Category: Cervical Cancer

The idea of modern hunter-gatherer societies in the world today is a subject that often ignites the academic community. Trying to solve world problems and public health issues are also central topics of discussion among the younger academic community and the scholarly academic community. Debates ranging from subsistence consumption to disease patterns among populations have generated a plethora of research to be done around the globe. Among some of this research are results showing a steep rise in human papillomavirus, otherwise known as HPV, and cervical cancer among the hunter-gatherer communities of the Amazon. This has left scholars to wonder what the cause could be since cervical cancer is considered to be a “modern disease”. Researchers are trying to see what amplifying difference or similarity of the hunter-gatherer lifestyle in comparison to the Western lifestyle is contributing to the increase of HPV among indigenous hunter-gatherer women.

Something that could contribute to the high incidence of HPV and cervical cancer among indigenous hunter gather women would obviously be the lack of HPV vaccinations. Possibly, another reason for the increase could be the lack of frequent hygienic actions among hunter-gatherers in comparison to Western society. The lack of reproductive protection would also be a leading cause for HPV and cervical cancer among indigenous hunter-gatherer women. While women are the only people that can have cervical cancer, it is well known among the medical community that men also can contract HPV through sexual intercourse and may even develop genital cancers as a result. If men can contract the virus, then researchers should explore what the total percentage of HPV is among these isolated hunter-gatherer communities to provide a broader picture of the rising outbreak. Among the peer reviewed papers that will be discussed and compared, it will be interesting to see the preventive measures that could be attempted among the hunter-gatherer populations.

Regardless of the simple way in which these indigenous people choose to live they are still susceptible to the diseases that affect all humans. While HPV is a sexually transmitted disease (STD) and typically does little harm beyond the warts that typify it, the disease can cause the body to become susceptible to other infections and conditions that can be much deadlier. For example, cervical cancer is one of the biggest responses to HPV female bodies tend to succumb to as the rapidly generated cells can quickly become cancerous. While this is a disease that is normally written off as a modern world disease, there are members of hunter-gather populations that do contract and end up with both HPV and cervical cancer as shown by the work of Fonseca et. al (2015) . These researchers worked with isolated indigenous women of the Amazon rainforest in 2015, then released a paper of their findings and possible solutions. The study by she and her colleagues is what ignited the research that was done for this very paper. Researchers had been surveying indigenous Amazonian tribes in order to track the rate of HPV spreading among native women. They were attempting to understand how the indigenous lifestyle and interaction with Western society impacted the chances of contracting the virus. The main tribe they worked with is the Yanomami, who are a hunter-gatherer tribe that is isolated deep within the Amazon rainforest. The researchers compared the Yanomami women’s rates of contracting HPV to those of other indigenous tribes that live and interact more closely with Western societies, such as women of the Macuxi and Wapishana tribes. Fonseca et al. (2015) came to the conclusion that there were both limitations and advantages of being an isolated hunter-gatherer group. When isolated there is less chance of contraction and spread of a disease that is mainly conceptualized as a “modern disease”, however, for those that are affected there is also a constraint on the aid for both this group of indigenous women and others effected by HPV. Taking samples from 664 women from 13 different indigenous tribes they were able to conclude that women over the age of 35 where far more likely to contract HPV and in turn contact cervical cancer (Fonseca et. al 2015). Therefore, the goal for the rest of the paper is to discuss and analyze research from other scientists to determine what could possibly explain the high rate of HPV among indigenous women and what can be done to aid them.

In order to understand a population, the environment in which they inhabit must be understood. The environment in which a person inhabits reveals as much about a population as individually testing members of said population. The ecology of the environment speaks volumes at to the way a human population will react when certain stressors are introduced into it. Laura Rival completed her paper in 2006 discussing the Amazon ecology that many of the Amazonian indigenous population still live in presently. In order to create a more holistic study and research practice, looking at data from other fields can always speak to differential factors that are important to the change of an environment and community. Historical Ecology is a sub field of ecological anthropology that allows anthropologists to ask vital questions that are sometimes overlooked within their own field. Questions such as, in what way does environmental change relate to the historical construction of human societies? Laura Rival (2006) is attempting to unpack the dense collection of historical ecology that has engulfed the Amazon rainforest and the effects that it has had not only on the indigenous population that was already located there but also how they would be impacted by a growing western society that would soon come to settle in their traditional places. One of the relationships she is attempting to dissect is the relationship between the indigenous populations and the forests that they inhabit; which would challenge the traditional thought taught of human occupation. One of Rival’s points seen within her research is that we must look at the onset pressures of outside forces, such as the push for agriculture, on the homeland of indigenous populations (Rival 2006). By the end of her paper she encourages that while we use older academic literature as a guide and tool for studying ecology in the present we cannot negate the population that actively lived within said ecology at the same time (Rival 2006).

While it is imperative to understand the environment in which a population is living and how it can affect their health, it is equally important to attain a better insight on the disease itself as this will allow researchers and new readers to the academic literature to brainstorm ideas on how to aid the situation or possibly even cure it. As stated in the introduction, the CDC labeled HPV as the most transmitted disease among humans. Researchers in 2012 questioned that if HPV is high among indigenous women, then what would be the rate of Human T-Lymphotropic virus (HLTV), a cancer-causing virus triggered by HPV. Blas et. al (2012) looked at the association between HPV and HTLV in indigenous women of the Peruvian Amazon. The scientists were looking at the relationship between the Human Papillomavirus (HPV) and Human T-Lymphotropic virus (HTLV) since being able to identify the association between both viruses could potentially aid in determining populations that are at a higher risk for developing cervical cancer. The research was conducted during 2010 and 2011 where cross sectional examinations where done within Amazonian Peruvian women (Blas et. al 2012). Taking a large sample size from two different cities they attempted to construct an indicator that would show scientists a marker that will allow identification as to whether a population is more at risk for HPV. Among looking for the connection between HPV and HTLV researchers are also trying to find other concepts that will aid in containing the virus and aiding those already affected. What they came to find is that the HTLV virus has a higher chance of forming within indigenous populations when HPV is already seen in the high-risk communities (Blas et. al 2012). After the research was concluded, Blas et. al (2012) suggested that more testing be done in a longitudinal manner to delineate the populations based on their stages of HPV in order to yield better results (Blas et. al 2012).

Understanding the way in which the virus interacts with other diseases and the rate at which it spreads itself is vital to Western medicine for understanding how it interacts overall with human populations. Looking at the relationship that the Amazonian indigenous people have with medicine and the way in which they see their own world, coupled with the way in which hunter-gather groups tend to persist around the world, could give better insight as to why the spread of HPV can be seen but why it is not moving through populations in the Amazon at the same rate as in places more westernized, for example, Rio de Janeiro or America.

Taking cells from patients is a standard practice of biomedical research worldwide from the 50s till today. The first immortal cell line (HeLa cells) were created from cervical cancer cells taken from Henrietta Lacks, a young mother of five children died in 1951 at the age of 31 after seeking treatment at Johns Hopkins Hospital for an aggressive form of cervical cancer. Dr. Richard TeLinde, who treated Henrietta with radiation took a sample of her cervical cancer tissue without obtaining her permission and sent it to Dr. George Gey, the head of tissue research at the Johns Hopkins University School of Medicine (Skloot 2010). Gey found that HeLa cells were able to survive outside the body and reproduce rapidly which made them ideal for research and enabled researchers and scientists in worldwide to make great advances in science and medicine. The controversial past of Henrietta’s story is now more widely known because of Rebecca Skloot’s 2010 best-selling book ‘The Immortal Life of Henrietta Lacks’. The ethical issues interlinked with HeLa cells and medical research raised within the context of the book such as informed consent, privacy, compensation, experiments on black people, the legal battles over the control of genetic material, and also the enormous benefits and value of the growth of the HeLa cell line in cancer research will be discussed in this essay.

Ethical Questions That Arise Within the Context of the Henrietta’s Story

There are human beings behind every biological sample used in the laboratory and sometimes even with the best of intentions, things go wrong. Initially, taking cells from Henrietta and using them for research without her consent didn’t violate any legal standards, because the concept of informing or obtaining consent from the donors of cells did not exist in the 1950s. After Gey and his assistant found that Henrietta’s tumor cells were dividing and growing rapidly in the laboratory, he ordered his assistant, Mary Kubicek, to take more cells from Henrietta while her body lay in the hospital’s autopsy room. Day, Henrietta’s husband agreed to sign an autopsy permission form when Gey told him the tests they run may help the Lacks children someday. Gey was neither open nor honest; the truth is that none of their children could benefit from the tests as their mother’s cancer was not hereditary. He simply wanted to culture more cells from other parts of Henrietta’s body. The rules have changed since then and they are still changing. According to the Australian National Health and Medical Research Council, participants of a clinical trial or research must give informed consent before taking part in the research; the consent form involves critical and essential elements of the process such as a detailed description of treatment and experimental procedures, purpose, duration, risks and benefits, nature of the illness, availability, confidentiality, subject’s rights and details of insurance coverage in case of injury.

Geneticist Stanley Gartler discovered that HeLa cells with a genetic marker named G6PD-A found exclusively in black Americans had traveled on dust particles and contaminated other human cell lines. After the 70s, researcher Victor McKusick wanted to do genetic tests on Henrietta’s children to find out more about HeLa contamination and how to stop it. Her children were also then used in research without their consent, asked to give blood without explaining the motive and what he will do with the samples. With no given explanation, they assumed that the study was to test them for cancer that killed their mother. This caused extreme worry and unnecessary grief for all of Henrietta’s children, who were never informed of the results of their cancer test which never happened.

The supreme court had determined that tissue removed from a patient no longer belongs to the patient and the doctor can dispose of the tissue any way he wants or use in research for the sake of medical progress. But researchers should respect the right for patients to make their own decisions and privacy wishes; not everyone has the same attitude about medical records as some people may more willing to share personal information than others. Henrietta was publicly identified as the source of HeLa cells when a team of scientists in the European Molecular Biology Laboratory (EMBL) sequenced the genome of HeLa cells and published their results in a public database (Sodeke et. al 2019). The Lacks family did not consent to release the information and this affected the privacy rights of the family members (Greely et al. 2013). “Future cures will come of this, but it needs to be handled in a way that protects people’s privacy so people know what they’re getting into when they donate. We aren’t in a place where people understand what’s happening” – said Skloot. Today researchers follow de-identified sampling and share limited personal information to protect the privacy of the donors.

Many of the benefits coming from tissue research aren’t available to those who provided samples for the research. Gey has never sold HeLa cells or profited from the discovery of them and never tried to patent them; he offered HeLa cells for scientific research to develop cures and save lives around the world (Skloot 2010). After Henrietta’s death, scientists freely and widely used her cells without permission from her family. Years later, Henrietta’s children accidentally learned that their mother’s cervical cancer cells were being used in researches which led to the creation of a massively profitable industry where their family didn’t have access to basic care back then. The book states Deborah’s word to Skloot, “But I always have thought it was strange, if our mother’s cells done so much for medicine, how come her family can’t afford to see no doctors? Don’t make any sense” (Skloot 2010, page 9). This proves that they lived in poverty and never received compensation or any of the financial benefits derived from their mother’s tumor cells.

The story of HeLa cells has often been described as one of the examples of patients and their families being mistreated because of the race. The Johns Hopkins Hospital where Henrietta Lacks was treated was one of the few hospitals that treated African American patients before the 1950s. However, black patients were treated in separated colored wards made of glass walls; there was no privacy at all and patient rights were ignored. They were not permitted to enter other parts of the hospital; even blood from whites and blood from black people did not cross the segregation line. When Henrietta was admitted to the hospital, her blood was taken, labeled ‘colored’ and stored in case she needed a transfusion. For many years white doctors and nurses treated black patients unwillingly, did not take care of them properly, and often ignored matters of patient privacy and basic human decency. Black people were not given a chance to question doctors, many black patients avoided going to the doctor until the situation was urgent; Henrietta was also often postponed going to the doctor because of the racism and classism she experienced there. TeLinde used patients from the colored ward for research because he thought that it was fair to use them as research subjects in exchange for free treatment offered them in the colored wards. However, patients never knew they were participating in research. Although TeLinde’s urge to save lives and avoid unnecessary hysterectomies is commendable, using public ward patients without their permission is unethical.

According to Skloot, Henrietta was the first to know she is ill; after giving birth to her son Joe, she was continuously in pain and bleeding. When she felt a lump on her cervix, she went to the gynecological clinic at Johns Hopkins Hospital where Dr. Howard Jones took a biopsy of the lump and discovered that she has cervical cancer. Henrietta’s pain was getting extreme and she believed her cancer was spreading and told her doctors about that several times, but they claimed that the pain was due to pregnancy and gonorrhea and nothing was wrong with her; but three weeks after they declared she is fine, and examining doctor found her cancer was indeed spreading and inoperable. The doctors did not give her pain medication until she was nearly dead and continued to give Henrietta radiation treatment to shrink her proliferating tumors and relieve her pain, but cancer got worsens and she passed away on October 4, 1951 (Rebecca Skloot, Part 1, Chapter 5).

