Perceived risk and risk reduction behaviours of female first-degree relatives of breast cancer patients attending care at Uganda cancer institute.

OBJECTIVE: The objective of this study was to assess the perceived risk of breast cancer (BC) and adoption of risk reduction behaviours among female first-degree relatives (FDRs) of BC patients attending care at the Uganda Cancer Institute (UCI). METHODS: A cross-sectional study was performed using a questionnaire to collect data between March to October 2019. Adult female FDRs of patients attending care at UCI were recruited consecutively. Breast cancer perceived risk was assessed using a verbal measure; 'My chances of getting BC are great' on a Likert scale with 5 response alternatives. Chi square tests and modified Poisson regression using generalised estimating equations model were used to determine associations and examine factors associated with perceived risk of BC. RESULTS: We enrolled 296 FDRs from 186 female BC patients. Few participants 118/296 (40%) had high perceived risk of BC. Majority 165/296 (56%), had ever practiced breast self-examination. At the multivariable modified Poisson GEE model, women aged 36-45 years were more likely to perceive themselves to be at high risk of developing BC compared to women aged 18-25 years (adjusted prevalence ratio: 1.174; 95% confidence interval [95%CI] = 1.05-2.88; p value = 0.030) after adjusting for age, religion, educational level and residence. CONCLUSION: Few FDRs of BC patients perceived themselves to be at high risk of developing BC and do not seek risk reduction measures including screening and early diagnosis approaches. Breast cancer health education especially targeting younger women should emphasize the increased risk of BC in FDRs.

Diagnostic and pre-treatment intervals among patients with cervical cancer attending care at the Uganda Cancer Institute: a cross-sectional study.

BACKGROUND: Majority of patients with cervical cancer in the low- and middle-income countries experience long diagnostic and pre-treatment intervals. This study sought to determine the factors associated with the diagnostic and pre-treatment intervals among patients with cervical cancer. METHODS: This was a cross-sectional study conducted at the Uganda Cancer Institute (UCI) during October 2019 to January 2020. Patients aged ≥ 18 years with histological diagnosis of cervical cancer were consecutively sampled. Data were collected using a pre-tested semi-structured questionnaire and a data abstraction form. Diagnostic intervals, defined as the time between first visit of a patient to a primary healthcare provider to time of getting confirmed diagnosis, of ≤ 3 months was defined as early & >3 months as late. Pre-treatment intervals, which is the time from histological diagnosis to starting cancer chemo-radiotherapy of ≤ 1 month was defined as early and > 1 month as late. Data were analysed using STATA version 14.0. We used modified Poisson regression models with robust variance to determine socio-demographic and clinical factors associated with the intervals. RESULTS: The mean age of the participants was 50.0 ± 11.7 years. The median diagnostic and pre-treatment intervals were 3.1 (IQR: 1.4-8.2) months and 2.4 (IQR: 1.2-4.1) months respectively. Half of the participants, 49.6% (200/403) were diagnosed early; one in 5 patients, 20.1% (81/403) promptly (within one month) initiated cancer chemo-radiotherapy. Participants more likely to be diagnosed early included those referred from district hospitals (level 5) (aPR = 2.29; 95%CI: 1.60-3.26) and with squamous cell carcinomas (aPR = 1.55; 95%CI: 1.07-2.23). Participants more likely to be diagnosed late included those who first discussed their symptoms with relatives, (aPR = 0.77; 95%CI: (0.60-0.98), had > 2 pre-referral visits (aPR = 0.75; 95%CI (0.61-0.92), and had advanced stage (stages 3 or 4) (aPR = 0.68; 95%CI: 0.55-0.85). Participants more likely to initiate cancer chemo-radiotherapy early included older patients (≥ 60 years) (aPR = 2.44; 95%CI: 1.18-5.03). Patients likely to start treatment late were those who had ≥2 pre-referral visits  (aPR = 0.63; 95%CI: 0.41-0.98) and those that took 3 - 6 months with symptoms before seeking healthcare (aPR = 0.52;95%CI: 0.29 - 0.95). CONCLUSION: Interventions to promote prompt health-seeking and early diagnosis of cervical cancer need to target primary healthcare facilities and aim to enhance capacity of primary healthcare professionals to promptly initiate diagnostic investigations. Patients aged < 60 years require targeted interventions to promote prompt initiation of chemo-radiation therapy.

Patients' attitudes towards involvement of medical students in their care at university teaching hospitals of three public universities in Uganda: a cross sectional study.

