Experiences and perceptions regarding clinical breast exam screening by trained laywomen in Malawi

Patients' experiences undergoing breast evaluation in Rwanda's Women's Cancer Early Detection Program

PURPOSE

There is urgent need for interventions to facilitate earlier diagnosis of breast cancer in low- and middle-income countries where mammography screening is not widely available. Understanding patients' experiences with early detection efforts, whether they are ultimately diagnosed with cancer or benign disease, is critical to optimize interventions and maximize community engagement. We sought to understand the experiences of patients undergoing breast evaluation in Rwanda's Women's Cancer Early Detection Program (WCEDP).

METHODS

We conducted in-person semi-structured interviews with 30 patients in two districts of Rwanda participating in the WCEDP. Patients represented a range of ages and both benign and malignant diagnoses. Interviews were recorded, transcribed, translated, and thematically analyzed.

RESULTS

Participants identified facilitators and barriers of timely care along the breast evaluation pathway. Community awareness initiatives were facilitators to care-seeking, while persistent myths and stigma about cancer were barriers. Participants valued clear clinician-patient communication and emotional support from clinicians and peers. Poverty was a major barrier for participants who described difficulty paying for transport, insurance premiums, and other direct and indirect costs of hospital referrals in particular. COVID-19 lockdowns caused delays for referred patients. Although false-positive clinical breast exams conferred financial and emotional burdens, participants nonetheless voiced appreciation for their experience and felt empowered to monitor their own breast health and share knowledge with others.

CONCLUSION

Rwandan women experienced both benefits and burdens as they underwent breast evaluation. Enthusiasm for participation was not reduced by the experience of a false-positive result. Reducing financial, logistical and emotional burdens of the breast diagnostic pathway through patient navigation, peer support and decentralization of diagnostic services could improve patients' experience.

Factors Influencing the Experience of Breast and Cervical Cancer Screening Among Women in Low- and Middle-Income Countries: A Systematic Review

PURPOSE

The persistent high morbidity and mortality from breast and cervical cancer in low- and middle-income countries (LMICs) may be influenced by global disparities in the uptake of screening services. This review sought to synthesize existing evidence to determine factors that influence the experience of women relating to breast and cervical screening in LMICs.

METHODS

A qualitative systematic review of the literature identified through Global Health, Embase, PsycInfo, and MEDLINE. Eligible studies included those outlining primary qualitative research or mixed-method studies with reporting of qualitative findings, detailing women's experiences of involvement with programs for breast or cervical cancer screening. Framework synthesis was used to explore and organize findings from primary qualitative studies and the Critical Appraisal Skills Programme checklist used for quality assessment.

RESULTS

Database searches yielded 7,264 studies for title and abstract screening and 90 full-text articles for screening, with qualitative data from 17 studies and a total of 722 participants included in this review. Four stages influencing experiences of women were generated across both breast and cervical cancer screening approaches, with individual (eg, knowledge of cancer), social (eg, religion, cultural beliefs), and health system (eg, accessibility) factors identified that influence women's initial and subsequent engagement.

CONCLUSION

This study synthesizes existing evidence of factors that influence engagement with breast and cervical cancer screening in LMICs. Evidence-informed recommendations are proposed that may improve the experience of cancer screening in LMICs, with further research necessary to explore their operationalization and impact on cancer care delivery.

Breast health awareness campaign and screening pilot in a Kenyan County: Findings and lessons

BACKGROUND AND AIM

Breast cancer is the leading cancer in terms of incidence in Kenya. We conducted a breast cancer awareness and screening pilot to assess feasibility of rolling out a national screening program in Kenya.

METHODS

Conducted in Nyeri County during October-November 2019, the pilot had three phases; awareness creation, screening (clinical breast examination and/or imaging) and final evaluation (post-screening exit interviews and retrospective screening data review). Descriptive statistics on awareness, screening process and outputs were derived.

