A Step Toward Timely Referral and Early Diagnosis of Cancer: Implementation and Impact on Knowledge of a Primary Care-Based Training Program in Botswana

Neo M Tapela, Michael J Peluso, Racquel E Kohler, Irene I Setlhako, Kerapetse Botebele, Kemiso Gabegwe, Isaac Nkele, Mohan Narasimhamurthy, Mompati Mmalane, Surbhi Grover, Tomer Barak, Lawrence N Shulman, Shahin Lockman, Scott Dryden-Peterson, Neo M Tapela, Michael J Peluso, Racquel E Kohler, Irene I Setlhako, Kerapetse Botebele, Kemiso Gabegwe, Isaac Nkele, Mohan Narasimhamurthy, Mompati Mmalane, Surbhi Grover, Tomer Barak, Lawrence N Shulman, Shahin Lockman, Scott Dryden-Peterson

Abstract

Introduction: Health system delays in diagnosis of cancer contribute to the glaring disparities in cancer mortality between high-income countries and low- and middle-income countries. In Botswana, approximately 70% of cancers are diagnosed at late stage and median time from first health facility visit for cancer-related symptoms to specialty cancer care was 160 days (IQR 59-653). We describe the implementation and early outcomes of training targeting primary care providers, which is a part of a multi-component implementation study in Kweneng-East district aiming to enhance timely diagnosis of cancers.

Methods: Health-care providers from all public facilities within the district were invited to participate in an 8-h intensive short-course program developed by a multidisciplinary team and adapted to the Botswana health system context. Participants' performance was assessed using a 25-multiple choice question tool, with pre- and post-assessments paired by anonymous identifier. Statistical analysis with Wilcoxon signed-rank test to compare performance at the two time points across eight sub-domains (pathophysiology, epidemiology, social context, symptoms, evaluation, treatment, documentation, follow-up). Linear regression and negative binomial modeling were used to determine change in performance. Participants' satisfaction with the program was measured on a separate survey using a 5-point Likert scale.

Results: 176 participants attended the training over 5 days in April 2016. Pooled linear regression controlling for test version showed an overall performance increase of 16.8% after participation (95% CI 15.2-18.4). Statistically significant improvement was observed for seven out of eight subdomains on test A and all eight subdomains on test B. Overall, 71 (40.3%) trainees achieved a score greater than 70% on the pretest, and 161 (91.5%) did so on the posttest. Participants reported a high degree of satisfaction with the training program's content and its relevance to their daily work.

Conclusion: We describe a successfully implemented primary health care provider-focused training component of an innovative intervention aiming to reduce health systems delays in cancer diagnosis in sub-Saharan Africa. The training achieved district-wide participation, and improvement in the knowledge of primary health-care providers in this setting.

Clinical trial registration: www.ClinicalTrials.gov, identifier NCT02752061.

Keywords: Botswana; cancer early diagnosis; health system delays; primary care; primary care providers; sub-Saharan Africa; training.

Figures

Figure 1
Figure 1
Map of Botswana and Kweneng-East district.