BACKGROUND: Comfort of patients with medical students is important and promotes appropriate clinical reasoning and skills development in the students. There is however limited data in this field in Uganda. In this study, we examined the attitudes and comfort of patients attending care at the medical and obstetrics/gynecology specialties in teaching hospitals of three public universities in Uganda. METHODS: We conducted a cross sectional study among patients attending care at teaching hospitals for three public universities; Makerere University (Mak), Mbarara University of Science and Technology (MUST), and Gulu University (GU). Logistic regression was used to determine the magnitude of associations between independent and dependent variables. Two-sided p < 0.05 was considered statistically significant. RESULTS: Eight hundred fifty-five patients participated in the study. Majority were aged 18 - 39 years (54%, n = 460), female (81%, n = 696) and married (67%, n = 567). Seventy percent (n = 599) of participants could recognize and differentiate medical students from qualified physicians, and had ever interacted with medical students (65%, n = 554) during earlier consultations. Regarding attitudes of patients towards presence of medical students during their consultations, most participants (96%; n = 818) considered involvement of medical students in patients' care as essential ingredient of training of future doctors. Most participants prefer that medical students are trained in the tertiary public hospitals (80%; n = 683) where they attend care. Participants who were single/never married were 68% less likely to recognize and differentiate medical students (aOR = 0.32, 95%CI: 0.22 - 0.53) from other members of the healthcare team as compared with married participants. Participants with university education had 55% lower odds of being comfortable with presence of medical students during consultation compared to those with primary education (aOR = 0.45, 95%CI: 0.21 - 0.94). Participants from MUST teaching hospital had twofold higher odds of being comfortable with presence of medical students compared to participants from Mak teaching hospitals (aOR = 2.01; 95%CI: 1.20 - 3.39). CONCLUSION: Patients are generally comfortable with medical students' involvement in their care; they prefer to seek care in hospitals where medical students are trained so that the students may contribute to their care. Medical students need to introduce themselves appropriately so that all patients can know them as doctors in training; this will promote patients' autonomy and informed decisions.

'There Were Moments We Wished She Could Just Die': The Highly Gendered Burden of Nodding Syndrome in Northern Uganda.

Nodding Syndrome (NS) occurs within a wide spectrum of epilepsies seen in onchocerciasis endemic areas of sub-Saharan Africa. It has debilitating consequences on affected individuals and increases the socio-economic, physical and psychological burden on care-givers and their households, diminishing their standing within the community. Social science research on the disproportionate burden of the disease on females is limited. Based on ethnographic research over 3 years in northern Uganda, we explored the burden of being ill and care-giving for persons with NS from a gendered perspective. We found that NS-affected females were at greater risk of physical and psychological abuse, sexual violence, unwanted pregnancies, sexually transmitted infections and stigma, in a context of deteriorating socio-economic conditions. Primary care-givers of the NS-affected, mostly women, struggled to make ends meet and were subjected to stigma and abandonment. Targeted interventions, including legal protection for affected females, stigma reduction, and psycho-social and financial support are needed.

Household poverty, schooling, stigma and quality of life in adolescents with epilepsy in rural Uganda.

BACKGROUND: Epilepsy remains a leading chronic neurological disorder in Low- and Middle-Income Countries. In Uganda, the highest burden is among young rural people. We aimed to; (i) describe socio-economic status (including schooling), and household poverty in adolescents living with epilepsy (ALE) compared to unaffected counterparts in the same communities and (ii) determine the factors associated with the overall quality of life (QoL). METHODS: This was a cross-sectional survey nested within a larger study of ALE compared to age-matched healthy community children in Uganda. Between Sept 2016 to Sept 2017, 154 ALE and 154 healthy community controls were consecutively recruited. Adolescents recruited were frequency and age-matched based on age categories 10-14 and 15-19 years. Clinical history and standardized assessments were conducted. One control participant had incomplete assessment and was excluded. The primary outcome was overall QoL and key variables assessed were schooling status and household poverty. Descriptive and multivariable linear regression analysis were conducted for independent associations with overall QoL. RESULTS: Mean (SD) age at seizure onset was 8.8 (3.9) years and median (IQR) monthly seizure burden was 2 (1-4). Epilepsy was associated with living in homes with high household poverty; 95/154 (61.7%) ALE lived in the poorest homes compared to 68/153 (44.5%) of the healthy adolescents, p = 0.001. Nearly two-thirds of ALE had dropped out of school and only 48/154 (31.2%) were currently attending school compared to 136/153 (88.9%) of healthy controls, p < 0.001. QoL was lowest among ALE who never attended school (p < 0.001), with primary education (p = 0.006) compared to those with at least secondary education. Stigma scores [mean(SD)] were highest among ALE in the poorest [69.1(34.6)], and wealthy [70.2(32.2)] quintiles compared to their counterparts in poorer [61.8(31.7)], medium [68.0(32.7)] and wealthiest [61.5(33.3)] quintiles, though not statistically significant (p = 0.75). After adjusting for covariates, ALE currently attending school had higher overall QoL compared to their counterparts who never attended school (ß = 4.20, 95%CI: 0.90,7.49, p = 0.013). QoL scores were higher among ALE with ≥secondary education than those with no or primary education (ß = 10.69, 95%CI: 1.65, 19.72). CONCLUSIONS: ALE in this rural area are from the poorest households, are more likely to drop out of school and have the lowest QoL. Those with poorer seizure control are most affected. ALE should be included among vulnerable population groups and in addition to schooling, strategies for seizure control and addressing the epilepsy treatment gap in affected homes should be specifically targeted in state poverty eradication programs.