Elsie’s treatment at Crownsville State Hospital was also an example of the mistreatment of black people at the hands of the medical profession. Henrietta was very emotional about leaving Elsie in an overcrowded hospital which was previously used as an insane asylum. Elsie has been diagnosed with ‘idiocy which might be diagnosed as autism today as she was nonverbal and exhibits many of the signs of the disorder. She was also epileptic, and at the time treatments for epilepsy were still quite primitive. Skloot states that Henrietta and Elsie used to cry when they see each other. It is clear Elsie was deeply unhappy in the hospital; but when doctors said Elsie will be better off in the hospital, Henrietta did not question it. This incident reveals the poor treatment the Lacks family received because of their economic status and race.

Major Differences Between Normal Cells and HeLa Cells

Like many tumors, HeLa cells contain defective genomes with one or more copies of multiple chromosomes. The normal cell contains 46 chromosomes, while HeLa cells contain 76-80 chromosomes in total. Harald Zur Hausen, the scientist who discovered the HPV (Human Papilloma Virus), found that Henrietta developed cervical cancer due to particular mutations in her cells as a result of HPV-18 and HPV-16. He discovered that Henrietta’s cells had multiple copies of the HPV genome in them contained several copies of HPV-18. HPV had inserted its DNA into the cells in Henrietta’s cervix, the additional DNA results in the production of a p53-binding protein that prevents it from transforming and suppressing local p53 tumors and contributes to the changes in micro RNA expression. This discovery, however, did not explain why Henrietta’s cells became so virulent and aggressive.

HeLa cells grow exceptionally fast, keeping track of their cancer status. This is because Hella cells grow easier and faster, doubling the number of cells in just 24 hours and making them ideal for large-scale testing. They grow so fast that they can infect and leave other cell cultures behind. Henrietta had syphilis, which caused suppression of the immune system and the aggressive growth of cancer cells. In 2013, it was shown that the scrambled HPV genome was inserted into the Henrietta genome near the c-myc proto-oncogene, which leads to its anatomical expression and rapid replication of HeLa cells. Lots of people had both HPV and syphilis at that time, but their cells were also not immortal as Henrietta’s.

Hela cells are immortal; this function can be explained by the expression of maximum telomeres. The early 1990s research on telomeres revealed an enzyme called telomerase in HeLa cells which allows cancer to regenerate itself; telomerase adds sequences at the end of chromosomes resulting undamaged and immortal cell. Although some cancer cells have active telomerase, they are not effective in comparison to HeLa cells particularly. HeLa cells gave researchers new clues about how to keep cancer from killing patients; this is an important step in figuring out how to stop cancer cells from spreading.

According to some scientists, the HeLa line was not the same as it had been when the first cells were cultured cell and no longer human at all. They also said that it should consider as a single-cellular organism that closely related to us, reproduces asexually through division and mutations that compound over time. However, Robert Stevenson, a researcher who helped to resolve the contamination ability of HeLa said “if someone took a sample from Henrietta’s body today and did DNA fingerprinting on it, this DNA would match that in HeLa cells”. The debate over whether HeLa cells are still human reveals how deep the divide between scientists and their subjects can be. When people began talking more about Henrietta’s legacy, scientists began to say the HeLa cells are not human. Robert Stevenson also said, “It’s much easier to do science when you disassociate your materials from the people they come from”. This disregard for human rights and for Henrietta as a human being reflects attitudes about race and class in medicine and in other fields.

Value of the Growth of the HeLa Cell Line in Cancer Research

Genetics has the power to transform cancer practice from prevention and early detection through treatment, this genetic knowledge comes from gene linkage studies or tumor specimen studies. Although many other cell lines are in use today, HeLa cells considered as ‘workhorse’ of cellular biology. HeLa cells have been used in studies of cancer cell migration and invasion, drug development benefiting hundreds of millions of patients. Cervical cancer is a global health problem, with more than half a million new cases a year (Sun et al. 2018). Harald Zur Hausen found out that by forcing its DNA into normal human cells, the HPV virus took control of the cell forcing them to produce various proteins associated with cancer. This proved to be one of the most important discoveries in that it allowed other scientists to use the knowledge to develop vaccines against the virus. Today, HPV vaccines help to protect young girls from the risk of HPV infections; according to statistics, the vaccine has reduced HPV by around 66% and prevented deaths associated with cervical cancer by about 70%.

However, despite the use of various therapeutic methods, more than one million women die each year from cervical cancer, making it life-threatening cancer and an urgent need for a therapeutic strategy. Clinical studies have shown that human papillomavirus (HPV) is the cause of cervical cancer; about 75% of fatal cervical cancers are associated with P5 dysfunction caused by HPV16. The HPV E6 gene product specifically interacts with the tumor suppressor protein p53 and acts as a potential trigger for its inactivation, with a high probability of developing cancer, as well as immortalization and transformation of cells. Therefore, the state of p53 is important for the growth, development, and treatment of cervical cancer.

Yoon et al. have shown that inhibition of TSC-22 mediated P5 proteasome degradation of H5V-positive HeLa successfully inhibits cell viability and induces apoptosis. Lee et al. found that vorinostat-induced acetylation of p53 can enhance doxorubicin-induced cytotoxicity in Hela cells. Another report demonstrated that cisplatin-induced apoptosis was independent of p53 in HPV-positive Hela. However, the inclusion of p53 in cervical cancer therapy, specifically in chemotherapy was controversial and required further clarification.

A study by Sun et al. investigated the functional roles of p53 over-expression in enhancing Lobaplatin (loba)-induced cell growth inhibition and apoptosis in cervical carcinoma cells. The results demonstrated that neither sub-lethal rAdp53 nor loba has any apparent apoptotic effect on Hela cells. The combination of rAdp53 and loba induced significant apoptosis and cell growth inhibition. P53 over-expression up-regulated the proapoptotic proteins Bax and Bak and xenograft cervical tumors derived from Hela cells demonstrated that co-treatment of rAdp53 and loba effectively inhibited tumor growth in vivo. The results of the study concluded that P53 restoration can sensitize cervical cancer cells to loba to induce apoptosis and cell growth inhibition.

Conclusion

Tissue culturing is not a bad thing, but there are challenges in how technology is used. Most of the advances in cancer research depend on tissue culture; we would have none of these if scientists were not collecting cells from people and growing them. Though HeLa cells were taken without consent from Henrietta, we cannot blame the doctors as during the 1950s taking cells and using them for research without her consent was not a crime. In modern ethical implication, clinical trials conducted on humans need to be accepted and confirmed participation by the participants through a procedure known as informed consent (Manti & Licari 2018). Today there are other immortal cell lines, but there still hasn’t been another cell line like HeLa, which grows in a very unique way. The contribution of these cells is going to get greater, not less. Instead of saying it should not have happened, we just need to look at how it can happen in a suitable way. Researchers have a responsibility to be sure that patients and their families understand how genetic information is used and offer their consent to allow further research on tissues and specimens so that another story similar to Henrietta Lacks’s will never happen again.

Abstract

The study was undertaken on the topic cervical cancer in Botswana that is, the people at risk of cervical sarcoma together with the incidence and prevalence rates of cervical cancer in Botswana. The study was further more described by briefly stating and discussing elements responsible for the occurrence of cervical sarcoma in the population. In making study more understandable the study was demonstrated using a model of causation called web causation theory clearly illustrating the causes of cervical cancer. Interventions currently done in Botswana were discussed using the Leavell’s theory on the levels of prevention and also describing the public health surveillance system used by ministry of health in Botswana.

Background

Cervical cancer

This is the cancer that transpires in the cells of the cervix, which is the lower part of the uterus that joins to the vagina. Human papillomavirus is a sexually transmitted infection that plays a major part on the cause of cervical cancer. These signs and symptoms include blood spots or menstrual flow that is extended and heavier than usual, bleeding after intercourse, discomfort during sexual intercourse, bleeding after menopause, and unexplained persistent pelvic.

It has four stages which are used to identify how much of the cancer cells are in the body. These stages are; Stage(i),Stage(ii),Stage(iii) and Stage(iv). Below is an image that shows these stages: Source: https://www.moderncancerhospital.com/cancer-staging/cervical-cancer-staging/

Globally

Worldwide 266 000 women died due to cervical cancer in 2012 and 90% of these mortality cases were in low and middle-income countries. According to WHO (2019), “cervical cancer is the fourth most cancer in women with estimated number of 570 000 new cases in 2018 and 90% of death were caused by cervical sarcoma in low & middle-income countries.”

Cervical cancer is midst the most commonly diagnosed cancers in women worldwide. Globogam (2018) estimate that 567 847 incidence of cervical cancer worldwide which is the fourth leading cancer, 615 072 new cases were reported in Europe and in 2015 these were an predictable 311 365 deaths from cervical cancer worldwide and 7.5% of the total number of cancer decreases in women.

The prevalence of cervical cancer of women who were alive after 8 years diagnosed with cervical cancer in 2018 estimate at 1 474 268 worldwide, 190 814 in Europe. In 2018 the collective risk of cervical cancer in women aged less than 75 years was 1.36% globally and 1.09% in Europe.

Botswana

Botswana obligates high rate of cervical cancer due to barriers of cancer screening programs and high HIV frequency. Starting from 2015, girls in schools were vaccinated against Human Papilloma Virus. Approximately 60% people living with HIV are cancer patients. In Botswana, cervical cancer is one of the leading causes of death among women. Between the years 2003 and 2011, 26% was recorded for all cancers among women of which 14% was cervical cancer, and the mean age of women affected by cervical cancer was 52years. According to Tapera.R et al “over 250 000 women in Botswana are in the age group 30-49 years and around 25% of total female population and are at high risk of developing cervical cancer.” Women are at a high possibility of acquiring cervical sarcoma and it will continue to rise until active interventions are put into work.

Risk factors of cervical cancer

Socio-economic factors

Cervical cancer is the most common among women who have low access to health services like (screening cancer). Therefore it put them at risk of be exposed to cervical cancer.

Reproductive and sexual factors

An increased risk of cervical cancer is mostly observed by people with multiple sexual partners hence the increased risk is attributable to an increase of Human papilomavirus (HPV).

Sexually transmitted infections (STIs)

Human papillomavirus (HPV)

These is one of the risk factors for cervical cancer and it is common in people who are affected with HPV once they are sexually active because it is a virus that is mostly diagnosed in some of the sexual transmitted infections (STIs) hence they start sex at an early age and have multiple concurrent partners that put them at a great risk of being infected with HPV.

Most cases of cervical cancer occur as a result of infection with HPV, the infection is usually transmitted by sexual contact which causes progression of squamous cells on the surface of the cervix and they mostly appear after 6months due to immunological intervention. The most prevalence of HPV occurs at the age of 25years, which can be related to sexual behavior and it is also observed at the age of 45years and the permanent infection with the high risk of HPV over time leads to development of the unusual growth of cells on the surface of the cervix that could potentially lead to cervical cancer; cervical intraepithelial neoplasia (CIN).

Oral contraceptives (OC) pills

The usage of combined oral contraceptives method is linked with increased risk of cervical cancer. Women who tend to use OC method than 5years or more can double the risk of cervical cancer.

Immune system deficiency

Women with lower immune systems are at high risk of developing cervical cancer because a lowered immune system can be caused by immune suppression or human deficiency virus (HIV), therefore when a woman is HIV positive her immune system is less able to fight off early cancer.

General factors

Genetics/family history

A female who has had a mother or aunt with cervical cancer is at risk of developing cervical cancer.

Pregnancy

Women who had their pregnancy before 17 years of age have higher chances or possibility of acquiring cervical cancer.

Behavioral factors

Smoking

Smoking may lead to cervical cancer, women who smoke are likely to get cervical cancer because tobacco products have been found in the cervical mucus of women who smoke and these substances harm the Deoxyribonucleic acid (DNA) of the cervix hence contributing to growth of cervical cancer.

Obesity

Due to conversion of androgen to estrogen in the peripheral adipose tissue, obesity especially after menopause it is considered to be increasing sex hormone levels. Therefore obese women are likely to seek screening for cervical cancer; the reasons be that obese women have to delay to receiving services due to their physical image, shame, and lack of willingness to lose weight. Even the technical problems of performing pep smear in obese women such as their anatomy can impact them to seek effective screening, hence be exposed to cervical cancer.

Disease causation (web of causation model)

It is a model that shows the interrelationship of multiple factors that add to the occurrence of a health issue or disease. It is usually used when a disease has no single factor that causes it or if the causes of the disease are interacting in various pathways. The web of causation model seeks to show the relationship between the social, biological, socio-economic, and physical causal processes. Below is the web of causation model showing the causation process of cervical cancer?

(Sexually active) (Pregnancy)(Multi-concurrent partners)(Human immune deficiency syndrome)(Smoking)(Human Papillomavirus)(Cervical cancer) (Obesity) (Lack of exercise)(Lack of access to health services) (Family history & background)

Levels of prevention

Primary prevention

Hpv vaccination

In Botswana the vaccination was introduced in 2015, where 9-13 years old girls in primary schools and those not attending schools were given the HPV vaccine, first dose which is given at first contact with the girl, second dose is administered 2 months after the first dose and third dose which is given 4months after the 2nd dose.