RESULTS

During the pilot, 1813 CBE, 217 breast ultrasounds and 600 mammograms were performed. Mammography equipment utilization increased from 11% to 83%. Of 49 women with suspicious lesions on mammography, only 22 (44.9%) had been linked to care 4 months after the campaign. Of 532 exit interview respondents; 95% (505/532) were ≥35 years of age; 80% (426/532) had been reached by the awareness campaign. Majority (75% [399/532]) had received information from community health volunteers; 68% through social groups. Majority (79% [420/532]) felt the campaign had changed their behavior on breast health. Although 77% (407/532) had knowledge on self breast examination (SBE); only 13% practiced monthly SBE. More than half (58% [306/532]) had previously undertaken a CBE. Approximately 70% (375/528) were unaware of mammography before the pilot; 86% (459/532) had never previously undertaken a mammogram. Fifty-five percent (293/532) of respondents had screening waiting times of >120 min.

CONCLUSION

Community health workers can create breast cancer screening demand sustainably. Adequate personnel and effective follow-up are crucial before national roll-out of a breast cancer screening program.

Implementation and Evaluation of Educational Videos to Improve Cancer Knowledge and Patient Empowerment

PURPOSE

Low health literacy is a leading cause of treatment abandonment among patients receiving cancer care at Kamuzu Central Hospital (KCH) in Malawi.

METHODS

We developed cancer educational videos featuring Malawian providers and played them in the KCH oncology clinic. The videos addressed cancer-related topics, including disease biology, common myths, diagnostic procedures, treatment, side effects, and survivorship. After 6 months of implementation, we compared results from 50 pre- and postintervention surveys to assess change in cancer knowledge and care experience.

RESULTS

Both pre- and postintervention cancer knowledge were good: a median of nine questions were answered correctly of 11 in both assessments. Despite the intervention, most continued to incorrectly identify cancer as an infection (pre: n = 26, 52%; post: n = 25, 50%; P = 1.0), although improvements were observed in patients' knowledge of correct actions for fever at home (pre: n = 38, 76%; post: n = 43, 86%; P = .31). Care experiences were overall good. Postintervention results indicate that more patients felt always listened to by their providers (pre: n = 18, 36%; post: n = 29, 58%; P < .01). However, we also noted a higher rate of patient dissatisfaction of care as more patients felt that they could not understand chemotherapy counseling (pre: n = 11, 22%; post: n = 22, 44%; P < .01). Assessments of video satisfaction indicate that patients found the videos very helpful in terms of understanding their disease (n = 47, 96%) and side effects (n = 48, 98%) and felt empowered to speak up with their providers (n = 46, 96%).

CONCLUSION

Standardized education materials for patients that can be feasibly implemented throughout sub-Saharan Africa are urgently needed. Cancer educational videos are a low-cost way to educate and empower patients with cancer in resource-constrained settings although in-person discussions remain a crucial part of care.

Knowledge, Perceptions, and Satisfaction of Moroccan Women Towards a New Breast Cancer Screening Program in Morocco

The purpose of this study was to evaluate the knowledge, perceptions, and satisfaction of Moroccan women who resided the Meknes-Tafilalt region regarding a newly implemented breast cancer screening program in the region. The study was conducted in 24 randomly selected health centers from Meknes-Tafilalt region, Morocco. We targeted all women who resided in the region of the program and who met the inclusion criteria to participate in the screening program. Data was collected through a face-to-face questionnaire. In this study, 318 women were included. Results revealed moderate knowledge of breast cancer and the screening program. Most of the participants (90.5%) had heard of the breast cancer screening program. Only 33.6% of women declared that they are well informed about the program. Fear emotions related to breast cancer were reported by 93.1% of participants. About 82% of women accept to repeat a screening test every 2 years. Recommending the breast cancer screening test to their family and friends was stated by nearly 90% of women. The majority of women (94.9%) expressed their satisfaction about the screening test activities provided by health centers. Our results showed a moderate level of knowledge about breast cancer, a very positive attitude, and high overall satisfaction towards the breast cancer screening program in the Meknes-Tafilalt region. These results can guide development of appropriate breast cancer prevention strategies and sensibilisation campaigns in Morocco.