References

    1. Lopes Gde L, Jr, de Souza JA, Barrios C. Access to cancer medications in low- and middle-income countries. Nat Rev Clin Oncol (2013) 10(6):314–22.10.1038/nrclinonc.2013.55
    1. de Souza JA, Hunt B, Asirwa FC, Adebamowo C, Lopes G. Global health equity: cancer care outcome disparities in high-, middle-, and low-income countries. J Clin Oncol (2017) 34(1):6–13.10.1200/JCO.2017.35.8_suppl.6
    1. Gakwaya A, Kigula-Mugambe JB, Kavuma A, Luwaga A, Fualal J, Jombwe J, et al. Cancer of the breast: 5-year survival in a tertiary hospital in Uganda. Br J Cancer (2008) 99(1):63–7.10.1038/sj.bjc.6604435
    1. Unger-Saldana K. Challenges to the early diagnosis and treatment of breast cancer in developing countries. World J Clin Oncol (2014) 5(3):465–77.10.5306/wjco.v5.i3.465
    1. Agarwal G, Ramakant P. Breast cancer care in India: the current scenario and the challenges for the future. Breast Care (Basel) (2008) 3(1):21–7.10.1159/000115288
    1. El Saghir NS, Khalil MK, Eid T, El Kinge AR, Charafeddine M, Geara F, et al. Trends in epidemiology and management of breast cancer in developing Arab countries: a literature and registry analysis. Int J Surg (2007) 5(4):225–33.10.1016/j.ijsu.2006.06.015
    1. Kohler RE, Gopal S, Miller AR, Lee CN, Reeve BB, Weiner BJ, et al. A framework for improving early detection of breast cancer in sub-Saharan Africa: a qualitative study of help-seeking behaviors among Malawian women. Patient Educ Couns (2017) 100(1):167–73.10.1016/j.pec.2016.08.012
    1. Almuammar A, Dryden C, Burr JA. Factors associated with late presentation of cancer: a limited literature review. J Radiother Pract (2010) 9(2):117–23.10.1017/S146039690999029X
    1. Buckle GC, Collins JP, Sumba PO, Nakalema B, Omenah D, Stiffler K, et al. Factors influencing time to diagnosis and initiation of treatment of endemic Burkitt lymphoma among children in Uganda and western Kenya: a cross-sectional survey. Infect Agent Cancer (2013) 8(1):36.10.1186/1750-9378-8-36
    1. Brown CA, Suneja G, Tapela N, Mapes A, Pusoentsi M, Mmalane M, et al. Predictors of timely access of oncology services and advanced-stage cancer in an HIV-endemic setting. Oncologist (2016) 21(6):731–8.10.1634/theoncologist.2015-0387
    1. Brinton L, Figueroa J, Adjei E, Ansong D, Biritwum R, Edusei L, et al. Factors contributing to delays in diagnosis of breast cancers in Ghana, West Africa. Breast Cancer Res Treat (2017) 162(1):105–14.10.1007/s10549-016-4088-1
    1. Patel JD, Galsky MD, Chagpar AB, Pyle D, Loehrer PJ, Sr. Role of American society of clinical oncology in low- and middle-income countries. J Clin Oncol (2011) 29(22):3097–102.10.1200/JCO.2011.35.6378
    1. Ezeome ER. Delays in presentation and treatment of breast cancer in Enugu, Nigeria. Nigerian J Clin Pract (2010) 13(3):311–6.
    1. Pace LE, Mpunga T, Hategekimana V, Dusengimana JM, Habineza H, Bigirimana JB, et al. Delays in breast cancer presentation and diagnosis at two rural cancer referral centers in Rwanda. Oncologist (2015) 20(7):780–8.10.1634/theoncologist.2014-0493
    1. Ibrahim NA, Oludara MA. Socio-demographic factors and reasons associated with delay in breast cancer presentation: a study in Nigerian women. Breast (2012) 21(3):416–8.10.1016/j.breast.2012.02.006
    1. Akhigbe AO, Omuemu VO. Knowledge, attitudes and practice of breast cancer screening among female health workers in a Nigerian urban city. BMC Cancer (2009) 9:203.10.1186/1471-2407-9-203
    1. Adesina A, Chumba D, Nelson AM, Orem J, Roberts DJ, Wabinga H, et al. Improvement of pathology in sub-Saharan Africa. Lancet Oncol (2013) 14(4):e152–7.10.1016/S1470-2045(12)70598-3
    1. Mpunga T, Tapela N, Hedt-Gauthier BL, Milner D, Nshimiyimana I, Muvugabigwi G, et al. Diagnosis of cancer in rural Rwanda: early outcomes of a phased approach to implement anatomic pathology services in resource-limited settings. Am J Clin Pathol (2014) 142(4):541–5.10.1309/AJCPYPDES6Z8ELEY
    1. Handayani K, Sitaresmi MN, Supriyadi E, Widjajanto PH, Susilawati D, Njuguna F, et al. Delays in diagnosis and treatment of childhood cancer in Indonesia. Pediatr Blood Cancer (2016) 63(12):2189–96.10.1002/pbc.26174
    1. Unger-Saldana K, Infante-Castaneda C. Is breast cancer delay really the patient’s fault. In: Deng M, Raia F, Vacarella M, editors. Relational Concepts in Medicine. Inter-disciplinary press; (2012). Available from:
    1. Unger-Saldana K, Infante-Castaneda C. Delay of medical care for symptomatic breast cancer: a literature review. Salud Publica Mex (2009) 51(Suppl 2):s270–85.10.1590/S0036-36342009000800018
