Health Impact Framework /Research Paper

Cervical Cancer in Sub-Saharan Africa

Penina Pierre

Delaware Technical Community College

NUR 310: Global Health

Mrs. Jeanmarie Maloney

7/30/2023

1
Health Impact Framework /Research Paper

Cervical Cancer in Sub-Saharan Africa

Cervical cancer is the fourth most common cancer to affect women and people with

cervixes, with 604,000 new cases and 324,000 deaths being reported in 2020. Cervical cancer is

caused by certain strains of HPV, with virus types 16 and 18 being responsible for over half of

high-grade cervical pre-cancers. Cervical cancer often occurs after infection and may take years

to develop; it is during these years that the HPV virus can turn normal cells in the cervix into

cancer cells resulting in cysts, lumps, and bleeding. Cervical cancer often becomes deadly when

it spreads to other tissues and organs and can be treated with chemotherapy. However, the

best treatment for cervical cancer is prevention. HPV vaccines can help prevent HPV infections

in the first place and PAP smears can detect any sign of cervical cancer when it’s early to get

treatment going as fast as possible. However, the access to this type of lifesaving healthcare is

limited for certain demographics and worsens the effects of cervical cancer on said

demographics.

How much more affected a certain group is by a disease is referred to as the “burden of

disease.” When calculating the burden of disease scientists need to account for factors such as

“morbidity, mortality, and disability” and “calculate the index by age, by gender, and by

region.” (Skolnik, 2021, Global Health 101, p. 34) It's through understanding all these factors

that scientists can “make comparisons of health status across regions within a country and

across countries.” A specific region that has one of the highest burdens of disease in regard to

2
Health Impact Framework /Research Paper

cervical cancer is Sub-Saharan Africa. According to an article published in 2021 cross-examining

the burden of disease between 195 countries in “developed countries such as the United States

of America (USA) and United Kingdom 40 and 42% of the women diagnosed with cervical

cancer respectively die from it” in contrast “in Africa and South Asia, the equivalent death rates

are nearly twice (78%) as high as the rates experienced in high-income countries” (Zhao, 2021).

The factors that are making health access for these countries and regions, and specifically sub-

Saharan Africa so hard to access can be explained through the health impact pyramid. In the

health impact pyramid, there are multiple factors that impact health results from

socioeconomic factors to laws making default options healthier, to clinical interventions, to long

term interventions, to counseling and Education. Certain factors have much more of an impact

than others, for example socioeconomic factors have much more of an impact on health than

all other four factors and therefore should be considered the most when trying to improve

health results. This essay will serve to examine the health burden of cervical cancer through the

lens of the health impact pyramid in order to see what is causing the high health burden and

the solutions that can be applied.

The first health impact that will be examined are socioeconomic factors. Socioeconomic

factors include education levels, poverty levels, where they live and more. For example, in the

United States socioeconomic factors can severely impact those in low-income communities.

Without enough income and good insurance, a patient may not have enough money to pay for

medical services such as PAP smears and HPV vaccines (in this specific context talking about

cervical cancer). This is true in other parts of the world, since cervical cancer is “clearly linked to

3
Health Impact Framework /Research Paper

disparities in human development, social inequality, and living standards” with “middle- and

low-income countries bear[ing] an unequal share (83%) of the global cervical cancer burden”

And only achieving “an average successful screening coverage of 19%, compared to 63% in

high-income countries” (Zhao, 2021). In addition, “in the developing countries, lack of resources

limits coverage of cervical screening for women and notably for those from rural communities

compared with urban areas as the rural population is extensively poor and their access to

health services is more difficult” (Zhao, 2021). When it comes to Sub-Saharan Africa, the

socioeconomic factors that specifically impact this region are not that different, “the high

burden of cervical cancer [in sub-Saharan Africa] is driven by other factors such as the lack of

population-level screening programs, inequitable access to health services, and poverty” (Zhao

2021). According to the article “Determinants and Levels of Cervical Cancer Screening Uptake

Among Women of Reproductive Age in South Africa: Evidence from South Africa Demographic

and Health Survey Data BMC Public Health” a woman’s place of residence was a “significant

contributor for the overall socioeconomic inequality in barriers for accessing health care”

(Akokuwebe 2021). This was because women in more “rural areas who had relatively poor

healthcare-seeking behavior, had limited accessibility, and availability of health facilities” with

rural residency also imposing “extra cost for transportation as well as lack of availability of

transportation” that may limit access to medical services and make women less motivated to

seek care. In addition, education level played a major part as well with “previous studies”

highlighting “that educational attainment and utilization of health care had strong positive

relationships” since educational attainment was “economic resources which enable women to

take control of their own health and facilitate easy access to health care” (Akokuwebe, 2021).