Awareness about cervical cancer

Students are also educated about cervical cancer at schools and ways of preventing themselves from the risk of developing cervical cancer and the health talks are conducted in clinics to raise understanding to the community about cervical cancer

Abstinence from sexual intercourse

Abstaining prevents one from being at risk of developing cervical cancer because the HPV virus which is responsible for formation of cervical cancer is transmitted through sexual intercourse therefore if a girl child or woman is abstaining from sex, the chances of her be at risk are low compared to individual who is sexual active.

Provide contraceptive counseling and services including condom

Women who are sexually active and using condom are at a lesser risk of developing cervical cancer compared to individual who don’t use protection because these condoms prevent them from getting the HPV which cause the cervical cancer.

Secondary prevention

It comprises of screening asymptotic patients or carrying out tests in symphonic or screen-positive patients to pick up precancerous lesions before they cause cancer. Cervical cancer screening involves detection of cancer in women who may not have symptoms and feel fit. Pre-cancerous lesions can be treated and development to cancer can be avoided when detected at an early stage. If it is identified at an early stage there is a high likelihood of it being cured. World Health Organization recently recommends two types of tests which are HPV testing and the Pap smear. Repeated screening is vital for every woman above age of 30 because cancer cells take several years to mature.

In Botswana, the Pap smear is the only available technique for screening of cervical cancer and has been introduced to all government hospitals to make it easily accessible to every client who wishes to do the check-ups for the past 20 years. It is a time consuming technique and there are high chances of loss of follow-up due to waiting a long time for the results. Even though the government has made it easy to do this check-up, they face a challenge of increased mortality rates caused by cervical cancer because patients may not go back to the hospitals to get their results, resulting in them only realizing they are infected at a later/advanced stage.

Tertiary prevention

According to Grover.S et al, “tertiary prevention involves the treating cervical sarcoma after diagnosis. Treatment consists of radiation therapy and chemotherapy rather than surgical procedure because there are no gynecological oncologists in Botswana. Patients who are assumed to have cervical cancer are referred to gynecology for further check-ups.” If the disease advances the government of Botswana refers the patient to take radiation therapy at Gaborone Private Hospital (GPH) at no cost all because it is the only facility in Botswana with the radiation machine.

Surveillance

Facility level

Data can be collected from variety of sources, therefore under facility-level cervical cancer data is collected using a register. Data from medical registry can be used to monitor cervical cancer trends, determine disease patterns, and also to guide planning and evaluation of disease control programs for example to see if whether prevention, screening and treatment of cervical cancer is making a difference or not. For instance in facility-level women are advised to do the cervical cancer screening and girls to take the HPV vaccine in order to prevent the disease hence clinical records, patient interviews can help in interpretation, and analysis of cervical cancer data in order to help in planning, implementation as well as evaluation in public health practice. There is also displaying of cervical cancer pamphlets in IEC corner and information displayed to empower the community with knowledge about cervical cancer.

DHMT level

All facilities are supposed to submit their reports to the district health management team about cervical cancer. DHMTs are responsible for training nurses in health facilities on how to perform Pap smear and they also ensure that they order enough HPV vaccines for the district.

Ministry level

The district health management teams report to the Ministry of Health and the ministry ensures that cervical cancer screening and treatment services are introduced to the public health facilities so that more women can have access to the services. They have to make sure that screening and treatment are done at the best basic infrastructure and by professional personnel; they are also responsible for buying medication and vaccine for cervical cancer, funding of cervical cancer workshop campaigns.

Critique

Limitations

• There is lack of cervical cancer materials therefore these limit people to be equipped with knowledge on how to prevent cervical cancer.
• Loss of skilled personnel to perform Pap smear can be limitation as now screening of cervical cancer will not be done.
• Some of the services of cervical cancer can only be found in urban areas and big villages which limit women who stay in rural areas to access those services.
• Lack of financial resources to do some of the cervical cancer programs and services that prevent cervical cancer.

Strengths

• Involving key stakeholders like women organizations, community-based organizations, government officials, and health workers because cervical cancer prevention programs have to address the factors that determine whether women use screening services and improving accessibility of screening services.
• Implementation of cervical cancer educational services in order to increase the number of women partaking in cervical cancer screening programs.

Recommendation

Government should consider training gynecological oncologists who can perform surgery on patients diagnosed with cervical cancer to remove the tumors from the cervix. It should also ruminate about installing radiation therapy machines in public health facilities, especially referral hospitals.

Conclusion

Cervical cancer is a great concern within the country and worldwide, as it has claimed so many lives and still does. It is the responsibility of women to take care of themselves and also encourage their children to go for Pap smear check-ups regularly.

References

1. Aggarwal P, (October 2014) world journal of clinical oncology, cervical cancer, issue 5 Volume (4) pp: 775–780, available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129540/
2. Denny. L, (2008), international journal of sexual reproductive health and right, prevention of cancer, Available https://www.tandfoline.com>doi>pdf, accessed on the 19 September 2019
3. Grover.S, (2015), cervical cancer in Botswana current state and future steps for screening and treatment programs, Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4630577/
4. Maseko. F, Chirwa. M and Muula. A, 9 January 2018), health systems challenges in cervical cancer prevention. Article in global health action,

1. Chapter 1

1.1. Background of the study

Cancer has emerged to be the 3rd leading killer disease in Kenya after infectious and cardiovascular diseases. Cervical cancer ranks amongst the most frequent cancer among Kenyan women. According to (HPV (Human Papillomavirus) Information Centre, 2018), each year more than 5000 Kenyan women are diagnosed with cervical cancer while more than 3000 die from the disease. Women between the age of 15 to 44 years often become at a risk of contracting cervical cancer, which is about 14.3 million people of the Kenyan population.

Cervical cancer has been most common in developing countries due to increased poverty levels and lack of information. Developed countries have enjoyed little ‘immunity’ over the disease due to extensive resources to aid early detection and prevention. (Rhoydah Mogoi, 2016) Nearly 75% of women in Africa who develop cervical cancer are in the rural settlements. These women often go untreated due to lack of finances and access to medical facilities for screening, and lack of awareness on the symptoms and prevention of the disease.

Information is a key tool in all facets of human existence. The mass media have played a crucial part in mobilization in the fight against diseases that have previously caused unrest among people such as HIV and Malaria. One of the most important controls of cervical cancer is attending regular checks to aid early detection. However, many Kenyan women have little information, hence realize the disease when it is almost late. Cancer has over the past been linked to misconceptions with those having little or no knowledge; some believing it is witchcraft. This lack of relevant information has contributed to ignorance and reluctance by women to visit health centers to ascertain health conditions. Some experience fear that cervical cancer is a disease that would make a woman’s life difficult.

Medical practitioners have also failed in providing relevant information to ease control of the disease (A. Nattembo, 2018). Most women have not realized the ‘real’ causes of cervical cancer. Mass media such as newspapers, social media, TV, and radio stations have been reluctant in delivering relevant information to people. The mass media should play an important role in creating awareness of cervical cancer screening, causes, and risk minimization practices.

1.2. Problem statement

Cervical cancer has contributed to the rise in mortality rate among women in Kenya and globally, yet it is preventable and curable. With poverty rates skyrocketing, victims have fallen into the risk of demise from the malignancy. Most of the women have little or no knowledge of the importance of regular cancer screening. Unfortunately, only about 16% of the Kenyan women populace attend regular cervical cancer screening.

Lack of relevant information among other factors has contributed to the low turnouts of women in the malignancy screening programs. Mass media has been putting minimal effort in “preaching” about cervical cancer; its symptoms, preventive measures, and cure before it goes through stages 3 and 4.

1.3. Objectives

1.3.1. General Objectives

• To help understand the role of mass media in creating awareness of cervical cancer in a bid to minimize mortality rates in Kenya.

1.3.2. Specific Objectives

• To help understand preventive and curative measures to adopt to control cervical cancer by Kenyan women.
• To realize factors that inhibit access of relevant information about cervical cancer and regular screening programs in Kenya.
• To understand influence of print and audiovisual media in facilitating knowledge about cervical cancer by Kenyan women.

1.4. Research questions

The research was guided by the following questions with compliance to the research objectives:

• What are the relevant channels of communication that can be incorporated to ensure information about cervical cancer and screening programs is received by the Kenyan women?
• How informed are Kenyan women who are at risk of developing cervical cancer?
• What is the influence of electronic media in providing information about cervical cancer to Kenyan women?
• What are the key issues that undermine access to relevant information about cervical cancer by Kenyan women seeking reproductive services?

1.5. Significance of the research

Over the past years, cervical cancer has brought some worrisome trends. At least 5250 new cases of cervical cancer are realized in Kenya each year (HPV Information Centre, 2018). According to statistics performed by HPV Information Centre, annually, more than 3000 deaths are experienced due to cervical cancer in Kenya.

The research was conducted to analyze the influence that mass media impacts on its audience as a way of providing a solution to the epidemic. With the large audience enjoyed by the audiovisual and print media, they have an obligation to turn things round. So far very little effort has been put by the mass media in establishing educational campaigns against cervical cancer morbidity. Media corporations were targeted by the researcher as they have control over what information is shared on their platforms.

The research was relevant in that the results would help medical institutions and practitioners in understanding better methods of passing out health information to the mass. It would help government agencies understand the weight and collective impact of the epidemic to the state’s economy.

1.6. Scope of the research

The study was conducted in Embakasi Central, Nairobi county. The researcher obtained data from 21 women aged between 15-45 years. The main aim was to analyze the role played by mass media in sensitization of Kenyan women about cervical cancer. The researcher incorporated two theories; limited-effects and class-dominant theory. The class dominant theory shows the control of mass media by corporations and their influence on the type of information aired in stations. The limited-effects theory shows the power of the media to influence decisions of the less informed.

The study focused on various factors that hindered access to information and how Kenyan women perceive importance of knowledge of health information. The research questions aimed at understanding the most appropriate channels of communication that Kenyan women preferred. This was to help the medics on how best to relay information to the users.

1.7. Limitations and delimitations of the study

The research was accompanied by several setbacks, i.e. the data collection process took longer than was expected to due to legal frameworks that were to be followed. Obtaining a permit letter from the area chief to conduct the study took 3 days which was much time in relation to the research time frame. However, the researcher managed to abide by the regulations.

Data collection from the target populace was so tiring as most were unwilling to offer information. Some women would ask for a “little tip” in order to fill in the questionnaires. The whole data collection process was gruesome and required patience for the researcher to get relevant and adequate information. The process was always in suspense whenever respondents felt to perform their personal duties. Therefore, the researcher hustled to get most of the data within the shortest time available.

2. Chapter 2

2.1. Literature review

2.1.1. Introduction

The chapter reviews the literature about the relevance of mass media as a tool used in sensitization of women about cervical cancer; its symptoms, effects, and preventive mechanisms.

Mass media is a type of communication level that reaches a large audience whether in written, oral, or broadcast form. Forms of mass communication include television, radio, newspapers, magazines, the Internet, billboards, posters, and so many others. Mass media plays a great role in connecting multitudes in different geographical situations by sharing common networks.

The literature identified two important theories that would shed light on role of the mass media in the minimization of cervical cancer morbidity: limited-effects theory and class dominant theory.

According to Paul Lazarsfeld’s limited-effects theory of media effects, the media rarely influences decisions made by individuals. However, the propaganda spread directly affects socially isolated –those with little access to information.

Advocates of class dominant theory argued that media is controlled by a few elites who then determine what information is shared. Therefore, it implied that the few elites could help create awareness of cervical cancer.

2.1.2. Causes of cervical cancer

Researchers have shown that cervical cancer occurs when cervical cells grow abnormally hence invading other tissues of the feminine body. The invasive nature of cervical cancer hence affects deeper tissues of the cervix which may lead to spreading to other parts of the body. Study has shown that cervical malignancy develops slowly hence its progression has provided chances for prevention and treatment through early detection. The researcher has focused the study in encouraging the mass media to enhance awareness to promote early detection of cervical cancer. Studies have also shown sexually active women to be in high risks of developing cervical activities due to increased hormonal activities.

The risk of developing cervical cancer is associated by infection by HPV. However, some factors such as early exposure to sex, multiple sexual partners, and use of birth control pills increase chances of exposure to HPV. Research has shown different forms of HPV to cause different biological changes in different body tissues which eventually may lead to cancer development.

Men have also played a part in causing cervical cancer in women. Research has shown that unprotected sex especially with uncircumcised males has led to greater exposure to HPV. In Kenya, 15% of males aged between 15-65years have not been circumcised.

Cigarette smoking has also been identified as another factor that causes cervical cancer. The chemicals in the cigarette smoke react with cervical cells hence causing cancerous changes.

2.1.3. Factors that undermine decrease of cervical cancer prevalence

There have been a lot of mythologies and mistaken beliefs that have hindered success in the fight against cervical cancer. These myths prompt off-beam decisions as they rely on fabricated sources of information, especially gossip and rumors. For instance, many women have believed that cervical cancer is equivalent to death sentence. Therefore, to avoid mental stress, these women stay away from cervical cancer screening programs. It is until so late that they show up for screening when the malignancy has developed to several stages, hopelessly curable.

Another key factor is the shortage of facilities required to treat cancer in Kenya. Most victims in Kenya are diagnosed at the advanced levels of the epidemic compared to victims in developed countries such as the United States of America. As a result, cervical cancer mortality rates skyrocket.

