A Narrative Synthesis of Literature on the Barriers to Timely Diagnosis and Treatment of Cancer in Sub-Saharan Africa.

Poor cancer survival outcomes in sub-Saharan Africa (SSA) have been linked to delays in diagnosis and treatment. Here we present a detailed overview of the qualitative literature evaluating the barriers to receiving timely diagnosis and treatment of cancer in SSA. The PubMed, EMBASE, CINAHL, PsycINFO databases were searched to identify qualitative studies reporting on barriers to timely diagnosis of cancer in SSA published between 1995 and 2020. A systematic review methodology was applied, including quality assessment and narrative data synthesis. We identified 39 studies, of which 24 focused on breast or cervical cancer. Only one study focused on prostate cancer and one on lung cancer. When exploring factors contributing to delays, six key themes emerged from the data. The first theme was health service barriers, which included: (i) inadequate numbers of trained specialists; (ii) limited knowledge of cancer among healthcare providers; (iii) poor co-ordination of care; (iv) inadequately resourced health facilities; (v) negative attitudes of healthcare providers towards patients; (vi) high cost of diagnostic and treatment services. The second key theme was patient preference for complementary and alternative medicine; the third was the limited understanding of cancer among the population. The fourth barrier was a patient's personal and family obligations; the fifth was the perceived impact of cancer and its treatment on sexuality, body image and relationships. Finally, the sixth was the stigma and discrimination faced by patients following a diagnosis of cancer. In conclusion, health system, patient level and societal factors all influence the likelihood of timely diagnosis and treatment for cancer in SSA. The results provide a focus for targeting health system interventions, particular with regards to awareness and understanding of cancer in the region.

Mapping awareness of breast and cervical cancer risk factors, symptoms and lay beliefs in Uganda and South Africa.

BACKGROUND: Breast and cervical cancer are leading causes of cancer burden in Sub-Saharan Africa (SSA). We measured breast and cervical cancer symptom and risk factor awareness and lay beliefs in Uganda and South Africa (SA). METHODS: Between August and December 2018 we conducted a cross-sectional survey of women ≥18 years in one urban and one rural site per country. Households were selected using systematic random sampling, then one woman per household randomly selected to participate. Data were collected by interviewers using electronic tablets customised with the locally validated African Women Awareness of Cancer (AWACAN) tool. This has unprompted questions (testing recall) followed by prompted questions (testing recognition) on risk factor, symptom awareness and lay beliefs for breast and cervical cancer. Mann Whitney and Kruskal Wallis tests were used to compare the association between socio-demographic variables and outcomes. Poisson regression with robust variance was conducted to identify independent socio-demographic predictors. RESULTS: Of the 1758 women interviewed, 90.8% had heard of breast and 89.4% of cervical cancer. 8.7% recalled at least one breast risk factor and 38.1% recalled at least one cervical cancer risk factor. 78.0% and 57.7% recalled at least one breast/cervical cancer symptom respectively. Recognition of risk factors and symptoms was higher than recall. Many women were unaware that HPV, HIV, and not being screened were cervical cancer risk factors (23.7%, 46.8%, 26.5% respectively). In SA, urban compared to rural women had significantly higher symptom and risk factor awareness for both cancers. In Uganda married women/living with a partner had higher awareness of breast cancer risk factors and cervical cancer symptoms compared to women not living with a partner. Women mentioned several lay beliefs (e.g. putting money in their bra as a breast cancer risk factor). CONCLUSION: We identified gaps in breast and cervical cancer symptom and risk factor awareness. Our results provide direction for locally targeted cancer awareness intervention programs and serve as a baseline measure against which to evaluate interventions in SSA.

Development and validation of the African Women Awareness of CANcer (AWACAN) tool for breast and cervical cancer.

BACKGROUND: Measuring factors influencing time to presentation is important in developing and evaluating interventions to promote timely cancer diagnosis, yet there is a lack of validated, culturally relevant measurement tools. This study aimed to develop and validate the African Women Awareness of CANcer (AWACAN) tool to measure awareness of breast and cervical cancer in Sub-Saharan Africa (SSA). METHODS: Development of the AWACAN tool followed 4 steps: 1) Item generation based on existing measures and relevant literature. 2) Refinement of items via assessment of content and face validity using cancer experts' ratings and think aloud interviews with community participants in Uganda and South Africa. 3) Administration of the tool to community participants, university staff and cancer experts for assessment of validity using test-retest reliability (using Intra-Class Correlation (ICC) and adjusted Kappa coefficients), construct validity (comparing expert and community participant responses using t-tests) and internal reliability (using the Kuder-Richarson (KR-20) coefficient). 4) Translation of the final AWACAN tool into isiXhosa and Acholi. RESULTS: ICC scores indicated good test-retest reliability (≥ 0.7) for all breast cancer knowledge domains and cervical cancer risk factor and lay belief domains. Experts had higher knowledge of breast cancer risk factors (p < 0.001), and cervical cancer risk factors (p = 0.003) and symptoms (p = 0.001) than community participants, but similar knowledge of breast cancer symptoms (p = 0.066). Internal reliability for breast cancer risk factors, lay beliefs and symptom and cervical cancer symptom subscales was good with KR-20 values > 0.7, and lower (0.6) for the cervical cancer risk subscale. CONCLUSION: The final AWACAN tool includes items on socio-demographic details; breast and cervical cancer symptom awareness, risk factor awareness, lay beliefs, anticipated help-seeking behaviour; and barriers to seeking care. The tools showed evidence of content, face, construct and internal validity and test-retrest reliability and are available for use in SSA in three languages.