From their own perspectives: a qualitative study exploring the perceptions of traditional health practitioners in northern Uganda regarding cancers, their causes and treatments.

BACKGROUND: Many cancer patients in the low- and middle-income countries seek care with traditional health practitioners (THPs) and use traditional and complementary medicines (T&CMs) for treatment of cancers. Little is known about the perceptions and influence of THPs on cancer patients' help-seeking and treatment decisions. We aimed to explore perceptions of THPs regarding cancers, cancer causes, and preferred treatments for cancers, in order to identify aspects that can inform interventions to improve cancer outcomes in Uganda. METHODS: We conducted this ethnographic study in northern Uganda. In-depth interviews were conducted at the respondents' homes in quiet, open places, and in the absence of none- respondents. Interviews were audio-recorded and transcribed verbatim within a week of the interviews. Thematic qualitative analysis approaches were used to identify themes and subthemes. RESULTS: We included 21 respondents in the study; most were male (16/21), married, with median age of 59 years (range 39 - 80). Most respondents perceived cancer as a new and challenging disease, while one respondent thought of cancer as a result of an imbalance within the body. Most confessed unawareness of the causes of cancers, but believed that cancer could result from the interplay of a number of factors including poor diets, ingestions of chemical agents, and assaults by the spirits of the dead. Some reported that cancers (especially of women's genital tracts) were sexually transmitted, or caused by accumulation of dirt. Only few healers treated cancers. Most respondents reported that they referred cancer patients to biomedical facilities, sometimes after they have first used their medicines. Most respondents hoped that collaborative research with scientists could help them identify potent T&CMs that cure cancers. CONCLUSION: Traditional health practitioners require training on cancer causes, symptoms and signs, and the necessity for prompt initiation of effective treatments in order to improve cancer outcomes. The predisposition of the majority of respondents to refer cancer patients to biomedical services sets a fertile ground for meaningful cooperation between biomedical and traditional health practices. The national health system in the low- and middle-income countries could formally recognize traditional health practices as a component of the national healthcare system, and encourage the two to practice side by side.

Doxycycline for the treatment of nodding syndrome (DONS); the study protocol of a phase II randomised controlled trial.

BACKGROUND: Nodding syndrome is a poorly understood neurological disorder of unknown aetiology, affecting several thousand children in Africa. There has been a consistent epidemiological association with infection by the filarial parasite, Onchocerca volvulus and antibodies to leiomodin and DJ-1, cross-reacting with O.volvulus proteins, have been reported. We hypothesized that nodding syndrome is a neuro-inflammatory disorder, induced by antibodies to O.volvulus or its symbiont, Wolbachia, cross-reacting with human neuron proteins and that doxycycline, which kills Onchocerca through effects on Wolbachia, may be used as treatment. METHODS: This will be a two-arm, double-blind, placebo-controlled, randomised phase II trial of doxycycline 100 mg daily for six weeks in 230 participants. Participants will be patients' ages≥8 years with nodding syndrome. They will receive standard of care supportive treatment. All will be hospitalised for 1-2 weeks during which time baseline measurements including clinical assessments, EEG, cognitive and laboratory testing will be performed and antiepileptic drug doses rationalised. Participants will then be randomised to either oral doxycycline (Azudox®, Kampala Pharmaceutical Industries) 100 mg daily or placebo. Treatment will be initiated in hospital and continued at home. Participants will be visited at home at 2, 4 and 6 weeks for adherence monitoring. Study outcomes will be assessed at 6, 12, 18 and 24-month visits. Analysis will be by intention to treat. The primary efficacy outcome measure will be the proportion of patients testing positive and the levels or titires of antibodies to host neuron proteins (HNPs) and/or leiomodin at 24 months. Secondary outcome measures will include effect of the intervention on seizure control, inflammatory markers, cognitive function, disease severity and quality of life. DISCUSSION: This trial postulates that targeting O.volvulus through drugs which kill Wolbachia can modify the pathogenic processes in nodding syndrome and improve outcomes. Findings from this study are expected to substantially improve the understanding and treatment of nodding syndrome. TRIAL REGISTRATION: Registered with clinicaltrials.gov ID: NCT02850913 on 1st August, 2016.