Social vices like rapes, prostitution and multiple marriages, and cohabitation have also contributed to cervical cancer prevalence in Kenya. These acts have contributed to the transmission of HPV. According to the United Nations Commission on the Status of Women, 35 percent of women worldwide have experienced sexual injustice by a non-partner in some point in life (UNDP, 2018). Approximately 700 million living women, were married as children. This was the focus of the research as the public ought to know contributions of early marriages in development of malignancy.

Geographical factors such as access to health centers has also contributed to increased prevalence of cervical cancer among Kenyan women. Mostly affected are women living in rural and rustic areas who have lacked means of access to health centers due to poor infrastructure and lack of finances.

2.1.4. Cervical cancer in Kenya

Statistics have shown that a total population of 14.3 million women in Kenya are at a risk of developing cervical cancer. With the poor use of mass media communication and lack of policies and strategies put in place to facilitate early detection of HPV in women, the mortality rates through cervical cancer should be expected to rise if corrective measures are not put in place. Nearly 30% of Kenyan young adults have had sex by the age of 15. Some of which have had little knowledge of protective sex hence they facilitate spread of cancer-causing HPV.

2.1.5. Global statistics regarding cervical cancer

Cervical cancer has been prevalent in many developing countries as they are inhabited by low-income women. HPV has been established to be the main cause of cervical cancer. For instance, HPV 16 and 18 have been found to cause around 70-75% of all cancer types.

The highest rates of cases of cervical cancer have been observed in sub-Saharan Africa, and Central and South America. In 2012, nearly 520,000 women were diagnosed of cervical cancer. In the same year, about 260,000 deaths were observed worldwide of cervical cancer, most of which were due to lack of screening programs. Unfortunately, 90% of these deaths occurred in the developing countries. This has shown that implementation of screening programs has not been well done in the developing countries (Nwabichie et al, 2017).

3. Chapter 3: research methodology

3.1. Introduction

Research methodology is the process used to collect information and data for the purpose of making research decisions. The methodology may include publication research, interviews, surveys, and other research techniques, and could include both present and historical information. This methodology involves the population to be studied, the research design, the sampling strategy, the process of data collection, data gathering tools, data analysis, and data presentation.

3.2. Research Design

The research design refers to the overall strategy that you choose to integrate the different components of the research in a coherent and logical way, thereby, ensuring you will effectively address the research problem; it constitutes the blueprint for the collection, measurement, and analysis of data. The research problem determines the type of design you should use.in our case, we used the descriptive design this research designs help provide answers to the questions of who, what, when, where, and how associated with a particular research problem; a descriptive research cannot conclusively ascertain answers to why. Descriptive research is used to obtain information concerning the current status of the phenomena and to describe ‘what exists with respect to variables or conditions in a situation.

3.3. Target population

This is the entire set of units for which the survey data are to be used to make inferences. Thus, the target population defines those units for which the findings of the survey are meant to generalize. Establishing research objectives is the first step in designing a survey. Defining the target population should be the second step. The researcher targeted women between the age of 15-44 years in Nairobi County.

3.4. Sample Design

A sample design is made up of two elements. Random sampling from a finite population refers to that method of sample selection which gives each possible sample combination an equal probability of being picked up and each item in the entire population to have an equal chance of being included in the sample. This applies to sampling without replacement i.e., once an item is selected for the sample, it cannot appear in the sample again.

3.5. Data Collection Instrument and Procedures

Data collection in research is the primary objective in the completion of a research, the method used was through the distribution of questionnaires. This enabled collection of vital data directly from respondents. Interviews were also being conducted to ensure accuracy, clarity, immediate feedback, and in revealing sensitive data. The method is advantageous because of its direct feedback to the researcher, clarifies certain questions or instructions by the interviewer, probing answers by asking the respondents to clarify their specific responses. The interviewer also supplemented the answers by including their observations.

The questionnaire was divided into four sections: The first part was designed to analyze demographic data, which focused on collecting the respondents’ personality characteristics other personal details to understand the person filling the questionnaires. The second part consisted of questions that were based on the identification of the working environment and how the respondents were affected by it.

The third part of the questionnaire looked at training and development of the respondents. Section four of the questionnaire assessed the impact of the company’s image and reputation. This section consisted of questions with five multiple-choice options for each question, representing different opinions. Pilot research was conducted to test the validity and reliability of the questionnaires. The results of the pilot research were however not included in the final report.

3.6. Data Analysis Methods

Data was collected via questionnaires. SPSS software was used to analyze collected data from multiple respondents in different parts of Nairobi. Descriptive analysis was used to provide the general characteristics of the research population through generating frequency tables, mean, and ranges. The analyzed data was presented via pie charts, graphs, and use of tables which was used to summarize the collected data.

3.7. Research Limitation

The research is limited to one organization and cannot be applied to other similar organizations. Some of the respondents were not free to give some information due to privacy and confidentiality furthermore; respondents may have also given biased information to protect their personal reputation.

Permission was sought from the local area chief before conducting the research. A letter from the institution was also included to indicate the academic purpose of the research, and reassure the maintenance of respondents’ privacy and confidentiality.

3.8. Research ethics

Participation was voluntary through informed consent from the individual respondents. Permission was sought from the local area chief before conducting the data collection exercise.

Acknowledgment was properly made to other people’s work and referenced accordingly in accordance with the requirements. No services of any professional agencies was sought to produce this work except for the data collection and in which only the organization under research was sought. No part or parts of this research shall be used for any purposes other than academic purposes.

3.9. Chapter Summary

This chapter has presented the research methodology that was used in analyzing the research questions. The research population consisted of randomly selected women in Nairobi. The sample size for this research was 15 respondents. The research relied entirely on primary data which was collected from the respondents using a structured questionnaire. Descriptive analysis was used to analyze the results of the research. The results and findings of this research are presented in chapter four.

References

1. Influence of Electronic Media in Creating Cervical Cancer Awareness among Women Seeking Reproductive Health Services at the Kenyatta National Hospital Nairobi, Kenya –Mogoi Ochieng’I Nyambane, Rhoydah (2016).
2. Role of print and audiovisual media in cervical cancer prevention in Bangladesh –Department of Obstetrics and Gynecology, Bangabandhu Sheikh Mujib Medical University, Bangladesh (2013).
3. ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in Kenya –Bruni L, Albero G, Serrano B, Mena M, Gómez D, Muñoz J, Bosch FX, de Sanjosé S (2018).
4. Attitudes, knowledge and perceptions towards cervical cancer messages among female university students –Anne Nattembo (2018).
5. Global Burden of Cervical Cancer: A Literature Review –Nwabichie Chinemerem Cecilia1, Rosliza A.M.*2, Suriani I.2 (2017).
6. The Weinstein Effect –http://www.ke.undp.org/content/kenya/en/home/blog/2017/the-weinstein-effect–the-global-scourge-of-sexual-harassment.html

Abstract:

This paper presents the Chicken Swarm Optimization algorithm for feature selection, which can be used for the prediction of cervical cancer. Cervical Cancer is the type of cancer that occurs at the cells of the cervix – the lower part of the uterus that connects to the vagina. Various strains of the human papillomavirus (HPV), a sexually transmitted infection, play a role in causing most cervical cancer. When exposed to HPV, a woman’s immune system typically prevents the virus from doing harm. In a small group of women, however, the virus survives for years, contributing to the process that causes some cells on the surface of the cervix to become cancer cells. Anyone can reduce the risk of cervical cancer by having screening tests and receiving a vaccine that protects against HPV infection. Feature Selection is a type of optimization algorithm and plays a vital role in the field of Machine Learning. In recent years there has been an exponential increase in the amount of data available for processing in Machine Learning problems. So, the Feature Selection was introduced to solve this problem. Feature Selection is used when there is a need to eliminate such redundant features so that a better subset of features can be obtained which helps in reducing the dimensionality of a dataset. The Chicken Swarm Optimization Algorithm is a new bio-inspired optimization technique, which is proposed for feature selection for prediction of cervical cancer. Impersonating the hierarchical order in the chicken swarm, which includes roosters, hens, and chicks. CSO can productively extricate the chickens’ swarm intelligence to optimize problems. CSO has the ability to attain exceptional optimization results in terms of optimization accuracy. In CSO the chicken swarm is divided into various sets or groups, which consist of a single rooster and a number of hens and chicks. Different chickens follow various kinds of motion. There exists competition amongst various chickens under specific hierarchical order.

Keywords: Cervical Cancer, Chicken Swarm Optimization, Feature Selection, Machine Learning, Evolutionary Algorithms, Classification, Nature Inspired;

1. Introduction

Cancer starts when cells in the body begin to grow out of control. Cells in nearly any part of the body begin to grow out of control. Cervical cancer starts in the cells lining the cervix – the lower part of the uterus (womb). The cervix is a part, which connects the body of the uterus to the vagina. Most cervical cancers are squamous cell cancers. Cervical cancer tends to occur during midlife [1]. It is most frequently diagnosed in women between the ages of 35 and 44. It rarely affects women under the age of twenty, and more than 15 percent of diagnoses are made in women older than 65 [2]. Early-stage cervical cancer generally produces no signs or symptoms but the signs of symptoms of more advanced cervical cancer may include pelvic pain, vaginal bleeding, or watery, bloody vaginal discharge that may be heavy and have a foul odor. It isn’t clear what causes cervical cancer, but it’s certain that HPV plays a role. HPV is very common, and most women with the virus never develop cervical cancer. This means other factors- such as your environment or your lifestyle factors also determine whether a person will develop cervical cancer [3].

Feature Selection aka variable selection is one of the core concepts in the field of Machine Learning which can hugely impact the performance of a model. The data features that we use to train our models have a great impact on the performance the model can achieve. Irrelevant or partially relevant features can negatively impact the performance of our model. So, the Feature selection should be the first and foremost step of any machine learning model design. Feature Selection is the process where you automatically or manually select those features which contribute most to our prediction variable or the output [4]. For the past few years, data is increasing day by day which in turn is introducing many problems along with it. Bigger data is more prone to noise, which needs to be treated because, if not, it could result in the decreased performance on the result. This is where feature selection comes into play. Feature selection reduces the computational cost of the model as well as the complexity of the dataset. Feature selection can be categorized in filter wrapper and embedded methods.

The evolutionary strategy is a scalable alternative to reinforcement learning. Evolutionary strategies, being less efficient than RL, offer many benefits. Evolutionary strategies can be defined as an algorithm that provides the user with a set of candidate solutions to evaluate a problem. The evaluation is based on an objective function that takes a given solution and returns a single fitness value. Based on the fitness results of the current solutions, the algorithm will then produce the next generation of candidate solutions that are more likely to produce even better results than the current generation. The iterative process will stop once the best-known solutions are satisfactory for the user [6].

A new bio-inspired algorithm, Chicken Swarm Optimization (CSO), is proposed for optimization applications. In the chicken swarm there exist, several groups, each group comprises a dominant rooster, a couple of hens, and chicks. Divide the chicken swarm and determining the identity of the chickens all depends on the fitness values of the chicken themselves. The chicken with best several fitness values would be acted as roosters, each of which would be the head rooster in the group. The chicken with worst several fitness values would be designated as chicks. The other would be the hen. The hens randomly choose which group to live in. The mother-child relationship between the hens and chicks is also randomly established.

• Chicken Swarm Optimisation feature extraction algorithm has been discussed.
• Chicken Swarm Optimisation is used as a search strategy to find optimal features.
• Random Forest and K-nearest neighbors are used to evaluate the quality of the selected features.
• We would like to underline that the main goal of proposing and implementing the chicken swarm optimization is to keep it as easy, simple, and understandable as possible.
• To evaluate the result, we have used two different classifiers (i) k-nearest neighbors (k-NN) and (ii) Random Forest.

The elucidation of the paper is as follows. The background study is explained under Section 2. The proposed method is discussed under Section 3. Results are discussed in section 4. Comparisons have been done in section 5 and finally, Section 6 concludes the work with future scope.

2. Background

2.1 Machine Learning Methods

In 2007, Muhammed Fahri Unlersen, Kadir Sabanci, Muciz Ozcan [1] proposed machine learning methods namely KNN and MLP for the prediction of the feature selection for determining the cervical cancer possibility. In it the two famous machine learning methods with best performances have been presented. These algorithms can be defined as:

2.1.1 K-Nearest Neighbours:

KNN is a non-parametric algorithm method used for the classification and the regression of the data. In both regression and classification, the input is the k closest training examples in the feature space [6]. As in the [5] KNN method is applied for the determination of the cervical cancer and the numbers of the neighbors are changed from 1 to 90.

Algorithm 1: (K-Nearest Neighbours (KNN)).

1. Let k be the number of nearest neighbors and S be the set of training sets.
2. For each point in the S:
3. 2.1 Calculate the distance between the current point ant the chosen point from the S.
4. 2.2 Store the distance to the ordered set.
5. Sort the ordered set of distances in ascending order of the distances.
6. Select the first k entries from the sorted list.
7. Get the labels of these entries.
8. If the type is regression, return the mean of the selected k labels.
9. If the type is classification, return the mode of the selected k labels

Fig. 1 Explaining the kNN algorithm.

