Perceptions of cervical cancer care among Ethiopian women and their providers: a qualitative study

Assessing the influence of the health system on access to cervical cancer prevention, screening, and treatment services at public health centers in Addis Ababa, Ethiopia

BACKGROUND

Cervical cancer is the second leading cause of cancer death among Ethiopian women. This study aimed to assess the influence of the health system on access to cervical cancer prevention, screening, and treatment services at public health centers in Addis Ababa, Ethiopia.

METHODS

This study used a cross-sectional survey design and collected data from 51 randomly selected public health centers in Addis Ababa. Open Data Kit was used to administer a semi-structured questionnaire on Android tablets, and SPSS version 26 was used to analyze the descriptive data.

RESULTS

In the study conducted at 51 health centers, cervical cancer prevention and control services achieved 61% HPV vaccination for girls, 79% for cervical cancer awareness messages, 80% for precancer lesion treatment, and 71% for cervical screening of women. All health centers were performing cervical screening mostly through visual inspection with acetic acid due to the inconsistent availability of HPV DNA tests and the lack of Pap smear tests. In 94% of health centers, adequate human resources were available. However, only 78% of nurses, 75% of midwives, 35% of health officers, and 49% of health extension workers received cervical cancer training in the 24 months preceding the study. Women had provider choices in only 65% of health centers, and 86% of the centers lacked electronic health records. In 41% of the health centers, the waiting time was 30 minutes or longer. About 88% and 90% of the facilities lacked audio and video cervical cancer messages, respectively.

CONCLUSION

This study revealed that the annual cervical cancer screening achievement was on track to fulfill the WHO's 90-70-90 targets by 2030. We recommend that decision-makers prioritize increasing HPV vaccination rates, enhancing messaging, reducing wait times, and implementing electronic health records to improve access to cervical cancer services in Addis Ababa.

Validation of the Amharic version of perceived access to healthcare services for patients with cervical cancer in Ethiopia: A second-order confirmatory factor analysis

BACKGROUND

Accessing healthcare services is a multifaceted phenomenon involving various elements, encompassing the demand, identification, reach, and utilization of healthcare needs. The literature offers methods for capturing patients' perceptions of healthcare access. However, to accurately measure patient perceptions, it is imperative to ensure the validity and reliability of such instruments by designing and implementing localized language versions.

AIM

The primary aim of this study was to validate the Amharic version of the perceived access to health-care services among patients diagnosed with cervical cancer in Ethiopia.

METHOD

A cross-sectional study was conducted among cervical cancer patients at oncology centers in Addis Ababa, Ethiopia. A consecutive sampling approach was used and data collection took place from January 1 to March 30, 2023. Following initial validation and pretesting, a KoboCollect mobile phone application was employed for data collection. Subsequently, the collected data underwent cleaning in Microsoft Excel and analysis through Amos software v.26 and R programming. Various validity and reliability tests, such as content validity, convergent validity, face validity, divergent validity, known-group validity, and reliability tests, were executed. A second-order confirmatory factor analysis was developed to calculate incremental model fit indices, including CFI and TLI, along with absolute measures, namely SRMR and RMSEA.

RESULTS

A total of 308 participants were involved in the study, with 202 (65.6%) being patients referred from outside Addis Ababa. The initial evaluation of content validity by expert panels indicated that all criteria were met, with a CVR range of 0.5 to 1, I-CVI values ranging from 0.75 to 1, an S-CVI value of 0.91, and face validity values ranging from 2.4 to 4.8. The internal consistency of items within the final constructs varied from 0.76 to 0.93. Convergent, known-group, and most divergent validity tests fell within acceptable fit ranges. Common incremental fit measures for CFI and TLI were achieved with corresponding values of 0.95 and 0.94, respectively. The absolute fit measures of SRMR and RMSEA were 0.04 and 0.07, indicating good and moderate fit, respectively.