    1. Tapela Neo M, Kebabonye-Pusoentsi M, Botebele K, Peluso MJ, Nkele I, Efstathiou J, et al. Tackling health system delays for cancer patients in LMICs: an innovative multicomponent programmatic intervention in Botswana. J Global Oncol (2016) 2(3 Suppl):41s–2s.10.1200/JGO.2016.003715
    1. Ndlovu K, Littman-Quinn R, Park E, Dikai Z, Kovarik CL. Scaling up a mobile telemedicine solution in Botswana: keys to sustainability. Front Public Health (2014) 2:275.10.3389/fpubh.2014.00275
    1. The World Bank Group. Available from: (Accessed: April 23, 2018).
    1. Botswana Health Accounts Report 2013/4. Statistical report. Available from: (Accessed: April 23, 2018).
    1. World Health Organization. Botswana country profile 2014. Available from: (Accessed: April 23, 2018).
    1. Botswana Population Census. 2011. Available from: (Accessed: May 15, 2017).
    1. Musabyemariya F, Kirby K, Nshimyiryo A, et al. Laying the foundation for national scale-up of cancer care: feedback on nationally implemented baseline cancer trainings for non-oncology clinicians in Rwanda. Presented at the Fifth Annual East African Health and Scientific Conference & International Health Exhibition and Trade Fair Kampala, Uganda (2014).
    1. Tapela NM, Mpunga T, Hedt-Gauthier B, Moore M, Mpanumusingo E, Xu MJ, et al. Pursuing equity in cancer care: implementation, challenges and preliminary findings of a public cancer referral center in rural Rwanda. BMC Cancer (2016) 16:237.10.1186/s12885-016-2256-7
    1. Bussmann C, Rotz P, Ndwapi N, Baxter D, Bussmann H, Wester CW, et al. Strengthening healthcare capacity through a responsive, country-specific, training standard: the KITSO AIDS training program’s support of Botswana’s national antiretroviral therapy rollout. Open AIDS J (2008) 2:10–6.10.2174/1874613600802010010
    1. Kirkpatrick DL. Evaluating Training Programs: The Four Levels. 2nd ed San Francisco, CA: Berrett-Koehler; (1998).
    1. Asirwa FC, Greist A, Busakhala N, Rosen B, Loehrer PJ. Medical education and training: building in-country capacity at all levels. J Clin Oncol (2017) 34(1):36–42.10.1200/JCO.2015.63.0152
    1. Gajalakshmi CK, Krishnamurthi S, Ananth R, Shanta V. Cervical cancer screening in Tamilnadu, India: a feasibility study of training the village health nurse. Cancer Causes Control (1996) 7(5):520–4.10.1007/BF00051884
    1. Ramogola-Masire D, de Klerk R, Monare B, Ratshaa B, Friedman HM, Zetola NM. Cervical cancer prevention in HIV-infected women using the “see and treat” approach in Botswana. J Acquir Immune Defic Syndr (2012) 59(3):308–13.10.1097/QAI.0b013e3182426227
    1. Sankaranarayanan R, Ramadas K, Thomas G, Muwonge R, Thara S, Mathew B, et al. Trivandrum oral cancer screening study G: effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial. Lancet (2005) 365(9475):1927–33.10.1016/S0140-6736(05)66658-5
    1. Warnakulasuriya KA, Ekanayake AN, Sivayoham S, Stjernsward J, Pindborg JJ, Sobin LH, et al. Utilization of primary health care workers for early detection of oral cancer and precancer cases in Sri Lanka. Bull World Health Organ (1984) 62(2):243–50.
    1. Stover J, Fidzani B, Molomo BC, Moeti T, Musuka G. Estimated HIV trends and program effects in Botswana. PLoS One (2008) 3(11):e3729.10.1371/journal.pone.0003729
    1. Kar SS, Thakur JS, Jain S, Kumar R. Cardiovascular disease risk management in a primary health care setting of north India. Indian Heart J (2008) 60(1):19–25.
    1. Labhardt ND, Balo JR, Ndam M, Grimm JJ, Manga E. Task shifting to non-physician clinicians for integrated management of hypertension and diabetes in rural Cameroon: a programme assessment at two years. BMC Health Serv Res (2010) 10:339.10.1186/1472-6963-10-339
    1. Rowe AK, De Savigny D, Lanata CF, Victora CG. How can we achieve and maintain high-quality performance of health workers in low-resource settings? Lancet (2005) 366(9490):1026–35.10.1016/S0140-6736(05)67028-6
    1. Moodley J, Kawonga M, Bradley J, Hoffman M. Challenges in implementing a cervical screening program in South Africa. Cancer Detect Prev (2006) 30(4):361–8.10.1016/j.cdp.2006.07.005
    1. Paredes P, Pena M, Flores-Guerra E, Diaz J, Trostle J. Factors influencing physicians’ prescribing behavior in the treatment of childhood diarrhoea: knowledge may not be the clue. Soc Sci Med (1996) 42:1141–53.10.1016/0277-9536(95)00387-8
    1. Aarons GA, Hurlburt M, Horwitz SM. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health (2011) 38:4–23.10.1007/s10488-010-0327-7
    1. Kruk ME, Nigenda G, Knaul FM. Redesigning primary care to tackle the global epidemic of noncommunicable disease. Am J Public Health (2015) 105(3):431–7.10.2105/AJPH.2014.302392

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