Use of traditional and complementary medicines by cancer patients at a national cancer referral facility in a low-income country.

OBJECTIVE: The aim of this study was to describe use of traditional and complementary medicines (T&CM) and associated factors among patients with cancer. METHODS: We conducted a cross-sectional study at the Uganda Cancer Institute (UCI) involving patients with selected solid tumours. Independent variables included age, sex, marital status, cancer site and stage. Main outcome variables were use and disclosure of use of T&CM. RESULTS: The majority of participants were women (n = 352; 81.9%). Breast cancer (n = 312; 71.9%) was the predominant cancer type. 55.4% of participants (n = 240) self-reported use of T&CM. Among them, 68.3% (140/205) reported using them to treat/cure cancer, 35.6% (72/202) for strengthening the immune system and 31.2% (63/202) for management of pain. Patients with advanced stage cancers were more likely to be users compared with those in stage one. The majority (81.9%, 195/238) of T&CM users did not disclose use to their healthcare professionals. The main reasons for nondisclosure included lack of inquiry by clinicians (79.6%, 117/147) and fear of disapproval and/or rebuke (11.6%, 17/147). CONCLUSION: Use of T&CM by patients with cancer under biomedical care is common but often undisclosed to the healthcare professionals.

Perceptions and beliefs of lay people from northern Uganda regarding surgery for diagnosis and treatment of cervical cancer.

OBJECTIVE: To explore perceptions and beliefs of people in a rural community in northern Uganda regarding surgery for the diagnosis and treatment of cervical cancer. The aim of the study was to inform interventions to reduce delay and improve timely diagnosis and prompt appropriate treatments for patients with symptoms of cervical cancer. METHODS: A semi-structured study guide informed by Kleinman's explanatory model for illness was used to collect data during 24 focus group discussions involving 175 men and women aged 18 to 59 years in Gulu, northern Uganda. Using thematic analysis, themes and subthemes were identified from the data through an iterative process and consensus among the authors. RESULTS: Surgery for diagnosis and management of cervical cancer was perceived as (1) appropriate when performed at early stage of cancer and by senior doctors, but (2) a potential catalyst for the spread of cancer and early death; and (3) a challenge to childbearing and motherhood as well as a source of distress to women and families if surgery involved removal of the uterus with subsequent permanent infertility. CONCLUSIONS: There are some negative perceptions about surgery for cervical cancer that may deter prompt help-seeking for symptoms. However, targeted messages for public awareness interventions to promote help-seeking can be built on the positive perceptions and beliefs that surgery could be curative when undertaken for early-stage cancer and by skilled doctors.

Turning a blind eye and a deaf ear to traditional and complementary medicine practice does not make it go away: a qualitative study exploring perceptions and attitudes of stakeholders towards the integration of traditional and complementary medicine into medical school curriculum in Uganda.

BACKGROUND: A substantial proportion of healthcare professionals have inadequate understanding of traditional and complementary medicine and often consider their use inappropriate. METHODS: We conducted a qualitative study to understand the perceptions and attitudes of medical students, medical school faculty and traditional and complementary medicine practitioners. In-depth interviews and focus group discussions were used to collect data. Thematic approach was used in data analysis to identify emerging themes and sub themes. Data analysis was supported with use of Atlas.ti v6.1.1. RESULTS: The majority of participants commended the inclusion of traditional and complementary medicine principles into medical school curricula. The main reasons advanced were that: patients are already using these medicines and doctors need to understand them; doctors would be more accommodating to use and not rebuke patients, thereby minimizing delays in care due to pursuit of alternative therapies; promote patient safety; foster therapeutic alliance and adherence to therapy; uphold patients' right to self-determination; lead to discovery of new drugs from traditional medicines; and set ground for regulation of practices and quality control. However, participants anticipated operational and ethical challenges that include inadequate number of faculty to teach the subject, congested curricula, increased costs in research and development to produce evidence-base data, obstruction by pharmaceutical companies, inaccessibility to and depletion of medicinal plants, and potential conflicts due to diversity in culture and values. A substantial minority of participants thought traditional medicine need not be taught in medical schools because there is lack of scientific evidence on efficacy, safety, and side effects profiles. These shortfalls could make the determination of benefits (beneficence) and harm (maleficence) difficult, as well as compromise the ability of physicians to adequately disclose benefits and harms to patients and family, thereby undermining the process of informed consent and patient autonomy. CONCLUSIONS: Training medical students in principles of traditional and complementary medicine is considered reasonable, feasible, and acceptable; and could lead to improvement in health outcomes. There are anticipated challenges to implementing a hybrid medical school curricula, but these are surmountable and need not delay introducing traditional and complementary medicine principles into medical school curricula in Uganda.