The distinctive roles of urban community health workers in low- and middle-income countries: a scoping review of the literature

Addressing urban health challenges in low- and middle-income countries (LMICs) has been hampered by lack of evidence on effective mechanisms for delivering health services to the poor. The urban disadvantaged experience poor health outcomes (often worse than rural counterparts) and face service barriers. While community health workers (CHWs) have been extensively employed in rural communities to address inequities, little attention has been given to understanding the roles of CHWs in urban contexts. This study is the first to systematically examine urban CHW roles in LMICs. It aims to understand their roles vis-à-vis other health providers and raise considerations for informing future scope of practice and service delivery models. We developed a framework that presents seven key roles performed by urban CHWs and position these roles against a continuum of technical to political functions. Our scoping review included publications from four databases (MEDLINE, EMBASE, CINAHL and Social Sciences Citation Index) and two CHW resource hubs. We included all peer-reviewed, CHW studies situated in urban/peri-urban, LMIC contexts. We identify roles (un)commonly performed by urban CHWs, present the range of evidence available on CHW effectiveness in performing each role and identify considerations for informing future roles. Of 856 articles, 160 met the inclusion criteria. Programmes spanned 34 LMICs. Studies most commonly reported evidence on CHWs roles related to health education, outreach and elements of direct service provision. We found little overlap in roles between CHWs and other providers, with some exceptions. Reported roles were biased towards home visiting and individual-capacity building, and not well-oriented to reach men/youth/working women, support community empowerment or link with social services. Urban-specific adaptations to roles, such as peer outreach to high-risk, stigmatized communities, were limited. Innovation in urban CHW roles and a better understanding of the unique opportunities presented by urban settings is needed to fully capitalize on their potential.

Community health workers and early detection of breast cancer in low-income and middle-income countries: a systematic scoping review of the literature

Background

Breast cancer is the leading cause of female mortality in low-income and middle-income countries (LMICs). Early detection of breast cancer, either through screening or early diagnosis initiatives, led by community health workers (CHWs) has been proposed as a potential way to address the unjustly high mortality rates. We therefore document: (1) where and how CHWs are currently deployed in this role; (2) how CHWs are trained, including the content, duration and outcomes of training; and (3) the evidence on costs associated with deploying CHWs in breast cancer early detection.

Methods

We conducted a systematic scoping review and searched eight major databases, as well as the grey literature. We included original studies focusing on the role of CHWs to assist in breast cancer early detection in a country defined as a LMIC according to the World Bank.

Findings

16 eligible studies were identified. Several roles were identified for CHWs including awareness raising and community education (n=13); history taking (n=7); performing clinical breast examination (n=9); making onward referrals (n=7); and assisting in patient navigation and follow-up (n=4). Details surrounding training programmes were poorly reported and no studies provided a formal cost analysis.

Conclusions

Despite the relative paucity of studies addressing the role of CHWs in breast cancer early detection, as well as the heterogeneity of existing studies, evidence suggests that CHWs can play a number of important roles in breast cancer early detection initiatives in LMICs. However, if they are to realise their full potential, they must be appropriately supported within the wider health system.

The global role, impact, and limitations of Community Health Workers (CHWs) in breast cancer screening: a scoping review and recommendations to promote health equity for all

Introduction: Innovative interventions are needed to address the growing burden of breast cancer globally, especially among vulnerable patient populations. Given the success of Community Health Workers (CHWs) in addressing communicable diseases and non-communicable diseases, this scoping review will investigate the roles and impacts of CHWs in breast cancer screening programs. This paper also seeks to determine the effectiveness and feasibility of these programs, with particular attention paid to differences between CHW-led interventions in low- and middle-income countries (LMICs) and high-income countries (HICs).Methods: A scoping review was performed using six databases with dates ranging from 1978 to 2019. Comprehensive definitions and search terms were established for ‘Community Health Workers’ and ‘breast cancer screening’, and studies were extracted using the World Bank definition of LMIC. Screening and data extraction were protocolized using multiple independent reviewers. Chi-square test of independence was used for statistical analysis of the incidence of themes in HICs and LMICs.Results: Of the 1,551 papers screened, 33 were included based on inclusion and exclusion criteria. Study locations included the United States (n=27), Bangladesh (n=1), Peru (n=1), Malawi (n=2), Rwanda (n=1), and South Africa (n=1). Three primary roles for CHWs in breast cancer screening were identified: education (n=30), direct assistance or performance of breast cancer screening (n=7), and navigational services (n=6). In these roles, CHWs improved rates of breast cancer screening (n=23) and overall community member knowledge (n=21). Two studies performed cost-analyses of CHW-led interventions.Conclusion: This review extends our understanding of CHW effectiveness to breast cancer screening. It illustrates how CHW involvement in screening programs can have a significant impact in LMICs and HICs, and highlights the three CHW roles of education, direct performance of screening, and navigational services that emerge as useful pillars around which governments and NGOs can design effective programs in this area.