2.1.2 Multilayer Perceptron:

The multilayer perceptron is the class of feedforward artificial neural networks. A MultiLayer Perceptron at minimum consists of 3 layers of nodes: input layer, hidden layer, and the output layer. Except for the input layer, each node is a neuron that uses a non-linear activation function [7]. As in the [5] MLP method is applied for the determination of the cervical cancer and had been investigated that presenting how many neurons in the hidden layer presents the best result.

Algorithm 2: (MultiLayer Perceptron (MLP)).

1. for all inputs neurons j do
2. set aj = xj
3. end for
4. for all hidden layers and output neurons j in topological order do
5. set netj = wjo + sum( k∈ Pred(j) wjkak)
6. set aj = flog(netj)
7. end for
8. for all output neuron j do
9. assemble aj in output vector y
10. end for
11. return y

Fig. 2 MultiLayer Perceptron

2.2 Feature Selection:

Feature Selection aka variable selection is one of the core concepts in the field of Machine Learning which can hugely impact the performance of a model. The data features that we use to train our models have a great impact on the performance the model can achieve. Irrelevant or partially relevant features can negatively impact performance of our model. So, the Feature selection should be the first and foremost step of any machine learning model design. Feature Selection is the process where you automatically or manually select those features which contribute most to our prediction variable or the output [4]. For the past few years, data is increasing day by day which in turn is introducing many problems along with it. Bigger data is more prone to noise which needs to be treated because if not, it could result in the decreased performance on the result. This is where feature selection comes into play. Feature selection reduces the computational cost of the model as well as the complexity of the dataset. Feature selection can be categorized in filter wrapper and embedded methods.

3. Methodology

3.1 Proposed chicken Swarm optimization

The voguish Chicken Swarm Optimization has been applied to the Publicly available Cervical Cancer (Risk Factors) dataset to optimize the problem of feature selection and detect the occurrence of the disease at its early age. It has been used for feature selection tasks. Two famous machine learning methods kNN & MLP [5] have been compared and also compared with the various algorithms from paper [8]. The performance of the proposed algorithm has been using two machine learning models, kNN & RandomForest. This implementation has been carried out using Python and its libraries.

Algorithm: Chicken Swarm Optimisation (CSO)

Ayush algorithm and flow chart

The flowchart of the CSO has been demonstrated in the Figure. 3

3.2 Implementation of the proposed method

In this section, the experimental setups, parameters, datasets & implementation of the proposed approach has been discussed.

3.2.1 Experimantal Setup

Ayush

3.2.2 Parameters

CSO contains six parameters. As chicken is primarily considered only as a food source and only hen lays eggs, which is also a source of food. That’s why keeping hens are more favorable for humans. Thus hen parameter would be greater than the Rooste parameter. Considering individual differences, not all the hens would be laying their eggs at the same time, that’s why Hen parameter will also be bigger than mother hen parameter. Also, we assume that the adult chicken population would surpass that of the chicks i.e. the chick parameter. Now the for the value of the swarm it should neither be too big nor be too small after many tests the value between 5 to 30 would generate the best results.

3.2.3 Dataset

The dataset i.e. Cervical Cancer (Risk Factors) Dataset is publicly available at the machine learning repository [9]. The dataset was collected at ‘Hospital Universitario de Caracas’ in Caracas, Venezuela. The dataset comprises demographic information, habits, and historic medical records of 858 patients. Several patients decided not to answer some of the questions because of privacy concerns (missing values). This dataset focuses on the prediction of the indicators/diagnosis of cervical cancer. The features cover demographic information, habits, and historic medical records best suited for the prediction of cervical cancer at its early ages. The characteristics of the dataset are:

• Data Set Characteristics: Multivariate
• Attribute Characteristics: Integer, Real
• Associated Tasks: Classification
• No. Of Instances: 858
• No. Of Attributes: 36
• Missing Values? : Yes
• Area – Life

3.3.4 Implementation

Ayush

4. Results And Discussions

The proposed Chicken Swarm Optimization Method has been applied to the selected Cervical Cancer (Risk Factors) Dataset and the results calculated are discussed in this section.

5. Comparison

In this Section, the proposed Chicken Swarm Optimization has been compared with the two different studies made on the Detection Of Cervical Cancer. Both of these studies are:

In 2018 Yasha Singh, Dhruv Shrivatsva, P.S.Chand, and Dr. Surrinder Singh has proposed a paper [8] in which they have compared the various algorithms for the screening of Cervical Cancer in the recent times in the chronological order. The comparison of this study has been shown in Fig. 4. In 2007, Muhammed Fahri Unlersen, Kadir Sabanci, Muciz Ozcan [1] proposed machine learning methods namely KNN and MLP for the prediction of the feature selection for determining the cervical cancer possibility. This comparison has been shown in the Fig. 5.

Fig. 4 Accuracy Comparison with other algorithms in study shown in [8]

Fig. 5 Accuracy Comparison with other algorithms in study shown in [9]

The proposed Chicken Swarm Optimisation shows the best accuracy of 99.53% in the feature selection from the Cervical Cancer (Risk Factors) dataset [8] with very fast computational time of few seconds.

The proposed Chicken Swarm Optimisation clearly outperforms kNN and MLP algorithm. Also, it also outperforms all the algorithms shown in Fig. 5. We can also infer that the Chicken Swarm Optimisation algorithm outperforms the other algorithms in feature selection without harming the accuracy in the original result. Thus, it is claimed that the feature selection using the Chicken Swarm Optimisation algorithm can be used at various practical applications and play a very significant role in the detection of the cervical cancer at the earlier stage

6. Conclusions And Future Works:

In this work, chicken swarm optimization algorithm for feature selection has been proposed. Chicken Swarm Optimisation algorithm has been proposed to get the minimized set of features and determine the comparative accuracy and the computational time without degrading the performances. The dataset discussed in Section 3.2.3 is applied in the CSO. The proposed algorithm has selected fewer features with higher accuracy of 99.53% as compared to any other algorithms. The result shows the proposed Chicken Swarm Algorithm has outperformed other feature selection algorithms. Researchers can apply the proposed algorithm for the feature selection and use it for early detection of Cervical Cancer.

In this paper, the cervical dataset has been used. The Cervical dataset can also be used for various Feature selection methods upcoming in future and it is also used to detect and prevent the early stages of cervical cancer.

Chicken swarm optimization is a very fast optimization algorithm. CSO has the ability to attain exceptional optimization results in terms of optimization accuracy. CSO can be applied for various other feature selection datasets as it can achieve good optimization in terms of accuracy as well as robustness.

Feature Selection i.e. Validation Selection is used when there is a need to eliminate redundant features so that a better subset of features can be obtained which helps in reducing the dimensionality of a dataset.

References:

1. Cervical Cancer: https://www.cancer.org/cancer/cervical-cancer/about/what-is-cervical-cancer.html
2. Occurrences http://www.nccc-online.org/hpvcervical-cancer/cervical-cancer-overview/
3. Causes and symptoms https://www.mayoclinic.org/diseases-conditions/cervical-cancer/symptoms-causes/syc-20352501
4. Feature Selection https://towardsdatascience.com/feature-selection-techniques-in-machine-learning-with-python-f24e7da3f36e
5. Evolutionary strategy http://blog.otoro.net/2017/10/29/visual-evolution-strategies/
6. Chicken Swarm Optimization https://www.researchgate.net/publication/278691165_A_New_Bio-inspired_Algorithm_Chicken_Swarm_Optimization
7. https://www.cancer.org/cancer/cervical-cancer/about/what-is-cervical-cancer.html
8. KNN: https://en.wikipedia.org/wiki/K-nearest_neighbors_algorithm
9. MLP: http://ml.informatik.uni-freiburg.de/former/_media/documents/teaching/ss09/ml/mlps.pdf
10. https://arxiv.org/pdf/1811.00849.pdf
11. Cervical cancer Dataset https://archive.ics.uci.edu/ml/datasets/Cervical+cancer+%28Risk+Factors%29

Introduction to public health assignment

Background

According to the WORLD HEALTH ORGANISATION (WHO), the world is facing many global threats or challenges which range from the outbreak of diseases, environmental effects like global warming which lead to climate change as well as non-communicable diseases like obesity and cancer.

Our group will focus on one of this threats namely cervical cancer which is a non-communicable disease (NCD). Non-communicable diseases are chronic conditions that progress slowly and share common behavioral risk factors including tobacco use, excessive alcohol consumption, and lack of physical activity or an unhealthy diet. Whilst people tend to think of non-communicable diseases as diseases of the elderly, this phenomenon is not exactly true for countries struggling economically or developing and undeveloped countries. According to the World Health Organization (WHO) studies conclude that countries with fragile health systems, particularly in low to middle-income countries (LMICs), account for 80 percent of NCD-related deaths.

What is cervical cancer?

Cancer is the rapid multiplication of cells which can result in tumors, damage to the immune system, and other fatal impairments. Cervical cancer is a type of cancer that starts in the cervix (opening of the uterus) which can invade or spread to other parts of the body.

According to Michigan Medicine Doctor Diana Harper, most cervical cancer starts with normal cells that develop into pre-cancerous changes. Several terms are used to describe these pre-cancerous changes including:

• Cervical Intraepithelial Neoplastic (CIN)
• Squamous Intraepithelial Lesion(SIL)
• Dysplasia

Doctor Harper also states that these pre-cancerous changes can be detected with a Pap smear. With early detection cervical cancer is easily treatable.

Causes and Risk Factors of cervical cancer include:

Smoking- The chemicals in cigarette smoke interact with the cells of the cervix(these harmful substances are absorbed by the lungs and carried in the bloodstream throughout the body, that is how they reach the cervix), causing precancerous changes that may-overtime- progress to cancer. Women who smoke are about twice as likely as nonsmokers to get cervical cancer. Smoking weakens the immune system, that is, they make the immune system less effective in fighting HPV infections

Prolonged use of contraceptives- contraceptives like a pill and the loop can cause impairments to the cervix if used continuously hence contributing to cancerous or pre-cancerous changes in the cervix.

Human Papilloma Virus (HPV)-HPV have been shown to lead to many of the changes in cervical cells and genetic material that comes from certain forms of HPV has been found in cervical tissues that show cancerous or precancerous changes. This is why HPV is known as a common factor that leads to cancer in the cervix.

Having many sexual partners- increases the risk of being infected or re-infected with HPV which is the main cause of cervical cancer.

Engaging in early sexual activities-girls who engage in early sexual activities are at a high risk of developing cervical cancer because their bodies are still developing and hormonal imbalances can also aggravate the precancerous changes if exposed to HPV.

The disease itself is not contagious but the risk factor, HPV, is the one that is transmitted from one person to another. Both men and women may carry it and is usually transmitted through sexual intercourse. An Article by Mayo Clinic mentions that when exposed to HPV, the body’s immune system typically prevents the virus from doing harm. Furthermore, the virus can survive for years in the body in a small percentage of people, and this contributes to the process that causes some cervical cells to become cancer cells. Another article on cervical cancer and HIV-two diseases, one response by UNAIDS says cervical cancer is highly prevalent in women living with HIV because they are 4-5 times more likely to develop pre-cancerous changes if they have HPV.

In the early stages, one may not bear any signs or symptoms of cervical cancer, but with time one may notice the following:

• Abnormal vaginal bleeding
• Increased vaginal discharge
• Bleeding after going through menopause
• Pain during sex pelvic pain

Cervical cancer is a global public health concern which has left organizations and private institutions fighting enormously to prevent and minimize the number of causalities or victims. Over3 00 000 women die of cervical cancer each year. Nine in 10 women who die from cervical cancer are in poor countries. Over 500 000 cases are registered each year. More than 85 percent of cervical cancer fatalities are from low and middle-income countries. In Sub-Saharan countries, cervical cancer accounts for about 15% of all cancers. Within Botswana cervical cancer is the leading cause of cancer death. More than two-thirds of cases occur in HIV-infected women with a national prevalence of 17-24%

Practical setting in botswana

In Botswana, about 60% of cancer patients are HIV positive, most present with advanced cervical disease e.g. cervicitis (the inflammation of the cervix) and cervical polyps and cysts (abnormal growths on the cervix). HIV-positive women in Botswana who are symptom-free at initial screening may be lost to essential future screening and follow-up care without greater targeted communication regarding cervical cancer and the importance of regular screening. Challenges remain such as delays in treatment, lack of trained human personnel, limited follow-up care, and little patient education. Between 2003 and 2011, cervical cancer accounted for 14% of all cancers in Botswana and 26% of all the cancers in women. Over 250,000 women in Botswana are in the age group 30-49 years which is about 25% of total female population and they are thus at high risk of developing cervical cancer. Among this subject of women, the HIV prevalence rate approaches 50%. The number of women at risk of cervical cancer will continue to grow until effective primary prevention efforts are established. Botswana is a middle-income country; it does not have advanced technology and skilled health professions for cervical cancer.

The ministry of health and various strategic partnerships strive to treat pre-invasive and invasive cancer, they came up with the see and treat program which is expanding through the country. They also came up with vaccination of school girls and women for the Human Papilloma Virus from 2015 as a way of minimizing the risks of cervical cancer. The ministry continues to educate people about cervical cancer and ways of modifying risk factors and has also availed the services of Pap smear in most of the local clinics and 40% of women tend to keep their follow-up appointments. Findings suggest that women treated at a first visit or referred for additional treatment due to the presence of more advanced diseases had more than doubled the odds of adhering to follow-up appointments compared to women with negative screens. Factors such as age, education, income, and marital status that have been shown elsewhere to be important predictors of adherence tend to be insignificant in Botswana.