Symptomatic presentation with cervical cancer in Uganda: a qualitative study assessing the pathways to diagnosis in a low-income country.

BACKGROUND: Symptomatic cervical cancer patients in low- and middle-income countries usually present with late stage disease and have poor survival. We explored the views of cervical cancer patients on their symptom appraisal and interpretations, and their help-seeking including lay consultations. METHODS: We conducted an in-depth interview study in two northern Ugandan hospitals. Theoretical models underpinned the study guide for data collection and analysis. We used thematic analysis techniques, informed by the theoretical concepts in the Model of Pathways to Treatment. Sub-themes and themes were identified through consensus among investigators. RESULTS: Eighteen women aged 35-56 years, recently diagnosed with cervical cancer were interviewed. Their first symptoms included abnormal vaginal bleeding, offensive vaginal discharge and lower abdominal pain. Most participants did not perceive themselves to be at risk for cervical cancer and they usually attributed the initial symptoms to normal bodily changes or common illnesses such as sexually transmitted diseases. Lay consultations with husbands, relatives and friends were common and often influenced decisions and timing for seeking care. Prompt help-seeking was frequently triggered by perceived life threatening symptoms such as heavy vaginal bleeding or lower abdominal pain; symptom burden sufficient to interfere with patients' work routines; and persistence of symptoms in spite of home-based treatments. Participants did not promptly seek care when they perceived symptoms as mild; interpreted symptoms as due to normal bodily changes e.g. menopause; and attributed symptoms to common illnesses they could self-manage. Their cancer diagnosis was often further delayed by long help-seeking processes including repeated consultations. Some healthcare professionals at private clinics and lower level health facilities failed to recognize symptoms of cervical cancer promptly therefore delayed referring women to the tertiary hospitals for diagnosis and treatment. CONCLUSION: Ugandan patients with symptomatic cervical cancer often misattribute their gynaecological symptoms, and experience long appraisal and help-seeking intervals. These findings can inform targeted interventions including community awareness campaigns about cervical cancer symptoms, and promote prompt help-seeking in Uganda and other low- and middle-income countries with high incidence and mortality from cervical cancer.

Understanding cervical cancer: an exploration of lay perceptions, beliefs and knowledge about cervical cancer among the Acholi in northern Uganda.

BACKGROUND: Cervical cancer is the most common cancer affecting women in Uganda; yet community understanding of the disease is limited. We explored community perceptions, beliefs and knowledge about the local names, causes, symptoms, course, treatment, and prognosis of cervical cancer in order to inform targeted interventions to promote early help-seeking. METHODS: Twenty four focus group discussions (FGD) with men and women aged 18 - 59 years and ten key informant interviews with persons aged ≥ 60 years were conducted at two sites in Gulu district between May and June 2012. A semi-structured interview guide informed by Kleinman's illness explanatory model and literature on community awareness of cervical cancer was used to collect data. Data analysis was supported with use of ATLAS.ti 6.1 in coding, organizing and tracking data segments. We used content analysis technique in data analysis and organised data into a structured format under distinct themes and categories. RESULTS: Cervical cancer was known by the local name "two remo", meaning "an illness that manifests with bleeding." Respondents believed that early onset of sexual activity, multiple male sexual partners and multi-parity cause cervical cancer. Respondents in half of FGDs also reported that use of condoms and family planning pills and injections cause cervical cancer. Symptoms of cervical cancer reported included vaginal bleeding, watery vaginal discharge and lower abdominal and waist pain. Respondents in most of the FGDs and key informants perceived cervical cancer as a chronic illness and that it can be treated with both modern and traditional medicines. The majority thought that cervical cancer treatment was supportive; the illness is not curable. CONCLUSIONS: While some lay beliefs about the causes of cervical cancer suggest some understanding of aetiology of the disease, other perceived causes particularly those related to use of family planning and condoms are potentially hurtful to public health. Awareness campaigns to promote early help-seeking for cervical cancer symptoms need to be culturally-sensitive and context-specific; and include messages on symptoms, risk factors, course, treatment and prognoses.

Awareness of cervical cancer risk factors and preventive approaches, and perceived causes of cervical cancer among secondary school girls: a cross-sectional study in Northern Uganda.