4
Health Impact Framework /Research Paper

The article ultimately concluded that interventions that would help women amass more

agency in the form of getting education and money could help lower socioeconomic barriers

keeping them from proper healthcare. Women making more money would decrease the

severity of poverty in African households and allow them to access expensive transportation.

Considering Sub-Saharan Africa is much more underdeveloped compared to other parts of

Africa, solutions for socio economic problems can only be implemented on a wide scale through

major governmental intervention, so until then simple community education such as

encouraging the agency of women or improving building techniques and standards will have to

be done. In addition, Sub-Saharan Africa’s underdevelopment also recontextualizes the other

health impacts and how this essay assesses them, since Sub-Saharan Africa may lack many

necessities that can make implementing solutions for those factors easier.

The next factor that will be explored is the health impact of making the default option

healthier. This health impact is usually implemented using a law, ordinance or program that

makes healthier options more inconvenient or expensive so that people will opt for the

healthier options. Since most of Sub-Saharan Africa is lacking in development, what will be

considered the default is different. Small options such as medical or educational buildings and

programs will be serving as making the default option healthier since these are basic resources

that many Sub-Saharan African villages do not have. The process of making medical clinics and

schools a common sight in Sub-Saharan villages is a difficult and expensive task since funding

must be raised for the building costs and for paying teachers and doctors and supporters for

funding are not easily accessible. However, the difficulty and lack of funding shouldn’t breed

discouragement since there have been programs that have been successful in increasing

5
Health Impact Framework /Research Paper

medical and educational access. The article, “Engaging Future Healthcare Professionals for

Rural Health Services in South Africa: Students, Graduates and Managers Perceptions” is a

qualitative study that seeks to gain insight into the perceptions and opinions of those

participating in a program meant to increase the number of medical workers in rural health

clinics. Although in said study there are medical clinics in the rural villages, these medical clinics

cannot be useful if there are no workers. According to the article rural Sub-Saharan African

areas suffer from a severe lack of medical workers and “rural medical clinics may be

understaffed with not enough practitioners to properly cater to the health concerns of the

population they’re serving” (Gumede, 2021). The article, though focusing on the experience of

those involved in the program, does provide background information about the program stating

that, “the Umthombo Youth Development Foundation (UYDF)” aimed to “attract and retain

health workers in rural health facilities'' and based it’s program off of evidence from Australia

and Canada that showed that, “students of rural origin are more likely to work in rural areas

than those from urban areas”(Gumede, 2021). The article outlined the way the program

worked. The article states that, “The UYDF addressed the shortage of healthcare workers in the

provinces of KwaZulu-Natal and the Eastern Cape, by identifying young people who were

eligible for scholarships in health sciences'' with the program involving, “an integrated model of

recruitment at school level, selection by a local hospital, comprehensive financial support, a

compulsory structured academic and social mentoring program, and experiential holiday work

at the hospitals”(Gumede, 2021). The article also states that, “Upon completion of their

degrees, graduates are absorbed into the hospitals where they were initially interviewed for the

scholarship” and ultimately concludes that “The UYDF has designed a system that was well

6
Health Impact Framework /Research Paper

thought-out and is achieving its goal of improving health services in underdeveloped rural areas

of South Africa'' although it could still be improved if it was more widespread and other integral

governmental services were improved (Gumede, 2021). However, the case of the IDF's program

shows that making healthcare clinics and workers more widespread can be done, and its

program offers a foundation that other organizations can build off of.

Long Lasting Protective Intervention

Biologically the cervix is made up of stratified squamous epithelium covering the

exocervix and mucus-secreting columnar epithelium characteristic of the endocervical canal.

The transition between these two groups of cells is named squamocolumnar junction. This area

is believed to be at greater risk from viral neoplastic transformers. The tumors that arise in the

ectocervix are more likely to be squamous cell Carcinomas which is responsible for 75% of

invasive cervical cancer cases. On the other hand, the tumors that arise from the endocervix are

often adenocarcinoma.

Human papillomaviruses (HPV) infections are responsible for approximately 95% of

malignant cervical cancer. Most HPV infections are transitory and cleared automatically.

However, repeated infection with HPV in some cases will cause the development of

premalignancy of cervical intraepithelial neoplasia or adenocarcinoma in situ. Without

treatment it could take years to decades from the transition of dysplasia to invasive

adenocarcinoma to occur in most women. However, in about 10% of patients, it can also

develop in less than a year. Often it is difficult to detect on Papanicolaou testing, and this is the

reason for the increase in cases of the subtype of cervical cancer.