Most of cervical cancer risk factors are lifestyle-related which makes it a preventable disease when treated on its early stages. Cervical cancer can be preventable by modification of risk factors and through health promotion and education. Even though cervical cancer can be treated, several deaths still occur due to late diagnosis early and lack of access to the life-saving treatment they need. In May 2018, WHO Director-General, Dr. Tedros made a worldwide call for action toward elimination towards cervical cancer, and to archive this, innovative strategies and technologies are needed and must be used to archive zero woman death due to cervical cancer. There are 2 main interventions that have been put forth to help prevent and treat cervical cancer.

Protective interventions

These are procedures aimed at preventing people from getting cancer. One of this interventions are;

• Vaccination of woman and children against HPV

Vaccines are available to protect young people against HPV infections that are commonly linked to cancer. They only work to prevent the HPV infections. They do not treat an infection that already exists, for the vaccines to be more effective they should be given before a person is exposed to HPV. They also prevent pre-cancers and cancers of the cervix.

• Screening-The check-up of the body for cancer before experiencing the symptoms. This is usually done after every three years. Screening is commonly done in two ways;
• -PAP Smear
• -HPV test pap smear

This is a routine procedure for testing cervical cancer. In this procedure, a health practitioner scrapes and brushes cervical cells which are then examined for abnormal growth. A PAP SMEAR can detect cancerous cells in the cervix or cells that show changes which speed the progression of the cancer. Women who are HIV positive or those that have a weakened immune system from various conditions are advised to have frequent tests.

• HPV test

In this test, cells which have been collected from the cervix are tested for infections with any of the types of HPV which usually leads to cancer. It can also be done with a Pap smear that is called co-testing.

Clinical interventions

These are procedures done to people who have already been diagnosed with cancer to help treat or cure cancer. They include;

• Radiotherapy
• Chemotherapy
• Surgery

CHEMOTHERAPY –This is a type of cancer treatment that uses one or more anticancer drugs as part of a standardized chemotherapy regimen. Chemotherapy may be given with a curative intent or it may aim to prolong life or to reduce symptoms.

SEE AND TREAT PROGRAM-This is a mode of cervical cancer screening which relies on visual test, making it simple, affordable, and sizeable to primary health care facilities in areas where modern laboratory infrastructure is unavailable or inaccessible. Since the results are available immediately, diagnosis and or treatment can be offered at the time of screening, minimizing follow-ups and losses.

SURGERY- this is where an infected part is removed. It is usually done in three ways;

• Cryosurgery- a very cold metal probe is placed directly on the cervix. This kills the abnormal cells by freezing them.
• Laser surgery- A focused laser beam, directed through the vagina, and is used to vaporize (burn off) abnormal cells or to remove a small piece of tissue for study
• Conisation- a cone-shaped piece of tissue is removed from the cervix, this is done using a surgical or laser knife (cold knife cone biopsy) or using a thin wire heated by electricity (the loop electrosurgical, LEEP or LEETZ procedure).

NB: Like any other medicine, most clinical interventions have side effects like; loss of appetite, hair loss, weight loss, and diarrhea above all. These side effects are preventable and most will pass once treatment stops.

Key indicators

Interventions are made to solve the issue of concern which in this case is cervical cancer. To monitor or check if this solutions or interventions are making a good impact on addressing the problem, we look at the following key indicators;

1. Decrease in number of women dying of cervical cancer.
2. Increase in women coming for see and treat and screening of cervical cancer.
3. Increase in number of cervical cancer survivors after being treated with radiotherapy and chemotherapy.
4. Increase in women who are eager about ways in which they can treat or prevent cervical cancer and also students in universities who want to study gynecology.
5. Decrease in new diagnoses of cervical cancer

References

1. www.who.int.news-room/fact-sheets/detail/noncommunicable-diseases
2. https://www.who.int>topics>cancers
3. https://www.ncbi.nlm.nih-gov>pmc
4. www.worldatlas.com
5. Biomedcentral.com/submissions Cancer. Net-Editorial-Board

Cancer research UK

1. Macmillan Cancer Support 2019

Health Issue

Before Malawi gained independence in 1964, it was colonized under Great Britain as a British protectorate called Nyasaland in 1907. In the 1950s, neighboring Rhodesia and Northern Rhodesia, now Zimbabwe and Zambia, respectively, had a much larger European population that was in favor of merging the three nations into one. Nyasaland resisted this union due to the higher proportion of Europeans in the other nations that would overshadow Nyasaland’s indigenous leadership. Despite resistance, the nations were joined in 1953, but after backlash from Africans in Northern Rhodesia and Nyasaland, all three nations were granted independence from Britain in 1963. After it gained independence Malawi was one of the poorest countries in the world. Civil war in neighboring Mozambique and periods of drought further challenged the country’s economic growth. In 2006, the country was pardoned from its structural adjustment loans which resulted in slight economic growth but with a heavily agriculture-dependent economy and loss of workers from HIV/AIDS, economic growth was reduced (The Commonwealth, 2019)

Cervical cancer is the most common form of cancer amongst women in Malawi, affecting 40% of the country’s female population. With 84% of the country’s population living in rural areas, accurate surveillance of the disease is difficult, but the International Agency for Research on Cancer’s (IARC) GLOBOCAN program reports an incidence rate of 75.9 individuals for every 100,000 individuals and the Malawi Cancer Registry reports a cervical cancer mortality rate of 49.8 individuals for every 100,000 individuals. Both the incidence and mortality rate of cervical cancer in Malawi is the highest across the globe. Furthermore, the five-year survival rate of the disease in Malawi is only 2.9% compared to 26.5% in Zimbabwe, and 68% in United States (Rudd et al. 2017). Other health metrics indicative of Malawi’s healthcare status is the maternal mortality rate of 684 per 100,000 live births and the infant mortality rate of 38.5 per 1,000 live births. Comparatively, the U.S. the maternal mortality rate is 18 per 100,000 live births and infant mortality rate is 5.9 per 1000 live births (Center for Disease Control, 2016).

Malawi has a three-tier healthcare system. The primary tier consists of community health centers and maternity units. The secondary tier consists of district hospitals which receive referrals from the primary tier community hospitals and provide more specialized services including diagnostic and laboratory testing. The tertiary tier provides highly specialized services for certain diseases. Healthcare is delivered through both the public and private sectors, with private sector non-governmental organizations providing many services at the primary level (African Health Observatory, 2018). The country is divided into twenty-nine districts, with each district having at least one district-level hospital. The government of Malawi provides free cervical cancer screening to all women (African Health Observatory, 2018).

A primary contributor to the high cervical cancer prevalence is the high rate of HIV/AIDS throughout the country. In Malawi, 11.7% of women between the ages of 15-49 are diagnosed with HIV and 25.4% of HIV-positive women were diagnosed with cervical cancer between 2007 and 2010 (UNAIDS, 2017 & Msyamboza et al., 2012). The immunosuppression caused by HIV makes HIV-positive women two to twenty-two times more likely to be infected by Human Papilloma Virus (HPV), leading to higher rates of pre-cancer and cancer at younger ages (De Vuyst et al., 2008). As of 2014, Malawi has been able to provide antiretroviral treatment (ART) to 66% of the country’s HIV-positive population, and 77% of those individuals remain living with HIV one year after beginning ART. (UNAIDS, 2017). Despite the increase in accessibility to ART since 2004, the incidence of AIDS-defining cancers, including cervical cancer, has continued to rise (Msyamboza et al., 2012).

In the 1980s, the Ministry of Health-Reproductive Health Directorate (MoH-RHD) and its partners established a cervical cancer prevention and control plan and in 2004, implemented a cervical cancer screening program with the use of low-cost Visual Inspection with Acetic Acid (VIA) (Maseko et al., 2015). As of 2014, over 100 health centers throughout Malawi offered VIA. However, as only 59,217 women were screened, 44% of women with cervical cancer may have been missed by the country’s screening program (Msyamboza et al., 2012).

Challenges to cervical cancer prevention in Malawi arise from a lack of clear and concrete policy regarding screening and vaccination. The National Sexual and Reproductive Health and Rights (SRHR) Policy of Malawi was created in 2009 to create a “framework for affordable, accessible, and acceptable sexual and reproductive health services” to ensure that men and women had fair access to their SRHR rights. Information regarding cervical cancer is included in the section on “reproductive cancer policy,” but does not specify the age at which a woman should be screened for cervical cancer nor does it state how often she should be screened. While the SRHR states that cervical cancer screening should be integrated into the primary health care tier, it does not specify the type of screening test that should be used or which health professionals should administer those tests. Additionally, it does not include HPV vaccination in its prevention guidelines (Maseko et al., 2015).

Malawi’s cervical cancer screening program has not been able to adequately screen a significant amount of the population because of both barriers for women in accessing the services and inadequate healthcare infrastructure, personnel, and supplies. In 2015 a study was conducted to assess the challenges faced by the health system for cervical cancer prevention. Researchers surveyed forty-one service providers from twenty-one health facilities across fourteen of the country’s twenty-nine health districts. It was found that out of twenty-one health facilities, only seven provided screening and treatment of cervical cancer and only six were open for screening Monday-Friday. The remaining centers were either open only once or twice a week. On average, ten women were screened at each clinic per day, and the most common reason reported for the low screening rate was a lack of awareness in the community regarding the availability of VIA. Another primary contributor to the low screening rate is a lack of trained health care providers and an imbalanced distribution of providers with more in urban areas than in rural areas. There is also a lack of district-level supervision of provider screenings due to transportation costs. Out of the surveyed health facilities, fifty-two percent reported running out of stock of one or more pharmaceutical products for VIA for a week’s time throughout the year. While most facilities had the necessary material and equipment for VIA, only approximately one-third of the facilities, had the materials necessary for cervical biopsy and cryotherapy. With transportation from rural areas being a major barrier towards cervical cancer treatment, lack of immediate removal of cervical neoplasms after VIA can be detrimental (Maseko et al., 2015).

Cervical cancer risk is higher in women who have given birth to three or more children. In Malawi, large families are culturally valued and thus the average birth rate for women in Malawi is 4.57 (World Bank, 2017). As of 2016, 44% of married women over the age of 20, 26% of married girls under 20, and 50% of unmarried sexually active adolescent girls utilized contraceptives (World Bank, 2016). However, in a largely male-dominated society, many women abstain from contraception due to a largely cultural practice of males making family decisions. Therefore, gender inequity plays a major role in limiting accessibility to contraception (RIPPLE Africa, 2019).

Another risk factor for cervical cancer is pregnancy before the age of seventeen, with individuals giving birth before seventeen being twice as likely to be diagnosed with cervical cancer than individuals giving birth at 25 or older. In Malawi, 9% of girls are married before the age of 15 and 42% of girls are married before the age of 18. 31.7% of girls have their first child between the ages of 18 and 22 (African Institute for Development Policy, 2017). Therefore, early childbirth is contributing to the prevalence of cervical cancer in the country.

A study conducted at the tertiary health facility in Blantyre, Queen Elizabeth Central Hospital (QECH), found that on average women waited forty-two weeks between onset of symptoms and an appointment at QECH. Nineteen of these weeks were spent waiting after a referral from a district hospital or health center. Contrastingly, in the United Kingdom, all patients with suspected cancer are required to be seen by a specialist in two weeks. The study found that a contributing factor to the delay in symptom onset and visiting a health center or hospital was consultations with traditional or herbalist healers (Rudd et al., 2017). There is a common misperception among many women that cervical cancer is incurable and therefore many women seek care from herbalists first to alleviate their symptoms before seeking hospital care when symptoms worsen. In Malawi, it is common for most villages to have at least on traditional healer (TH). In rural areas, 80% of Malawians initially consult traditional healers about ailments due to the lower cost of herbal remedies and proximity (Truter, 2007). Due to the trust that many women place in traditional healers, integrating traditional healers into cervical cancer prevention is pivotal.

Intervention

The southern region was selected for this intervention as 52% of all cancer incidence in Malawi is from this region. Additionally, 18% of the southern region is infected with HIV/AIDS as opposed to 10% and 8% of the central and northern regions, respectively (Msyamboza et al., 2012). With HIV/AIDS as a major risk factor for cervical cancer, this intervention will first focus in the southern region and then potentially expand to the central and northern regions. This intervention will occur more specifically in Balaka, Malawi, a southern rural district, eighty-nine kilometers from Blantyre. Blantyre is the second-largest city in Malawi and functions as the industrial and commercial capital of Malawi. One of the four central, or tertiary tier, healthcare facilities in Malawi is located in Blantyre. Balaka contains one district, or secondary tier healthcare facility, and seven health centers, or primary healthcare facilities.

This intervention aims to integrate traditional healers into cervical cancer prevention to reduce the time spent between initial symptom appearance and treatment in women with suspected cervical cancer. It also aims to sensitize community members on the importance of cervical cancer screening and HPV vaccination. Currently, there is no clear delineation of the age and frequency of cervical cancer screening necessary in the national SRHR. This intervention will communicate these important factors to the general public. It also aims to increase the capacity of primary healthcare facilities to accurately conduct cervical cancer screening and HPV vaccination through increased trained personnel, resources, and oversight. Lastly, the intervention will specifically focus on targeting cervical cancer screening in HIV-positive individuals who are at a significantly higher risk for cervical cancer, by training ART staff in VIA.

