Development and Implementation of a Culturally Appropriate Education Program to Increase Cervical Cancer Screening among Maasai Women in Rural Tanzania

Abstract

Background: In Tanzania, the incidence of cervical cancer is nearly ten times that found in the US. Tanzanian women of the traditional Maasai tribe are financially and educationally marginalized and face a language barrier that reduces access to health care. While cervical cancer (CACX) screening programs are available locally, in our experience, Maasai women were less likely to use these services compared to local women of other tribal backgrounds.

Objectives: A novel patient education program was designed to teach Maasai women about the natural history of cervical cancer and available screening and treatment. The program addressed the importance of preventative health and informed consent. Additionally, we sought to better understand the specific barriers Maasai women face in accessing and utilizing CACX screening services.

Methods: The program used simple, scripted language translated into Maa language, the Maasai native language, with accompanying culturally appropriate 3D models. The effectiveness of the program was evaluated through pre and post-intervention surveys administered to Maasai and non-Maasai women as well as local healthcare providers, assessing knowledge of cervical cancer, screening, and treatment. Paired t-test analyses were used to analyze significance. Extensive question and answer sessions followed the education sessions from which additional barriers to screening were identified.

Findings: Maasai women had minimal understanding of preventative health services prior to the intervention. While all groups showed an increase in knowledge following the education program, Maasai women demonstrated the greatest statistically significant improvement in knowledge. The proportion of Maasai women in attendance to CACX screening clinics increased by 18% after the intervention.

Conclusions: Through a culturally sensitive and accessible patient education program, Maasai women gained knowledge of cervical cancer screening and treatment. This program serves as an adaptable model for other marginalized populations to increase patient understanding and informed consent, and to address issues that pertain to underutilization of health care services.

Figure 1

Clinical Site Locations. Highlighted in dark green is the Ngorongoro district of the Arusha province of Tanzania (the remainder of which is shaded in light green). This figure was made using Google Custom Maps and an image from Wikipedia (ZH – Own work, CC BY-SA 3.0. https://commons.wikimedia.org/w/index.php?curid=15893018).

Figure 2

Interactive nature of the educational presentations. At the marketplace presentations, participants were encouraged to engage with the educational materials and ask questions.

Figure 3

Depicting anatomy, pathophysiology, and the pelvic exam in a culturally sensitive manner. a. Anatomy was shown in situ superimposed on a human figure to help orient the women as we found that isolated pictures of organs in the human body which are “hidden” in the body did not register with the women. The uterus and cervix were discussed in terms of pregnancy and delivery as this is a familiar process to these women. b. The healthy cervix was shown alongside treatable pre-cancer and invasive cancer. The women held props made from doorknobs with painted clay “lesions,” which represented the progression from normal to invasive cervical cancer. c. A pelvic model made from felt and a cardboard box facilitated demonstration of the speculum exam. Women were also allowed to hold the speculum in order to demystify this tool.

Figure 4

Educational Screening Quiz. The statements were designed after observations of local beliefs and utilization of the local health care clinic.

Figure 5

Distribution of Maasai Screened for CACX Post-Intervention Varied by Site.