Barriers to biomedical care and use of traditional medicines for treatment of cervical cancer: an exploratory qualitative study in northern Uganda.

Use of traditional medicines for treatment of cancers has increased worldwide. We used a qualitative approach to explore barriers to biomedical care and reasons for use of traditional medicines for the treatment of cervical cancer in Gulu, northern Uganda. We carried out 24 focus group discussions involving men and women aged 18-59 years. We employed content analyses technique in data analysis. Traditional medicines were used mainly due to barriers to biomedical care for cervical cancer. The barriers included health system factors, for example long distances to health facilities and unavailability of medicines; health workers' factors, for example negative attitudes towards patients and demands for bribes; individual patient's factors, for example inability to pay for medical care; and socio-cultural beliefs about superiority of traditional medicines and perceived greater privacy in accessing traditional healers. Barriers to biomedical care and community beliefs in the effectiveness of traditional medicines encourage use of traditional medicines for treatment of cervical cancer but might hinder help-seeking at biomedical facilities. There is need for targeted culturally sensitive awareness campaign to promote effectiveness of modern medicine and to encourage cautious use of traditional medicines in the treatment of cervical cancer.

Stereotypes on Nodding syndrome: responses of health workers in the affected region of northern Uganda.

BACKGROUND: Nodding Syndrome is a debilitating disorder of yet unknown etiology that has affected children and adolescents aged 3 - 18 years in parts of sub Saharan African countries including Uganda, South Sudan, Tanzania and Liberia. OBJECTIVE: To identify stereotypes and negative attitudes held by primary care health workers about nodding syndrome. METHOD: Of one hundred health workers invited by the Uganda Ministry of Health for training on nodding syndrome from the three most affected districts of Pader, Lamwo and Kitgum forty were interviewed using a predesigned tool. Content and thematic analysis was applied. RESULTS: There were 22 females. The median age was 33 years (range 23-54 years). The participants included Psychiatric Clinical Officers, Medical Clinical Officers, Laboratory Technicians, Midwives, Registered and Enrolled Nurses. Overall, four broad categories of negative stereotypes were identified; Nodding syndrome is 1) an incurable disease, 2) is associated with evil spirits and curses, 3) is disabling, making the patient a burden to society and 4) is a fatal illness. CONCLUSION: Primary health care workers who lead the care of patients with nodding syndrome have several negative stereotypes that may potentially impact negatively on the quality of care they provide.

Bacteriuria among adult non-pregnant women attending Mulago hospital assessment centre in Uganda.

BACKGROUND: Urinary tract infections (UTIs) in women are a common problem in primary health care settings. Resistance of bacterial uropathogens to commonly used antibiotics is common in many places. OBJECTIVES: To determine the prevalence of UTI, associated uropathogens and their antimicrobial susceptibility. METHODS: A cross section study carried out at Mulago hospital outpatients' department. Midstream urine samples (MSU) were collected from 399 women, who gave informed consent and fulfilled other study criteria. Quantitative culture method, identification of uropathogens and antibiotic susceptibility testing using the Kirby-Bauer disc diffusion technique were applied to the isolates. RESULTS: Out of 399 MSU samples, 40 pure significant bacterial growths (≥10(5) colony forming units (cfu)/ml of urine) were isolated and these included Escherichia coli, 23 (57.5%), Staphylococcus aureus, 9 (22.5%), Enterococci spp, 6 (15%) and Klebsiella pneumoniae, 2 (5.0%). Overall, sensitivities were: nitrofurantoin (98.3%), cefuroxime (89.3%), and cotrimoxazole (20%) by all uropathogens isolated. CONCLUSIONS: Culture positive UTI among adult non-pregnant women are a common problem, occurring in 10% of the study population. Most bacterial uropathogens showed high sensitivity to nitrofurantoin but low sensitivity to SXT. RECOMMENDATIONS: Nitrofurantoin should be considered as drug of choice for empirical treatment of community acquired uncomplicated UTI in adult non-pregnant women.

Bacteriuria among Adult Non-Pregnant Women Attending Mulago Hospital Assessment Centre in Uganda

Background: Urinary tract infections (UTIs) in women are a common problem in primary health care settings. Resistance of bacterial uropathogens to commonly used antibiotics is common in many places. Objectives: To determine the prevalence of UTI; associated uropathogens and their antimicrobial susceptibility. Methods: A cross section study carried out at Mulago hospital outpatients' department. Midstream urine samples (MSU) were collected from 399 women; who gave informed consent and fulfilled other study criteria. Quantitative culture method; identification of uropathogens and antibiotic susceptibility testing using the Kirby-Bauer disc diffusion technique were applied to the isolates. Results: Out of 399 MSU samples; 40 pure significant bacterial growths (105 colony forming units (cfu)/ml of urine) were isolated and these included Escherichia coli; 23 (57.5); Staphylococcus aureus; 9 (22.5); Enterococci spp; 6 (15) and Klebsiella pneumoniae; 2 (5.0). Overall; sensitivities were: nitrofurantoin (98.3); cefuroxime (89.3); and cotrimoxazole (20) by all uropathogens isolated. Conclusions: Culture positive UTI among adult non-pregnant women are a common problem; occurring in 10of the study population. Most bacterial uropathogens showed high sensitivity to nitrofurantoin but low sensitivity to SXT. Recommendations: Nitrofurantoin should be considered as drug of choice for empirical treatment of community acquired uncomplicated UTI in adult non-pregnant women