FormalPara Key Points

  • Cervical cancer screening uptake in Botswana’s Indigenous communities remains low.

  • Our research explored culturally appropriate ways to improve cervical cancer screening uptake in western Botswana.

  • Community leaders and healthcare workers were consulted to develop collaborative, inclusive screening. Locally trained female community healthcare assistants were engaged to support participant recruitment and healthcare talks in the community.

  • Adopting culturally accepting and gender-choice-flexible services that overcome intimacy reticence may improve cervical cancer screening uptake in Indigenous and marginalized communities.

Botswana is a landlocked country with a population exceeding two million people and a national adult literacy rate of 87%. Cervical cancer and HIV are important public health concerns in Botswana [1], which was one of the southern African countries hardest hit by the HIV/AIDS pandemic and has an estimated 20.8% of adults living with HIV infection (corresponding to 390,000 adults) [2]. However, great progress has been made in the control of HIV/AIDS infection countrywide owing to the government’s effective antiretroviral therapy (ART) program [3, 4].

Recent data show that the incidence of cervical cancer in Botswana stands at 34.4 per 100,000 people, with a mortality rate of 20 per 100,000 [5]. However, cervical cancer is preventable with organized screening, treatment, and follow-up.

Botswana’s primary prevention strategy involves quadrivalent HPV vaccination, which was introduced in 2015 and is currently reaching almost 100% coverage of the target group of girls aged 9–13 years [6]. This is aligned with the World Health Organization (WHO) country cooperation strategy of reducing vaccine-preventable diseases [10]. Secondary prevention includes screening with Pap smears and its alternative, “See and Treat,” which combines screening and treatment in single visits [7].

Despite the widespread availability of services, cervical cancer screening uptake in Indigenous communities remains very low, as evidenced by recent studies reporting uptake of 7–9% [5, 6, 8, 9]. The WHO expects that by 2030, 90% of girls by 15 years of age should be fully vaccinated with the HPV vaccine, 70% of women screened with high-performance tests, and 90% of women who are identified with cervical cancer should receive treatment and care [10]. In order to achieve the WHO targets, much wider coverage of the population needs to be achieved. The primary aim of this community-based study was to enroll women from marginalized or Indigenous communities of western Botswana and determine their risk factors, burden of cervical lesions, and barriers to cervical cancer screening uptake.

Study Sites

The study sites included Kacgae, Bere, and D’Kar settlements in the Ghanzi district, which are serviced through health posts, and Lokgwabe and Ncojane villages in the Kgalagadi district, which are serviced through a health post and a clinic, respectively (Fig. 33.1). The lack of radio coverage in these settlements presents a communication challenge in terms of spreading accurate healthcare screening information and creating awareness. Therefore, word of mouth, primarily through community leaders, was a critical tool.

Fig. 33.1
A map of Botswana. 5 study sites are marked in Kgalagadi and Ghanzi districts. The sites in Ghanzi district are Dekar, Bere, and Kacgae. The sites in Kgalagadi district are Ncojane and Lokgwabe.

Map of Botswana with the study sites indicated in the Ghanzi and Kgalagadi districts. (Map: P Rantshabeng)

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Study Population

According to the Botswana 2022 census, the settlements and villages chosen for the study had the following populations: Kacgae—746, Bere—874, D’Kar—2814, Lokgwabe—1792, and Ncojane—2242 people. The majority of Kacgae and Bere residents identify as Basarwa, belonging to the !Xoo Tribe. D’Kar residents also identify as Basarwa, belonging to the Naro Tribe. Ncojane and Lokgwabe residents identify as a collective of Bakgalagadi Tribes, including Bangologa, Batlhware, and Barolong as the majority. In total, 171 women enrolled in the study, the majority of whom spoke and understood Setswana well.

Study Methods

Community Consultations and Engagement

Community-leader consultations were undertaken before the study commenced, guided by the understanding that Indigenous communities are held together by centuries-long traditions of having chiefs as the community glue. These consultations were used to engage community leaders at the initial stages of participant recruitment, seek access permission, explain the study aims, and discuss the procedures. We focused on the need to provide a place for culturally appropriate, safe conversations, as advised by the University of Botswana’s San Research Center. The conservative nature of Indigenous communities was emphasized, which made the engagement of community leaders prior to the study recruitment a critical exercise. Consultations involved settlement/village chiefs, political leaders (councilors), village development committee chairs and their deputies, local health-post nurses, and social welfare officers. We noted that in the Indigenous communities, chiefs and their appointed leaders became vital mouthpieces for researchers.