HIV risk screening and HIV testing among orphans and vulnerable children in community settings in Tanzania: Acceptability and fidelity to lay-cadre administration of the screening tool

INTRODUCTION

HIV risk screening tool validation studies have not typically included process evaluations to understand tool implementation. The study aim was to assess the fidelity to which an HIV risk screening tool was administered by lay workers and acceptability of delivering home-based screening coupled with HIV testing to beneficiaries in an orphans and vulnerable children (OVC) program.

METHODS

This cross-sectional study was conducted March-April 2019 in two regions of Tanzania. Community case workers (CCW) were observed conducting screenings with OVC 2-19 years and participated in focus group discussions. Research staff used structured observation checklists to capture if screening questions were asked or reworded by CCW. In-depth interviews were conducted with older adolescents and caregivers in their homes following screening and testing. A composite score was developed for the checklist. Qualitative data were thematically analyzed to address screening and testing perceptions and experiences.

RESULTS

CCW (n = 32) participated in 166 observations. Commonly skipped items were malnutrition (34% of all observed screenings) and sexual activity and pregnancy (20% and 45% of screenings for adolescents only). Items frequently re-worded included child abuse (22%) and malnutrition (15%). CCW had an average composite observation score of 42/50. CCW in focus groups (n = 34) found the screening process acceptable. However, they described rewording some questions viewed as harsh or socially inappropriate to ask. Overall, adolescent beneficiaries (n = 17) and caregivers (n = 25) were satisfied with home-based screening and testing and reported no negative consequences. Learning one's HIV negative status was seen as an opportunity to discuss or recommit to healthy behaviors. While respondents identified multiple benefits of home testing, they noted the potential for privacy breaches in household settings.

CONCLUSIONS

We found sub-optimal fidelity to the administration of the screening tool by CCW in home environments to children and adolescents enrolled in an OVC program. Improvements to questions and their delivery and ongoing mentorship could strengthen tool performance and HIV case finding using a targeted testing approach. Overall, home-based HIV risk screening and testing were acceptable to beneficiaries and CCW, could improve testing uptake, and serve as a platform to promote healthy behaviors for those with limited health system interactions.

Breast and cervical cancer screening services in Malawi: a systematic review

Background

To identify and to assess factors enhancing or hindering the delivery of breast and cervical cancer screening services in Malawi with regard to accessibility, uptake, acceptability and effectiveness.

Methods

Systematic review of published scientific evidence. A search of six bibliographic databases and grey literature was executed to identify relevant studies conducted in Malawi in the English language, with no time or study design restrictions. Data extraction was conducted in Excel and evidence synthesis followed a thematic analysis approach to identify and compare emerging themes.

Results

One hundred and one unique records were retrieved and 6 studies were selected for final inclusion in the review. Multiple factors affect breast and cervical cancer service delivery in Malawi, operating at three interlinked levels. At the patient level, lack of knowledge and awareness of the disease, location, poor screening environment and perceived quality of care may act as deterrent to participation in screening; at the health facility level, services are affected by the availability of resources and delivery modalities; and at the healthcare system level, inadequate funding and staffing (distribution, supervision, retention), and lack of appropriate monitoring and guidelines may have a negative impact on services. Convenience of screening, in terms of accessibility (location, opening times) and integration with other health services (e.g. reproductive or HIV services), was found to have a positive effect on service uptake. Building awareness of cancer and related services, and offering quality screening (dedicated room, privacy, staff professionalism etc.) are significant determinants of patient satisfaction.

Conclusions

Capitalising on these lessons is essential to strengthen breast and cervical cancer service delivery in Malawi, to increase early detection and to improve survival of women affected by the disease.

