on these topics. Only three participants (two from the same clinic) mentioned that their clinics offered CBE.

To gather insights into the effectiveness of the training, we used three simple tools:

A pre-training questionnaire: this 17-question survey helped us understand the participants’ background, including their knowledge of breast cancer and CBE, any prior training they had and the challenges they faced in detecting breast cancer early in their communities. It was designed to collect useful information that could help us refine the course to make it more relevant locally.

A pre–post training technical questionnaire (breast health knowledge test): developed by breast health experts, this questionnaire focused on the core content of the course and healthcare practices in Malawi. Participants completed it before and after the training to measure how much they had learnt. The questionnaire included 30 multiple-choice questions (each assigned a score of 0–5), with a total score of up to 150 points.

A feedback form: this simple survey asked participants how satisfied they were with the training, how confident they felt in their new knowledge and any suggestions for improvement. It included both rating-scale questions and open-ended ones to gather more detailed feedback.

We analysed the responses to these surveys (see online supplemental material) to gauge the impact of the training. For the technical questionnaire, we used statistical tests to see if participants’ knowledge had improved significantly. The feedback form helped us understand how participants felt about the course and what could be improved for future sessions.

Working environment: perceived barriers to detection and treatment of breast cancer

In Malawi, current health policies recommend that women of reproductive age receive a routine CBE during visits to health centres for other services like cervical screenings. However, participants shared that this rarely happens. Nearly half (7 out of 15) said it is uncommon, and a quarter (4 out of 15) reported it does not happen at all.

Most participants reported that lack of knowledge about signs of breast abnormalities and how to perform a breast self-examination was a common barrier for women in seeking medical advice and, in turn, detection of malignancies. Fear of finding something worrisome and potential rejection from their husbands in case of breast health issues was also mentioned as important in women’s decisions. On the supply side, most respondents reported that accessibility of health services (distance), lack of trained staff and long waiting times were key obstacles to early cancer detection, among others.

For those women who did seek help and were diagnosed with breast cancer, further factors hindered treatment. Long appointment waiting times, financial difficulties covering travel and accommodation for care in distant cities and fear of treatment side effects were all reported as significant barriers to care.

Measuring effectiveness: impact on knowledge

Before the course, participants scored an average of 69.6 points on the breast health knowledge test, with scores ranging from 27 to 96. The area where they scored the lowest was on CBEs, suggesting this was a topic they knew less about. On the other hand, they performed best on a question about general breast health, such as the changes in glandular tissue during menopause.

After completing the course, participants’ average score jumped to 119.5, with scores ranging from 96.25 to 141. The lowest scores were on questions about how breast cancer can spread to other parts of the body, while the best results came from questions about common breast cancer treatments.

Overall, the results showed a statistically significant improvement in participants’ knowledge after the training, with a marked increase in their understanding of key breast health topics.

Feedback and adaptation: improving the course for scale-up

Overall, the feedback received by participants was positive in terms of the perceived usefulness of the course in improving their knowledge, as well as its content and delivery. All agreed that their understanding of breast cancer had increased, they could identify breast cancer abnormalities warranting further investigations and were now confident in performing a CBE.

In response to open-ended questions, participants praised the training for being well-organised, with clear content and plenty of resources. They especially valued the combination of theory and practice, and the opportunity for hands-on participation.

Overall, participants rated the training highly (average score of 9/10), recognising its potential to benefit healthcare professionals in rural areas. While many were satisfied with the course format, some suggested extending the practical sessions at the breast clinic for more hands-on experience.

An after-action review was conducted immediately after the training by observers from the Malawi MoH, district health authorities and civil society. This feedback helped refine the course curriculum, which was reviewed by the national project working group in March 2023. A second peer review took place at the MoH’s Essential Health Package Technical Working Group in September 2023, before final approval was granted by the MoH Senior Management Team in late 2023.

Future direction and opportunities

Since the initial pilot, 25 more primary care workers have been trained, and the course, along with its manual, has been finalised and formally handed over to the MoH for scale-up. The final product is a complete package on how to recognise breast issues and examine the breast (perform a CBE) with extensive elements on timely referral procedures and quality assurance in breast cancer care. Designed as a practical guide for primary caregivers, the course can also be used by students in tertiary training institutions (nurses and medical doctors). It fills an important gap in the medical training curriculum in Malawi because previously no such course was available. The content is tailored to the Malawi context and the needs of local healthcare cadres to maximise its impact and ensure sustainable improvements in care, but it can easily be adapted to other cadres and similar contexts.