In Kacgae, several community–leader consultations took place at the kgotla, the Chief’s official premises, while some consultations involving community Elders took place around the fire in the evening. These consultations helped the researchers assimilate into the environment and better appreciate the settlement’s history, cultural aspects, and anticipated barriers to screening. The consultations were conducted in the native language, Setswana, noting that the majority of people in Botswana speak and understand this language. A multilingual translator service was used only in Bere. In each community, information was shared about the proposed health screening and consent procedures, and they were provided with assurances about ethical recruitment practices. These engagements enabled a better understanding of local community needs with regard to public health, helped manage the expectations of both the researchers and the community, established mutual respect, and ensured confidence in the health screening procedures.

Participant Recruitment and Barriers to Cervical Cancer Screening

Recruitment started on the first day with fewer participants than expected in Kacgae and none at all in Bere. In Ncojane, Lokgwabe, and Dekar, enrollments began well. It is noteworthy that cervical cancer screening registers in Kagcae and Dekar indicated low uptake for previous years. Preliminary investigations indicated personal barriers such as fear, intimacy reticence, and general privacy concerns. In addition, health system barriers such as long turnaround times were cited by those with prior screening experience. Understanding that scientific concepts can be intimidating, we consulted with community leaders and healthcare workers to develop strategies for a more collaborative and inclusive screening exercise. They advised engaging trusted, locally trained female community healthcare assistants (HEAs) for the recruitment exercise. These HEAs went house to house, introducing the researchers and creating awareness.

In addition, researchers proposed holding healthcare talks in private spaces where women felt safe to talk about sexual and reproductive health issues. Community halls were used to hold these health talks, and through learning models and educational videos to demonstrate sample collection procedures, participants’ fears about the proposed screening and possible treatment procedures were allayed. Differences between the proposed Pap smear and the cervical cancer screening modality commonly used in the region (See and Treat) were also discussed. We found that awareness and previous experience with See and Treat initially contributed to participation anxiety because some women who had experienced lesion excision on their first screening visit had spread news that cervical cancer screening was painful. Therefore, potential participants were fearful of cervical cancer screening and stayed away from the research sites at the initial stages of the screening process. T-shirts featuring messages about cervical cancer screening from the researcher-affiliated institution were distributed to participants postscreening. Banners were also mounted to spread the message about cervical screening awareness and increase service visibility in the study sites.

Key Findings

The participant interviews revealed that the majority of the women residing in the settlements had barely graduated from primary education, and therefore a lack of healthcare knowledge constituted a significant barrier to screening uptake. Additionally, intimacy reticence was cited as a barrier to cervical cancer screening and treatment uptake, especially in facilities dominated by male healthcare workers. To overcome this hurdle, a women-only researcher team was deployed for data collection. These strategies greatly improved knowledge and understanding among potential participants, leading to higher attendance at the screening sites in the follow-up visits—from the planned 171 enrollees to 228 women.

Community-leader-driven conversations at the initial stages of the study improved our understanding of critical cultural challenges and personal barriers to participating in the proposed healthcare screening exercises. Continuous community consultations highlighted the need for linguistically and culturally tailored healthcare talks to help understand and overcome cultural and personal barriers that could prevent these women from participating in health screening.

Conclusion

Botswana has seen great improvements in terms of access to cervical cancer screening countrywide. However, screening uptake among Indigenous populations faces additional challenges. Our research highlights some important lessons and underscores the importance of effective community engagement in the planning stages of health screening exercises where participation is core and results could impact policy. Women from Indigenous groups are seldom heard, and they are underrepresented in matters affecting their personal health. This can lead to decisions that may not serve them well. However, given a chance to lead discussions regarding their health and in their native language, positive interventions are possible. Adopting culturally tolerant and gender-choice-flexible service provision to overcome intimacy reticence may harmonize and improve screening participation in Indigenous and marginalized communities.

The researchers would like to acknowledge generous funding from the University of Botswana Office of Research and Development. We also acknowledge the assistance of Mr. Kesalopa from the National Health Laboratory, Mr. Nichodimus Cooper from the Nama Heritage in Lokgwabe, and the various community leaders from Kacgae, Bere, and Dekar settlements and Lokgwabe and Ncojane villages. Lastly, we would like to acknowledge the participants who made this work possible.