BACKGROUND: The majority of women in low- and middle-income countries have low awareness of cervical cancer. This study sought to establish awareness of cervical cancer risk factors and preventive approaches, as well as sources of information and perceived causes of cervical cancer among secondary school girls in northern Uganda. METHODS: This was a cross-sectional study conducted in rural northern Uganda. We collected data using an investigator administered pre-tested questionnaire. Analysis was done with STATA version 14.0. Multivariate analyses with logistic regressions models were used to determine magnitudes of association between independent and outcome variables. Odds ratios and accompanying 95% confidence intervals are reported. Statistical significance was considered if the two sided p-value <.05. RESULTS: Most participants (97%; n = 624) had heard of cervical cancer before this study. The most common source of information about cervical cancer was friends (31.1%; n = 194). More than half of the participants (59%; n = 380) had heard about a vaccine that prevents cervical cancer, but only a third (33%; n = 124) had ever received a dose of the vaccine. The majority of participants (89%; n = 550) reported that cervical cancer could be prevented; however only half (52%; n = 290) knew that vaccination of girls aged 9-13 years could prevent cervical cancer. The majority of participants did not recognize the risk factors for cervical cancer; for example, only 15% (n = 98), 7% (n = 45), and 1.4% (n = 9) recognized early onset of sexual intercourse, infection by the human papillomavirus (HPV), and smoking respectively. On adjusting for age, students' class, and religion, students in schools with school health programs were twice (aOR = 2.24: 95%CI; 1.24-4.06) more likely to know that cervical cancer is preventable. CONCLUSION: Secondary school girls need information on cervical cancer risk factors and approaches to prevention so that they may avoid exposures to the risk factors and promptly seek and undertake preventive approaches including HPV vaccinations.

Educational interventions through school health programs are viable strategies to improve the knowledge of secondary school girls on cervical cancer risk factors and preventive approaches.Peers/friends are key sources of information on cervical cancer to secondary school girls.Peers/friends are a sustainable strategic resource, and therefore students could be trained to provide peer training on cervical cancer risk factors and preventive approaches to fellow secondary school girls.

Traditional health practices: A qualitative inquiry among traditional health practitioners in northern Uganda on becoming a healer, perceived causes of illnesses, and diagnostic approaches.

BACKGROUND: The practice of traditional and complementary medicine is increasing in most low-and middle-income countries especially for chronic communicable and non-communicable diseases. In this study, we aimed to understand how people gain healing power and become traditional health practitioners (THPs), perceived causes of illnesses, and how THPs diagnose illnesses. METHODS: This was a cross-sectional qualitative interview-based study. We used semi-structured in-depth guides to collect data from THPs identified through the Acoli cultural institutions and snowball sampling technique. The study team visited the THPs and interviewed them in their homes. Some THPs allowed the study team to visit them more than once and as well observe their healing practices and medicines. Thematic analysis approach was used to analyze the data. Atlas.ti version 9.2 was used to support data analysis. RESULTS: Twenty two THPs aged 39-80 years were included in the study. Most of the respondents were male, and married. We identified three main themes: (i) how people gain healing power and become traditional health practitioners; (ii) perceived causes of illnesses; and (iii) how illnesses are diagnosed. The majority of respondents reported that most people become THPs through: inheriting healing power from their parents or grandparents; transfer of healing powers from senior healers; instructions during visions and dreams; and, acquiring healing power during spirits possessions. Perceived causes of illnesses included: fate and natural causes, spirits attacks, curses by elders, witchcraft, contagion and infections, poor hygiene, heredity, and malevolent actions. THPs diagnose illnesses through various approaches including consultations with spirits, observing patterns of occurrences and events, evaluation of symptoms and signs of illnesses, use of bones from animals/birds and other objects to diagnose illnesses, performing diagnostic rituals, and using biomedical laboratory testing in health facilities. CONCLUSION: Healing knowledge and powers are acquired in particular ways that can be traced to appraise authenticity of healers during registration and licensing to ensure safety of patients. Understanding perspectives of the THPS on causes of illnesses and how diagnoses are made potentially informs strategies for integration and or collaboration between the national biomedical health system and traditional health practices.

Factors associated with diagnostic and pre-treatment intervals among breast cancer patients attending care at the Uganda Cancer Institute: A cross-sectional study.