7
Health Impact Framework /Research Paper

The slow moving, and insidious nature of cervical cancer is both something that is

terrifying but also reassuring, as the transformation of the HPV infection into a cancer is not

fast working and can eventually be caught but can also develop into something more deadly

over time without the affected person even knowing. The discovery that high risk or multiple

HPV infections could lead to cervical cancer was imperative in long lasting and clinical

prevention of cervical cancer as it gave another avenue for prevention, increasing chances of

making it easier and more globally widespread means of prevention. The alternate prevention

was prophylactic vaccination, developed in the 1990’s and now considered the primary

prevention for cervical cancer. Prophylactic vaccination works by activating a high amount of

HPV type specific antibodies in the body that are enough to prevent the infection from

transforming into cancer. These types of specific antibodies specifically target HPV types 16 and

18 (the ones responsible for causing the cancer) and 6 and 11 (the types responsible for making

genital warts). The article “Cervical Cancer: A Global Health Crisis” explains the process behind

the antibody activation and it’s discovery by stating that, “The critical discovery that led to the

vaccines we have today” was that the “major capsid protein of HPV, L1, could self-assemble

into so-called virus-like particles, which were shown to be highly immunogenic” (Small, 2017).

Eventually, “Two vaccines, both based on virus-like particles made from HPV types 16 and 18,

were produced, with each using a different adjuvant. One was bivalent (types 16 and 18) and

the other vaccine was quadrivalent to include the types responsible for genital warts (types 6

and 11)” (Small, 2017). The vaccines were tested, and trials were performed on patient cohorts

in between the ages of 15 and 16 and they demonstrated a reaction to the virus-like HPV

strains with high levels of the type of specific antibodies mentioned earlier. This reaction of

8
Health Impact Framework /Research Paper

antibodies was found to have “achieved very high efficacy (>95%) in preventing HPV infection

and similar efficacy in preventing type-specific cervical intraepithelial neoplasia as well as

vaginal and vulvar lesions” (Small, 2017). However, the vaccine was not as effective in female

patients who had already developed an HPV infection. Though, the vaccine still holds a good

amount of merit, and the American Academy of Pediatrics recommends the vaccine before

sexual activity for boys in between the ages of 12-13 in order “to prevent HPV-induced cancers

of the oropharynx, anus, and penis” (Small, 2017). The HPV vaccine is effective for both sexes

and the vaccination of both sexes could increase herd immunity.

Clinical intervention

Clinical intervention for cervical cancer includes different interventions such as surgery,

hysterectomy, trachelectomy and pelvic lymph node dissection, brachytherapy, radiation, and

chemotherapy. The choice of treatments is based on the stages or severity of the disease. The

Federation of Gynecology and Obstetrics (FIGO) stage is a system used to treat cervical cancer

in accordance with the severity of the cancer. For early stage IA1 of cervical cancer, or cancer

where the lymph node is not affected, surgery is the ideal choice for treatment and a cone

biopsy is done. When a lymph node is involved, the cancer is staged IA2 at this point, it is

recommended to have several surgeries that include a cone biopsy with negative surgical

margins and lymph node dissection. For some patients, other options such as pelvic radiation

and brachytherapy are recommended. In the case of patients with high risk of A1 to IAB, radical

9
Health Impact Framework /Research Paper

trachelectomy and pelvic lymph node dissections can be suggested. “Here currently are

ongoing trials evaluating reduced-intensity surgery for patients with early-stage lesions. The

Simple Hysterectomy and Pelvic node dissection in Early cervix cancer (SHAPE) trial is evaluating

simple versus radical hysterectomy for patients with cervical tumors measuring <2 cm in size.

SHAPE is a CCRN trial that has immediate application to under-resourced countries.” (Small &

al, 2017, section treatment)

Counseling and education on patient cervical cancer

Patient education and counseling are the base of any treatment plan. Patients’ participation in

their plan of care is not a right but a way to ensure that treatment will be done, and goals will

be accomplished. When patients understand the disease process and its prognosis, the means

of disease transmission and its severity, patients can be aware of how to protect themselves

and to prevent themselves from being infected. It is imperative to Instruct women in Sub

Saharan Africa the importance of keeping screening appointments up to date, to be compliant

with the doctor’s advice of treatment modality. To be willing to participate in seance of

information/formation on safe sex practices, and the mode of transmission and the disease

process. Lifestyle changes and lifestyle choices can help prevent acquiring STDs that can cause

cervical cancer by getting one partner instead of multiple partners. Get vaccinated the young

boys and girls vaccinated before acquiring STDs and for the women to keep PAP smears

10
Health Impact Framework /Research Paper

updated. It is important to complete the course of treatment for a better prognosis. Report to

the healthcare provider any unusual sign of vaginal bleeding, or discharges that could indicate

serious infection.