The personnel required for this intervention include a multidisciplinary team of gynecologists, community health workers, gynecological nurses, and medical students. The model of this intervention will function through “mirror organizations” whereby the David Geffen School of Medicine (DGSOM) team will partner with an identically composed University of Malawi College of Medicine (UMCOM) team. Integrating local partnership into the model is essential to understanding the local moral world within which the project will be functioning. Understanding cultural and traditional beliefs will be pivotal to creating an acceptable intervention to reduce cervical cancer rates.

In this intervention, we recognize the need for a bottom-up approach in integrating THs into cervical cancer prevention. Modeled after an intervention integrating THs into HIV care and testing, this intervention will create a partnership between the district hospital in Balaka and the International Traditional Healers Association in Blantyre (Gqaleni et al., 2011). A TH would be selected as the district coordinator for Balaka, and would then select and recruit other THs across the district to be trained. The training workshops would be led by a joint team of nurses from the Mbera Community Health Centre, a governmental primary care facility, nurses from the David Geffen School of Medicine, and the district TH. THs that volunteer to participate in the training would learn how to identify the common symptoms of cervical cancer, which include vaginal discharge, pelvic and back pain, and bleeding between periods. THs would be trained to direct women who experienced these symptoms immediately to primary or secondary health facilities, allowing women to access screening and treatment earlier.

This intervention will also focus on community sensitization of cervical cancer. It will attempt to communicate more immediate prevention factors of cervical cancer such as HPV vaccination and cervical cancer screening in addition to more distal prevention practices. These will include increasing awareness as to how multiple childbirths, early pregnancy, and HIV infection increase the risk of cervical cancer. As males play a large role in decision-making and family planning, it will be imperative to sensitize males as well. As THs have a strong cultural and moral value amongst Malawians, their involvement in the sensitization campaign will create a more formative impact. Therefore, the District TH will also recruit a coalition of THs from villages in Balaka to attend cervical cancer prevention education training. This training will be led by the District TH. After the District TH is trained by public health educators from the University of Malawi. The sub-district THs will be provided training materials such as visual and informative posters to lead training sensitization workshops in their respective villages. They will be advised to garner male and female family members to attend the workshops by hosting them after religious services, in which both males and females are often present. A commonly cited barrier to cervical cancer screening is a lack of awareness as to the necessary age to start screening and how frequently women should be screened thereafter. Therefore, this sensitization campaign will involve publicizing the translated motto of “Get screened for cervical cancer between 21 and 29, every 3 years, and between 30 and 65 every 5 years”. Malawi has led a strong campaign against HIV/AIDS through a similar manner, and therefore we hope to bring the same level of awareness to cervical cancer. The message will be publicized through posters throughout the busiest parts of the district as well as through the local radio station.

As of January of 2019, the Malawian government, in conjunction with the World Health Organization announced a campaign for free HPV vaccinations in all public and private schools, health clinics, and hospitals throughout the country (Magombo-Mano, 2019). With the HPV vaccination available, it will be imperative that the community is aware of its importance. Therefore, the intervention’s sensitization campaign will specifically target fathers and husbands, often the decision-makers in the family, to encourage them to vaccinate their female family members. In order to do so, public health workers and medical professionals from both the Mbera Community Health Centre, DGSOM team, and UMCOM team will facilitate health fairs in villages throughout the Balaka district. These health fairs will provide information about the HPV vaccination as well as ease of access to the vaccination. As the vaccination requires two doses, the health fair will return after six months to administer the second dose.

This intervention will also work to increase the capacity of primary health facilities to provide screening and treatment through VIA by increasing trained personnel. As previously mentioned, most facilities are only able to offer screening one to two days a week with approximately ten individuals screened per day. Additionally, only seven of twenty-one facilities provided both screening and treatment. With transportation as a major barrier to healthcare for Malawian women, this intervention will seek to make screening and treatment available at all seven community health centers in Balaka. VIA can be conducted by paramedical workers, midwives, nurses, and clinicians. As midwives and nurses make up the primary healthcare force in primary care centers, this intervention will train more of these professionals to perform VIA. A joint team of medical professionals from the UMCOM and DGSOM will conduct this training, to ensure that local leadership is spearheading the intervention. Additionally, materials needed for the immediate treatment of neoplasms, such as cryotherapy machines and NO2 cylinders will be provided to each of seven primary centers to ensure that treatment is not further prolonged for the many individuals who cannot easily travel to alternate centers.

Lastly, this intervention will focus on addressing a population heavily affected by cervical cancer, which is the HIV-positive population. With HIV as a major risk factor for cervical cancer, this intervention will focus on training ART providers in Balaka’s HIV clinics in VIA. While formerly ART could only be provided by hospitals since 2004 ART delivery was moved to community health centers to increase access for more people (Jahn et al., 2015). In Balaka, HIV prevalence is 16% in women (Balaka District Health Office, 2014). Therefore, this intervention will train medical assistants and nurses in HIV clinics to offer VIA and to educate patients on their risk for cervical cancer. The joint team of medical professionals from UMCOM and DGSOM will conduct these training sessions.

This multifaceted approach will be used to address the biosocial factors that contribute to the high prevalence of cervical cancer in Malawi. By emphasizing local partnership as a key facet of this project, the intervention seeks to work from the grassroots level.

Introduction

The role of the General Practice Nurse (GPN) within the cervical screening programme is evaluated with emphasis on abnormal cytology result. Cervical sample taking started in the 1960s however it was not until 1988 that a national screening programme was introduced in Scotland, with the aim of reducing the rates of cervical cancer. Since it’s introduction there has been an incidence drop of around 24% in the rates of cervical cancer (Cancer Research UK, 2018).

Cervical screening does not detect cancer, it detects cell changes that could develop into malignancy. At this stage changes can be easily and effectively treated (ISD Scotland, 2010). The majority of cervical sample taking is carried out by GPNs. It is important that they are adequately trained. In-depth knowledge in all areas of the screening process is vital to help inform and support women through all stages of the process. It is also necessary to have knowledge about what happens once an abnormal cytology sample has been found and the processes that follow. To ensure a minimum of discomfort and distress, sensitivity and good communication skills are needed at every stage of the process (Greenfield and Pederson, 2011).

The Importance of Cytology Screening

In 2015, cervical cancer accounted for 2% of all new, female, cases of cancer in the UK and is the 14th most common female cancer (Cancer Research UK, 2018). Worldwide, cervical cancer is the second most common female cancer (GOV.UK, 2014). 1964 saw the introduction of cervical screening but initially was opportunistic and not organised until, in 1988, a standardized call-recall system was introduced. Since the 1990s, the trend has been a reduction of 24% in the incidence rates of cervical cancer (Cancer Research UK, 2018), and it has been estimated that mortality rates dropped by about 60% between 1974 and 2004 in the UK (GOV.UK, 2014).

The aim of cervical screening is to detect changes to the cells in the cervix that could then develop into malignancy. Pre-cancerous cervical cells do not cause any symptoms and can only be detected by screening. Cell changes that are detected early can be easily and effectively treated, meaning the cells will never develop to become cancerous (ISD Scotland, 2018). The diagnostic processes are not 100% reliable and false positive or negative results are possible. If screening is carried out at regular intervals, it reduces the risk of pre-cancerous cells being missed (NICE, 2012).

In Scotland, all women aged between 25-64 and registered with a GP are invited to attend for cervical screening. Routine screening is done 3 yearly for those between 25-49 and 5 yearly for those between 50-64 (NHS Health Scotland, 2018). The screening programme changed in 2016 from 20-60-year olds being screened three yearly routinely. Evidence indicated that any cell changes in those under 25 tended to resolve on their own and that investigation led to unnecessary anxiety and treatment. Cervical cancer is rare in those under the age of 25 years. It was also decided that routine screening for women over the age of 50 should be undertaken 5 yearly as this offered good protection to women as this age group has lower risks of developing cervical changes (SCCRS, 2016).

Once a cytology sample has been taken, it is entered into a national IT database, Scottish Cervical Call/Recall system (SCCRS). All staff involved in the cervical screening process have access to and use this database. SCCRS was introduced in May 2007 to bring consistency to screening practices across Scotland. A woman’s pathway can be easily tracked throughout the screening processes. GPNs will be able to see results, when a cytology sample is next due and whether a woman is on a routine or non-routine recall for cytology. Colposcopists and family planning staff will be able to access up-to-date information about a woman’s cervical screening history ensuring a quicker, more effective treatment to those who need it (SCCRS, 2016). Around nine out of ten tests are reported as normal. Abnormal tests are categorised as borderline (CIN1), moderate (CIN2) or severe abnormal (CIN3) (Perry, 2012). CIN1 would mean a recall of six months, two consecutive negative results would return the woman to routine (3-5 yearly) recall however, three borderline result would trigger a referral to colposcopy. A result of CIN2 or CIN3 triggers a referral to colposcopy or if severe a referral to a gynaecological oncologist (Perry, 2012).

Obtaining a Sample

The room used to carry out a cytology test should be private and warm. The woman should be given the opportunity to empty her bladder and be offered a chaperone. There should be screens for privacy surrounding a height adjustable couch with an adjustable light source and disposable paper towel. The woman should be allowed to undress her lower half privately and settle onto the couch. While she is doing so, the GPN can be washing their hands, putting on disposable gloves and preparing the speculum. If needed, a water-based lubricant can be used on the sides of the speculum but not the tip as this could contaminate the sample. Once the woman is comfortable, with knees raised and heels together, she can be asked to relax her stomach muscles and allow her knees to fall to the sides. The labia and vaginal entrance should be checked prior to gently inserting the speculum with its screw facing sideways, then slowly turned until the screw facing upwards. The blades of the speculum can then be slowly opened and the cervix located (RCN, 2006). Throughout the procedure, the comfort of the woman should be checked and reassurance given. Once the cervix has been located, the sample brush should be inserted into the OS and turned through 360 degrees five times, ensuring an adequate sample of cells is taken from the transformation zone. During this process, the cervix can be observed for any sign of abnormality. The speculum can then be gently removed and the sample brush pushed vigorously into the bottom of the sample pot 10 to ensure the cells have been left in the preserving fluid (Perry, 2012).

Abnormal Results

Nursing and Midwifery Council (NMC) states in its code of conduct that nurses must preserve people’s dignity, treating them with kindness and respect at all times. Nurses must listen to individual concerns and respond appropriately to anxiety and distress (Nursing and Midwifery Council, 2018). This seems rather more poignant when considered alongside a procedure that is so invasive, very personal and with potential for being distressing. The code also states that care professionals must communicate clearly and ascertain the understanding an individual has, so that informed consent can be given and the procedure can be carried out without undue delay. An older study by Chew-Graham et. al (2005) showed great variation in how care professionals involved in cervical sample taking prepared women for the procedure and what to expect afterwards. Many of the respondents to the study reported that they did not tend to discuss the reliability of the test or what would happen in the event of an abnormal result and the follow up this would entail.

It is not uncommon to receive an abnormal cytology result, and there are high levels of anxiety associated it. High anxiety often stems from poor understanding of what an abnormal result means with many thinking it is a diagnosis of cancer (Chew-Graham et. al, 2005). This highlights the necessity of giving women clear information about the screening process. The implications of possible sample outcomes should be clarified at the time of the sample being taken to avoid unnecessary anxiety when the results are obtained. Another older study carried out by Wilson and Hines (2000) found that women were far more likely to attend for colposcopy appointments when they had more information given to them explaining what the abnormal result meant and what to expect from their colposcopy appointment. This information was given in the form of a leaflet and then backed up by further verbal discussion to address any remaining concerns. Further to this, they found that a simple booklet increased knowledge and decreased anxiety whereas the more detailed booklet increased knowledge but did not alleviate anxiety. Further studies have also indicated that if a person feels they have received good levels of information about treatment, its strengths and weaknesses they feel more satisfaction from the consultation and are more likely to participate in the follow-up (Wroe et. al, 2013). However, it should be acknowledged that this study was not specific to cervical cytology and looked more generally into how information giving and involvement in decisions affected adherence to further treatment.

A disturbing fact is that nearly half of the annual new cervical cancer cases occur in women who have never had a cervical cytology test (Perry, 2012). Between 2013 and 2015, the peak rate for cervical cancer cases was in 25-29 – year old (Cancer Research UK, 2018) and yet there is evidence to show that the age group 25-34 have a lower participation in cervical screening (NHS Health Scotland, 2018). Within this age group, the highest screening uptake is from the women who have been HPV vaccinated. It is thought this may be due to the education given during the vaccination programme and the women being more aware of why screening is beneficial (ISD Scotland, 2018). This highlights a need to talk to the women in this age catchment and educate them about the purpose and benefits of the screening programme. Other factors that increase the risk of cervical cancer include; sexual activity at a young age, multiple sexual partners, smoking, multiple births, family history and HIV infection (Perry, 2012). GPNs need to engage and discuss these factors with women to help them make informed choices about whether to participate in the cervical screening programme or not and encourage compliance with follow up treatment if required. GPNs are ideally placed to be able to follow up women who do not attend screening appointments. It is possible to check the cervical screening status of women over the age of 25 years and at new patient checks. Telephone consultations can be used to discuss the benefits of screening and address any fear the woman may have about the procedure. In some cases, it may be appropriate to allocate more time to an appointment to give an anxious woman time to feel comfortable enough to consent to such an invasive procedure. Providing a service that is friendly, considerate, reassuring and empathetic, will contribute to a better experience for the woman and they will be more likely to attend to their next appointment (Richards, 2010).