BACKGROUND: Most breast cancer (BC) patients in Uganda are diagnosed with advanced-stage disease and experience poor outcomes. This study examined the diagnostic and pre-treatment intervals and factors associated with these intervals among BC patients attending care at the Uganda Cancer Institute (UCI). METHODS: This was a cross-sectional, facility-based study. Data were collected using structured questionnaire administered by trained research assistants and analyzed using STATA version 14.0. Modified Poisson regressions models were used to determine the strength of associations between independent variables and diagnostic and pre-treatment intervals. RESULTS: The mean age (±SD) of the 401 participants was 47.1 ± 11.7 years. Four in 10 participants had stage III (41.9%; n = 168) and over a third (34.7%; n = 140) stage IV cancers. The median interval from first consultation to diagnosis, i.e. diagnostic interval (DI) was 5.6 months (IQR: 1.5-17.0), while the median interval from histological diagnosis to start of chemotherapy, i.e. pre-treatment interval (PTI) was 1.7 months (IQR: 0.7-4.5). Majority (85%, n = 341) of participants were diagnosed at ≥3 months from first consultation with clinicians. Participants with tertiary education and those who lived within 100-199 km from the UCI were about four times and twice more likely to be diagnosed early (DI <3 months from first consultation) ([aPR = 3.88; 95% CI: 1.15-13.0] and [aPR = 2.19; 95% CI: 1.06-4.55]), respectively. About half (48.3%; n = 176) of participants started chemotherapy within 1 month of cancer diagnosis. Patients who lived more than 300 km from the UCI were less likely to start chemotherapy within 1 month of histology diagnosis of cancer. [Correction added on October 17, 2023 after first online publication. The term ', i.e.' has been included in the results section in this version.] CONCLUSION: Majority of breast cancer patients are diagnosed late and in advanced stages. There is need to promote all efforts toward timely diagnosis when cancers are still in early stages by identifying factors responsible for prolonged diagnostic intervals among breast cancer patients.

The use of traditional medicine practitioner services for childhood illnesses among childbearing women: a multilevel analysis of demographic and health surveys in 32 sub-Saharan African countries.

BACKGROUND: Insights into the use of traditional medicine practitioners (TMP)-for common childhood diseases such as diarrhea and respiratory infections are important to understand the role of Traditional Medicine (TM) in reducing the increasing childhood morbidity and mortality in sub-Saharan Africa (SSA). However, a comprehensive picture of TMP utilisation and its associated factors for childhood illness in SSA is lacking. This study aimed to estimate the prevalence of the use of traditional medicine practitioner services to treat childhood illnesses among women with children under five years old and to identify individual and community-level factors associated with TMP use in SSA. METHODS: The analysis used Demographic and Health Surveys (DHS) dataset collected between 2010 and 2021 among 353,463 under-fives children from 32 SSA countries. Our outcome variable was the use of TMP for childhood illness, defined as having diarrhoea or fever/cough or both. Using STATA v14, we employed the random effect meta-analysis to estimate the pooled prevalence of TMP use for childhood illness and a two-level multivariable multilevel modelling to determine the individual and community-level factors associated with consultation of a TMP. RESULTS: Approximately [2.80% (95%CI: 1.88-3.90)] women who sought healthcare for childhood illnesses utilised the service of a TMP with the highest occurring in Cote d'Ivoire [16.3% (95%CI: 13.87-19.06)] and Guinea (13.80% (95%CI: 10.74-17.57)] but the lowest in Sierra Leone [0.10%(95%CI:0.01-1.61)]. Specifically, approximately [1.95% (95%CI: 1.33-2.68)] and [1.09% (95%CI:0.67-1.60)] of women sought the service of a TMP for childhood diarrhea and fever/cough, respectively. Women with no formal education [AOR = 1.62;95%CI:1.23-2.12], no media access [AOR = 1.19;95%CI:1.02-1.39), who lived in a male-headed household [AOR = 1.64;95%CI:1.27-2.11], without health insurance [AOR = 2.37;95%CI: 1.53-3.66], who considered it a problem getting permission to visit a health facility [AOR = 1.23;95%CI:1.03-1.47] and who perceived the size of their children at birth to be above average[AOR = 1.20;95%CI:1.03-1.41] had higher odds of using TMP for childhood illnesses. CONCLUSIONS: Although the prevalence of TMP for childhood illnesses appeared low, our findings highlight that TMPs continue to play a critical role in managing childhood illnesses in SSA. It is essential that policymakers and service providers should incorporate the potential role of TMPs in the design, review and implementation of child health policies in SSA. Also, the interventions for curtailing childhood illnesses should be focused on the characteristics of women who use TMPs for childhood diseases identified in our study.

Delays in seeking, reaching and access to quality cancer care in sub-Saharan Africa: a systematic review.