Cultural factors affecting health disparities among women in Sub-Saharan Africa

Culture and tradition play an important role in the way that the population or group of said

patients see illness and how illness is treated. In Sub Saharan Africa illness is seen as a

punishment or result for breaching tradition or as being due to bad luck or the malevolent

actions of a witch. In addition, women are dominated by men, the right to tell their partner to

use protective measures during sex to protect them from getting contaminated with an STD

isn’t a normalized practice. Furthermore, in most regions of Africa polygamy is practiced.

Multiple partners pose a huge risk for contracting STDs and polygamy may be increasing these

risks in the regions of Africa where they are most practiced. Women may see fear of diagnosis

of the illness therefore choose to not get screened for cervical cancer. Others also believe that

having PAP Smears done may clean their womb. Others are feeling embarrassed to get the test

done by an opposite sex doctor, some may think that the test is painful, and some women are

even prevented by their partners from getting the Pap smears done. Nurses as healthcare

professionals are in a place to advocate for patients by providing holistic care that treats a

patient, physically, emotionally, spiritually, socially and culturally. It is sometimes difficult to

adapt to some practices, but it is important to teach the patient about the safe and healthy way

to live life. Treating patients according to their belief and practices could enhance a healthy way

to live and increase patient compliance with treatment.

11
Health Impact Framework /Research Paper

“More nurses are becoming policy entrepreneurs: leaders who position themselves to

influence policy; who bring together problems, policies and politics into a novel

amalgam - new policy; and who soften up the system by presenting participants in the

network (visible and invisible) with alternative representations of their realities. This

leads to the opening of a window of opportunity, as described by Kingdon - the potential

for a truly new policy perspective.

That window is opening wider as demand grows worldwide for solutions to acute

problems including current and future health worker shortages, and the rising need for

expert care of older people, alongside huge public interest in nursing. There is greater

global awareness of the importance of investment in health as a public good, and of

nurses’ massive actual and potential contribution to improving health, creating gender

equality and strengthening economies. Meanwhile more nurses are finding the courage

to become “silence breakers” and join the worldwide wave of protests violence, sexual

harassment and other abusive behavior against women” (Salvage, 2020, Section The

window of opportunity)

Conclusion

Cervical cancer is a global problem and addressing it can seem like a herculean task, especially

in more disadvantaged regions such as Sub-Saharan Africa. However, through assessing the

12
Health Impact Framework /Research Paper

medical needs of Sub-Saharan women and people with cervixes through the framework of the

health impact pyramid medical professionals can more accurately and effectively combat

cervical cancer by removing the various social, cultural, and economic factors barring people

from getting proper care in the first place. In places that are more disadvantaged this may be

difficult work, but the framework allows medical professionals, governmental officials, and

other organizations to address each impact by how it uniquely presents itself in the area and

breaking down the problem to manageable tasks. Ultimately this makes the herculean task of

preventing cervical cancer in Sub-Saharan Africa something more achievable.

13
Health Impact Framework /Research Paper

References

Small.W., et al. (2017) Cervical cancer: A global health crisis

https://doi.org/10.1002/cncr.30667

Haruna, Abdallah. (2021). Unveiling The Influence Of Culture On Healthcare Delivery In Sub-

Saharan Africa.

https://www.researchgate.net/publication/

350850043_Unveiling_The_Influence_Of_Culture_On_Healthcare_Delivery_In_Sub-

_Saharan_Africa

Gumede, D.M., Taylor, M. & Kvalsvig, J.D. (2021). Engaging future healthcare professionals

for rural health services in South Africa: students, graduates and managers perceptions. BMC

Health Serv Res https://doi.org/10.1186/s12913-021-06178-w

https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06178-w\

Akokuwebe, M. E., Idemudia, E. S., Lekulo, A. M., Motlogeloa, O. W. (2021).

Determinants and Levels of Cervical Cancer Screening Uptake Among Women Of

Reproductive Age In South Africa: Evidence From South Africa Demographic

14
Health Impact Framework /Research Paper

And Health Survey Data, 2016. BMC Public Health, 1(21).

https://doi.org/10.1186/s12889-021-12020-z

Zhao, M., Wu, Q., Hao, Y., Hu, J., Gao, Y., Zhou, S., & Han, L. (2021). Global, regional, and

national burden of cervical cancer for 195 countries and territories, 2007–2017: Findings from

the global burden of disease study 2017 - BMC Women’s health. BioMed Central.

https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-021-01571-3

https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-021-01571-3

Salvage, J., White,J., (2020)Our future is global: nursing leadership and global health. Rev Lat

Am Enfermagem. ;28:e3339. doi: 10.1590/1518-8345.4542.3339. Epub PMID: 32876292;

PMCID: PMC7458571.

15