However, individual choice is important and if someone decides to withdraw from the cervical screening programme, their choice must be respected and their human rights upheld (Nursing and Midwifery Council, 2018).

Human papillomavirus (HPV)

There are around 40 types of HPV that affect the genital tract. These are sexually transmitted meaning the risk increases with the number of sexual partners a woman has had. HPV infections can be classed as high or low risk depending on their association with the development of cancer. Over 99% of cervical cancers test positive to high-risk HPV types with HPV16 and 18 being responsible for over 70% of these (GOV.UK, 2014). An HPV vaccination programme began in September 2008; initially it was offered routinely to girls aged 12-13-years and a catch-up programme was offered to girls up to 18 years. The original vaccine protected against two types of HPV. In September 2012, the vaccine was changed to protect against four types of the virus (GOV.UK, 2011).

A retrospective study was devised. Data was extracted from SCCRS to document the effect of the HPV vaccination on the cervical cytology. It was found that complete vaccination with three doses correlated to a reduction in all grades of cytological cell changes, higher reduction observed for higher grade changes (Palmer etal., 2016). Continued monitoring is necessary due to the introduction of the quadrivalent HPV vaccine in 2012, the recipients of which will start to be screened in 2037. It should also be noted that some did not complete the vaccination course and some of the girls in the catch-up programme may have been sexually active prior to vaccination, reducing its effectiveness (Palmer etal., 2016). A Danish study also showed promising decreases in cervical cytology changes in women involved in their HPV vaccination programme (Thamsborg etal., 2018).

Infection with some HPV viruses has been shown to be instrumental in the development of cervical cancer. Testing for HPV in samples that show borderline cytological changes can identify women who are at high risk of developing cervical cancer. This indicates who would benefit from referral to colposcopy and who can reasonably remain on routine screening (Kelly et. al, 2011).

Conclusion

The GPN has a vital role to play within the cervical screening programme. It is important that all GPNs practice in a way that allows women to safely move through the screening programme with as little discomfort and anxiety as possible. Behaving in a friendly and approachable manner to encourage women to talk about their concerns, and keeping up-to-date about advances in the screening programme, ensure that GPNs are able to give sound information on which women can base informed choices about engaging with the programme. GPNs are also ideally placed to identify and engage non-attenders in a dialogue that could result in more women taking part in the programme.

In 1999, Elizabeth Reichel looked at worldviews surrounding global religions based on the culture and the ecology that encompassed gender-based knowledge among indigenous Amazonian hunter-gatherer groups. The dynamic difference between gender-based knowledge among hunter-gatherer groups is tied closely in with cosmology and perception of their worldview. This is heavily worked into the social structure of these indigenous groups; their cosmology and worldview impacts everything from property rights to the status of chiefdoms. Looking at the concepts that surround Thoughts of Knowledge as being the basis of existence for these populations that stretches from their nature surrounding them to the end of their cosmos. The two groups that are interacted with are the Tanimuka and Yukuna. Lastly, one of the vital parts of research was the interaction that these two populations had with rejecting alien concepts of Thoughts of Knowledge and its added application to the western modern world as well as their own traditional worldview.

The fact that the worldview that many of them share is a “universal home” philosophy is interesting. This means that they see the universe as their home community within their living shelters as much as the see the universe within themselves (Reichel 1999). While to an etic that may seem a drastic way to view themselves; it is simply just a worldview that someone that grew up staunchly only seeing western world view as the way as a ridiculous way to perceive the world. If their universe is being changed drastically and without asking their permission; it is clear that any sort of stressor that is to arise will take root in the community – which is the universe—and begin to leave its negative mark. A paper done Desmarcherlier et. al looked at the ritual and medicinal use of plants within the Amazon as used by the Ese’eja. In Peru, there is a tribe called Ese’eja, they are a hunter gatherer tribe that focuses heavily on fishing as one of their primary sources of subsistence. When analyzing their culture and the relationship in which they have with their environment.

It must be kept in mind that there cannot be any disassociation from religious beliefs and their own worldview. Researchers give description to what Shamanic practices are taking place and how they allude to the position of health within the Ese’eja tribe. A main focus of their practices and culture is the knowledge and collection of medicinal plants. The medicinal plants that aid in creating medicine or are used in healing rituals. The shamanic practices give an insight into the worldview that Ese’eja see themselves surrounded within (Desmarcherlier et. al 1996). With their vast knowledge of medicinal plants to use in and among the community. They relay heavily on the forest as an aspect of their healing and religious practices. When the universe, or their home is tainted and in need of healing the forest is the first thing that many of the shamans turn too (Desmarcherlier et. al 1996). In 2010 Van Solinge and Tim Boekhout complied documents to explain and reveal the crimes that deforestation and conflicts in the amazon have brought onto the indigenous population that have laid claim to this land as their home for generations. Van Solinge and Time Boekhout look at the effects of deforestation crimes and conflicts that have ravaged the amazon for decades. Looking at the relationship it has created for indigenous groups and that of western populations.

They also look at the change it has created for hunter-gatherer populations that inhabit the amazon and what it means for them as their home is decimated. The article also looks to call to the public what this means for our human population as a whole as the amazon makes up a large portion of the oxygen that is consumed worldly. They attempt to show that this problem is so much bigger than just the amazon, it is an international crisis that must be addressed. Solinge and Boekhout also examine and discuss possible solutions that could begin to aid those that are personally affected by this on a day to day basis. The main goal of their paper was to discuss and reveal the tragic incidents that have been happening in the Amazon. If we want to aid the Amazon and its inhabitants, then a step back is needed to be taken in order to let the population and the forest heal. One thing they could have pushed for the introduction of western medicine in the groups hurt most by the crimes done to the amazon are still choosing to live. The medicine that they could receive could easily be funded by government money. Though, the main point of the paper was to detail and deliver the crimes and allegation that were going on within and to the rainforest and that they did extraordinarily well. Recently, in 2015 Luz et al. looked at the cultural change affect the indigenous population and their own hunting activity. They were looking at indigenous populations in the Amazon. The effect and adaptations that a hunter-gatherer population must make in order to try and maintain its traditional lifestyle is arguably one of the biggest stressors that these people face today.

Hunter gatherer populations rely on subsistence as an important factor of their economic activity. Subsistence is one of the fundamental foundations of their society. Thus, understanding the cultural effect of encroaching western society can give insight into the dynamic and sometimes dangerous situations that some hunter gatherer populations must entangle with. The researchers are attempting to discuss and properly dissecting the relationship between cultural change and the detachment from traditional culture. They are wanting to explore the loss of traditional culture and how that will affect the way that other researchers study hunter-gatherer groups. Looking at three changes among traditional culture that they are analyzing is the interaction and engagement of hunting. At the same time, dissecting how that compares to hunting efficiency and catch within their territory. Lastly, looking at the change in how traditional cultural interacts with schooling and market areas and how drastically they change with contact and sometimes integration to western society (Luz et al. 2015). They conclude with wanting to push for more conservation in the forest and to aid in the shock of societal and lifestyle changes these people are to face. If they wish to continue their traditional lifestyle then people should leave them be. Looking at the diet and the way in which these groups choose to subsist will guide for a more holistic view on how they work within their own world and how the world reacts to them biologically.

Liliane Costa Conteville et al. in 2019 looked at gut microbiomes and biomarkers and the placement of their functionality within the diversity of semi-nomadic hunter-gatherer groups of the Amazon. Popular among academics is the idea that populations that have maintained a hunter-gatherer lifestyle while still practicing traditional modes of transportation can be living time capsules (Conteville et al. 2019). They can give a peek at possibly what human microbiome would closely represent for our hunter gatherer ancestors of the past. Thus, giving researchers a basis for them to analyze the evolution of human microbiome and attempt to detangle the relationship it has with human health and disease. Using a method of data collecting called shotgun metagenomic data researchers are analyzing the Yanomami from Brazil. They are a semi-nomadic hunter gatherer population that lives deep in the Brazil and Venezuela Amazon. While attempting to recreate a similar construction of what the human microbiome would be; researchers are looking at how relations and interactions with western society add to the drastic change to humans microbiome (Conteville et al. 2019). In 2013, London Stuart worked on a dissertation thesis for their PhD. They were looking at diet as a double-edged sword; their evidence, the pharmacological properties of food among hunter-gatherers of the Amazon.

The construction of food systems within hunter gatherer societies are evaluated across the Waorani tribe in the Amazon in comparison to the neighboring indigenous tribe that subsists off of agriculture community. The anti-inflammatory nature of the food systems that the Waorani use could possibly contribute to their health. While it does help regulate infectious pathogens that could be passed throughout the community and inflammatory diseases it is also supporting the beneficial growth of good microbiomes for humans to have within their body. This study alone provides enough evidence to show the role that diet plays in human health. This is stressed that in doing so this is often ignored by scientists that specialize in nutrition and agriculture; while also not sharing knowledge like this to policymakers so that the make create policy that would aid the community instead of barring them. Albert and Tourneau examine ethnographies that show the spatial patterns that are used by hunter-gatherers subsistence strategies that they use. In this article researchers are studying the spatial patterns of land use in the Amazon rainforest by the Yanomami community that inhabit the Brazilian Amazon (Albert and Tourneau 2007). They combine high resolution satellite imagery and the global positioning system survey data along with ethnographic fieldwork that depicts natural resource is confined within “reticular space” rather than “territory zones”.

Looking at how the Yanomami interacts with other groups of the amazon and how this entails on the depth of knowledge that they know for the reticular space they inhabit. Finally, they are arguing that this is essential to understanding the environment that these indigenous protected areas contribute and discuss long term sustainable ideas that can aid in managing their environment in the Amazon. The genetic variation and longevity of hunter-gatherers of the Amazon coupled with their remote placement is what gives way for diseases to either die off when it reaches the community or for it to consume the community. The diet and active lifestyle are what can aid to the longevity that many of this population are accustomed to. In 1998 Black et al. looked at the genetic variation of across several hunter-gatherer groups. Researchers worked with 505 individuals belonging to four populations of three different Brazilian Indigenous tribes. The goal was to look at the genetic variation between these tribes. They are also looking at how this contributes to the health of these populations.

One of their main concepts is to discuss the genetic variation between two people who are assumed to be part of the same tribe but yet shared a large degree of genetic variation (Black et al. 1998). The researchers are aiming to emphasize the idiosyncrasies of genetic variation in hunter gatherer populations. The populations main economic resource is the subsistence strategy with extremely rudimentary agriculture. Being able to distinguish the genetic variation between tribes can aid in the discussion of solutions to aid the health of these hunter gatherer populations. (Black et al. 1998). In 2007 Michael Gurven and Kaplan Hillard looked at the longevity among hunter gatherer populations and what their relationship with longevity and ecology has to do with them. Longevity that occurs post reproduction is large feature of human life. Only becoming a recent phenomenon caused largely in part to the improvements of the quality of life – i.e. sanitation, public health and the advances in medical science. However, among hunter-gatherer populations Gurven and Hillard attempt to dissect and disprove that prehistoric human lives were “nasty, brutish, and short” to quote Thomas Hobbs in his depiction of prehistoric societies. They argue that the development of longevity that we see in today’s population would not be without in thanks to the lifestyle an evolution adaptation that happened while we were still hunter gatherers.

They discuss age-specific dependency and its relations to resource production is helped to explain the adaptive longevity in humans though an evolutionary lens (Gurven and Hillard 2007). By the end of the research they understood that the link between a long life would be the activity that they participated in thought their life and their subsistence of rudimentary agriculture with seasonal hunting and gathering (Gurven and Hillard 2007). The idea of modern hunter gather societies in the world today is a subject that has ignited the academic community. But if this paper has done anything; it was to prove that they are very much alive and around in today’s world. Trying to solve world problems is also a center of topic to discuss among the younger academic community and the scholarly academic community. Debates ranging from subsistence consumption to disease patterns among populations has kindled a plethora of research to be done around the globe. Among some of the research done, results showing a high rise of human papillomavirus; otherwise known as HPV, and cervical cancer among the hunter gathers communities of the Amazon. This has left scholars to wonder what the cause could be due to cervical cancer being referred to as a “modern disease”. Researchers are trying to see what the amplifying difference of the hunter gather lifestyle in comparison to the western lifestyle contributes to the high rate of HPV among indigenous hunter gather women. Something that could contribute to the high cause of HPV and cervical cancer among indigenous hunter gather women could be the lack if HPV vaccinations. Possibly, does the lack of hygienic actions in comparison to western society by hunter gathers have to do for the high rate of HPV and cervical cancer. While women are the only people that can have cervical cancer, it has recently been confirmed that men can contract HPV through sexual intercourse. For future studies if men can contract the virus and pass it along; what is the total percentage of HPV among Amazon Indigenous hunter gather communities?