OBJECTIVES: Late presentation and delays in diagnosis and treatment consistently translate into poor outcomes in sub-Saharan Africa (SSA). The aim of this study was to collate and appraise the factors influencing diagnostic and treatment delays of adult solid tumours in SSA. DESIGN: Systematic review with assessment of bias using Risk of Bias in Non-randomised Studies of Exposures (ROBINS-E) tool. DATA SOURCES: PubMed and Embase, for publications from January 1995 to March 2021. ELIGIBILITY CRITERIA: Inclusion criteria: quantitative or mixed-method research, publications in English, on solid cancers in SSA countries. EXCLUSION CRITERIA: paediatric populations, haematologic malignancies, and assessments of public perceptions and awareness of cancer (since the focus was on patients with a cancer diagnosis and treatment pathways). DATA EXTRACTION AND SYNTHESIS: Two reviewers extracted and validated the studies. Data included year of publication; country; demographic characteristics; country-level setting; disease subsite; study design; type of delay, reasons for delay and primary outcomes. RESULTS: 57 out of 193 full-text reviews were included. 40% were from Nigeria or Ethiopia. 70% focused on breast or cervical cancer. 43 studies had a high risk of bias at preliminary stages of quality assessment. 14 studies met the criteria for full assessment and all totaled to either high or very high risk of bias across seven domains. Reasons for delays included high costs of diagnostic and treatment services; lack of coordination between primary, secondary and tertiary healthcare sectors; inadequate staffing; and continued reliance on traditional healers and complimentary medicines. CONCLUSIONS: Robust research to inform policy on the barriers to quality cancer care in SSA is absent. The focus of most research is on breast and cervical cancers. Research outputs are from few countries. It is imperative that we investigate the complex interaction of these factors to build resilient and effective cancer control programmes.

Moving forward through consensus: a national Delphi approach to determine the top research priorities in prostate cancer in Uganda.

OBJECTIVE: To identify key areas for research in prostate cancer (PC) in the Ugandan context by establishing the major health system, socioeconomic and clinical barriers to seeking, reaching and receiving high-quality cancer care. DESIGN: Modified Delphi Technique. SETTING: Government and private-not-for-profit hospitals. METHODS: We applied a two-stage modified Delphi technique to identify the consensus view across cancer experts. In round 1, experts received a questionnaire containing 21 statements drawn from a systematic review identifying the reason for the delay in accessing cancer care. Each statement was scored out of 20. Statements scoring ≥15 from over 70% of participants were prioritised for inclusion while statements for which <30% of participants gave a score of ≥15 were excluded. Sixteen statements were included in round 2 as they did not receive consensus for inclusion or exclusion. RESULTS: We found that the top six research priority areas arise from challenges including: (1) lack of diagnostic services-ultrasound, laboratory tests and biopsy facilities; (2) high costs of services, for example, surgery, radiotherapy, hormone therapy are unaffordable to most patients, (3) lack of essential medicines, (4) limited radiotherapy capacity, (5) lack of awareness of cancer as a disease and low recognition of symptoms, (6) low healthcare literacy. The lack of critical surgical supplies, high diagnostic and treatment costs were ranked highest in order of importance in round 1. Round 2 also revealed lack of diagnostic services, unavailability of critical medicines, lack of radiotherapy options, high costs of treatments and lack of critical surgical supplies as the top priorities. CONCLUSION: These research priority areas ought to be addressed in future research to improve prompt PC diagnosis and care in Uganda. There is need to improve the supply of high-quality affordable anticancer medicines for PC patients so as to improve the survivorship from the cancer.

Evaluating Pain Management Practices for Cancer Patients among Health Professionals: A Global Survey.

Background: Cancer incidence in the world is predicted to increase in the next decade. While progress has been in diagnosis and treatment, much still remains to be done to improve cancer pain therapy, mainly in underserved communities in low-income countries. Objective: To determine knowledge, beliefs, and barriers regarding pain management in both high- and low-income countries (according to the WHO classification); and to learn about ways to improve the current state of affairs. Design: Descriptive survey. Setting/Subjects: Fifty-six countries worldwide; convenience sample of 1639 consisted of 36.8% physicians; 45.1% nurses, and 4.5% pharmacists employed in varied settings. Results: Improved pain management services are key elements. Top barriers include religion factors, lack of appropriate education and training at all levels, nonadherence to guidelines, patients' reluctance to report on pains, over regulation associated with prescribing and access to opioid analgesics, fear of addiction to opioids, and lack of discussions around prognosis and treatment planning. Conclusion: The majority of patients with cancer in low-income countries are undertreated for their pain. Promoting cancer pain accredited program of training and education on pain management for physicians and nurses is crucial, as well as advocating policymakers and the public at large.