Three rounds of mentorship and monitoring visits have been conducted by the Blantyre District Health Office and the project team to assess how participants are applying the new skills in their workplace and for quality control. These visits confirmed that all seven pilot health facilities are now offering CBE, benefitting 1525 clients between May and November 2023. Further evaluations of referral rates and breast cancer detection are planned.

These developments are very timely as the WHO’s new roadmap aims to save 2.5 million lives from breast cancer by 2040, urging countries to focus on early detection so that at least 60% of the breast cancers are diagnosed and treated at an early stage.⁸ Our breast health course can play a key role in helping Malawi advance these goals.

The availability of the breast health course is a step towards improving the faith of Malawians with breast health issues; however, many barriers need to be overcome to maximise its impact. The pilot participants identified obstacles to breast cancer detection within their communities, including lack of awareness, cultural beliefs and logistical challenges. Other studies in this area confirm these are common challenges in Malawi^{14 15} as well as wider SSA,^{1 32 33} and addressing them is vital for improving early detection rates. These findings have been incorporated into the training to strengthen the health promotion and communication aspects of the course and have been used to inform the awareness-raising component of the project. They may also be useful in informing potential future interventions, for example, regarding affordability of breast cancer services and social support for patients.

In an already overburdened health system, potential downstream challenges include increased demand on referral centres and diagnostic services, which could exacerbate existing resource constraints. Our approach addresses these challenges by improving the ability of frontline staff to accurately assess patients and make appropriate referrals. In line with international recommendations for such settings,²² the focus is on symptomatic patients rather than general screening, precisely to avoid overburdening services. We anticipate not only more timely transfer of patients with suspicious lesions but also more effective triage at the primary care level. Over time, this should lead to greater efficiencies within the health system, as patients are managed more appropriately—reducing unnecessary referrals and easing the burden on higher-level care facilities.

While there are some limitations to our work in Malawi, such as the small number of participants and differences in how individuals learnt, the results so far are promising.

Lessons for other countries facing similar challenges

Key lessons from this experience include, first, the importance of cross-sector collaboration. The Akazi course was developed based on an assessment of Malawi’s breast cancer care gaps, ensuring that stakeholders at all levels were involved throughout the process. Crucially, the engagement and decision-making role of national and local authorities has been vital for the course’s institutionalisation and long-term sustainability. Using participatory principles has proven effective in fostering strong teamwork, addressing shared challenges and building lasting, sustainable partnerships.

Second, the practical element of the course was particularly appreciated by participants, highlighting the need to develop training means appropriate to the local context and overcoming shortages of training materials—silicone models in particular. The solution applied in the Akazi project was to take advantage of the breast health clinic located near the training venue to create an opportunity for the trainees to practise on patients under the supervision of the training team. Future iterations of this course need to consider how to ensure access by the trainees to patients with potential breast health issues at the time of the training to maximise the learning experience and CBE skill development. This is a particular challenge in Malawi, where only two breast health clinics, open for a few hours 1 day a week, are available.

Third, in Malawi, we focused on integrating breast health into existing services, like family planning and maternal care, to make it easier for women to access services without needing separate visits. This approach can be adapted in other African countries where resources and access to specialised clinics are limited.

Conclusion

With breast cancer rates rising globally, early detection is becoming an essential strategy to improve treatment outcomes and survival rates for those affected. In Malawi, there is a growing recognition of the need to strengthen cancer control systems, and the country has committed to improving access to high-quality, equitable early detection services by 2029.¹⁰ Achieving this goal relies heavily on a well-trained healthcare workforce that is not only skilled but also sensitive to the local needs and cultural context.³⁴

In response to this need, our initiative set out to address the current gaps in training by co-developing and testing a comprehensive breast health curriculum tailored specifically for Malawi. The launch of the Akazi course in 2023 marked a milestone—this is the first-ever dedicated breast health course for frontline healthcare providers in the country. Participants demonstrated significant improvements in their knowledge, and the feedback was overwhelmingly positive.

These efforts must also be accompanied by strategies that address persistent barriers identified by frontline health workers, including limited patient awareness, cultural stigma and systemic issues such as long waiting times and distance to care, all of which continue to delay diagnosis and treatment.

As we share our experiences, we hope this initiative will not only contribute to improving breast cancer care in Malawi but also provide valuable lessons for other countries facing similar challenges. By adapting this model, we believe it could help strengthen early detection efforts in other resource-limited settings across SSA, paving the way for better breast cancer outcomes across the region.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.