Expanding the use of community health workers in urban settings: a potential strategy for progress towards universal health coverage

Community health worker (CHW) programmes have been used for decades to improve access to health services in rural settings in low- and middle-income countries. With more than half of the world's population currently living in urban areas and this population expected to grow, equitable access to health services in urban areas is critically important. To understand the extent to which CHW programmes have been successfully deployed in low-income urban settings, we conducted a review of the literature between 2000 and 2018 to identify studies evaluating and describing CHW programmes implemented fully or partially in urban or peri-urban settings. We identified 32 peer-reviewed articles that met our inclusion criteria. Benefits have been documented in several urban settings in low- and middle-income countries including those to address TB/HIV, child health, maternal health and non-communicable diseases through a variety of study designs.

Outcomes and prognostic factors for women with breast cancer in Malawi

BACKGROUND

Breast cancer incidence in sub-Saharan Africa (SSA) is increasing, and SSA has the highest age-standardized breast cancer mortality rate worldwide. However, high-quality breast cancer data are limited in SSA.

MATERIALS AND METHODS

We examined breast cancer patient and tumor characteristics among women in Lilongwe, Malawi and evaluated risk factor associations with patient outcomes. We consecutively enrolled 100 women ≥ 18 years with newly diagnosed, pathologically confirmed breast cancer into a prospective longitudinal cohort with systematically assessed demographic data, HIV status, and clinical characteristics. Tumor subtypes were further determined by immunohistochemistry, overall survival (OS) was estimated using Kaplan-Meier methods, and hazards ratios (HR) were calculated by Cox proportional hazard analyses.

RESULTS

Of the 100 participants, median age was 49 years, 19 were HIV-positive, and 75 presented with late stage (III/IV) disease. HER2-enriched and triple-negative/basal-like subtypes represented 17% and 25% tumors, respectively. One-year OS for the cohort was 74% (95% CI 62-83%). Multivariable analyses revealed mortality was associated with HIV (HR, 5.15; 95% CI 1.58-16.76; p = 0.006), stage IV disease (HR, 8.86; 95% CI 1.07-73.25; p = 0.043), and HER2-enriched (HR, 7.46; 95% CI 1.21-46.07; p = 0.031), and triple-negative subtypes (HR, 7.80; 95% CI 1.39-43.69; p = 0.020).

CONCLUSION

Late stage presentation, HER2-enriched and triple-negative subtypes, and HIV coinfection were overrepresented in our cohort relative to resource-rich settings and were associated with mortality. These findings highlight robust opportunities for population- and patient-level interventions across the entire cascade of care to improve breast cancer outcomes in low-income countries in SSA.

Breast Cancer Risk Factors: a Cross- Cultural Comparison between the West and the East

Background: The incidence of breast cancer in Lebanon is higher than any other Middle –Eastern country, is diagnosed at a younger age than women in Western countries, and is more aggressive and fatal. Therefore addressing risk factors in this population is of paramount importance. Methods: A descriptive cross-sectional, comparative design evaluated the risk factors for breast cancer in a convenient sample of 105 Lebanese-American women with 250 Lebanese. Odds Ratio, Chi square t-tests or ANOVA were used to compare the two groups’ risk factors and knowledge of screening tools. Associations found to be statistically significant were included in three multiple logistic regression models to estimate the odds of each variable for performing a mammography, a clinical breast exam (CBE) and a breast self-exam (BSE). Results: There were more Muslims in the Lebanese-American sample who perceived having a better income, and had a better understanding of the effectiveness of the mammogram, the CBE and the BSE. The Lebanese group reached menopause at an older age, t = 2.66, p = 0.05, smoked more, OR = 1.42, p = 0.001 and were five times more likely to live close to a main road or highway, OR = 5.75, p = 0.001 than the Lebanese-American group. The Lebanese- Americana group breast fed longer χ2= 11.68, p = .008, used contraceptives more, OR = 1.74, p = 0.027, exercised more, OR = 1.61, p < 0.001, and consumed more vegetables and fruits than their Lebanese counterparts, OR= 1.22, p = 0.002, and OR = 1.27 p = 0.001, respectively. For ever having a mammogram, the duration of breastfeeding (>6 months), effectiveness of the mammogram, and exercise were significant predictors. While for ever having a CBE, smoking, eating fruits, and exercise were significant. No variables were related to performing a BSE. Conclusion: The Lebanese women had higher risk factors for developing breast cancer, and had less knowledge of the benefits of breast cancer screening tools, calling for the importance of promoting healthy life styles and education.