CONCLUSION

The study indicated a high internal consistency and validity of items with good fit to the data, suggesting potential accuracy of the domains. A five-domain structure was developed which enables adequate assessment of perceived access to health-care services of patients with cervical cancer in Ethiopia. We suggest that the tool can be utilized in other patient populations with a consideration of additional constructs, such as geographic accessibility.

Understanding referral of patients with cancer in rural Ethiopia: a qualitative study

BACKGROUND

Cancer incidence is increasing in Ethiopia mainly due to increased life expectancy, while oncological capacities remain limited. Strong referral linkages between different levels of the healthcare system are key to provide timely access to cancer care. In this qualitative study, we assessed limitations and potential of cancer patient referral in the rural Southwest of Ethiopia.

METHODS

We held four focus group discussions (FGD) with health professionals at one primary and three secondary hospitals and conducted eight in-depth interviews (IDI) with the hospitals´ medical executives and local health bureau representatives. Data was analysed inductively using thematic analysis and emerging themes were categorized within the revised concept of access by Penchansky and Saurman.

RESULTS

The inevitable referral of patients with cancer in the rural Southwest of Ethiopia is characterized by the absence of clear communication protocols and the lack of formal referral linkages. The newly implemented hub-system has improved emergency referrals and could be expanded to non-emergency referrals, sensitive to the needs of advanced oncological care. Liaison officers can pave the way but need to be trained and equipped adequately. Referred patients struggle with inadequate transportation systems, the lack of accommodation close to specialized facilities as well as the inability to navigate at those sites due to language barriers, illiteracy, and stigmatization. Few Non-Governmental Organizations (NGOs) help but cannot compensate the limited governmental support. The shortage of medications at public hospitals leads to patients being directed to costly private pharmacies. In the light of those challenges, cancer remains to be perceived as a "death sentence" within the rural communities.

CONCLUSIONS

Standardized referral linkages and a multi-faceted support network throughout the cancer care continuum are necessary to make oncology care accessible to Ethiopia´s large rural population.

Dimensions of patient-centred care from the perspective of patients and healthcare workers in hospital settings in sub-Saharan Africa: A qualitative evidence synthesis

INTRODUCTION

The United States Institute of Medicine defines patient centred care (PCC), a core element of healthcare quality, as care that is holistic and responsive to individual needs. PCC is associated with better patient satisfaction and improved clinical outcomes. Current conceptualizations of PCC are mainly from Europe and North America. This systematic review summarises the perceived dimensions of PCC among patients and healthcare workers within hospitals in sub-Saharan Africa (SSA).

METHODS

Without date restrictions, searches were done on databases of the Web of Science, Cochrane Library, PubMed, Embase, Global Health, and grey literature, from their inception up to 11th August 2022. Only qualitative studies exploring dimensions or perceptions of PCC among patients, doctors and/or nurses in hospitals in (SSA) were included. Review articles and editorials were excluded. Two independent reviewers screened titles and abstracts, and conducted full-text reviews with conflicts resolved by a third reviewer. The CASP (critical appraisal skills program) checklist was utilised to assess the quality of included studies. The framework synthesis method was employed for data synthesis.

RESULTS

5507 articles were retrieved. Thirty-eight studies met the inclusion criteria, of which 17 were in the specialty of obstetrics, while the rest were spread across different fields. The perceived dimensions reported in the studies included privacy and confidentiality, communication, shared decision making, dignity and respect, continuity of care, access to care, adequate infrastructure and empowerment. Separate analysis of patients' and providers' perspective revealed a difference in the practical understanding of shared-decision making. These dimensions were summarised into a framework consisting of patient-as-person, access to care, and integrated care.

CONCLUSION

The conceptualization of PCC within SSA was largely similar to findings from other parts of the world, although with a stronger emphasis on access to care. In SSA, both relational and structural aspects of care were significant elements of PCC. Healthcare providers mostly perceived structural aspects such as infrastructure as key dimensions of PCC.

TRIAL REGISTRATION

PROSPERO Registration number CRD42021238411.

Health seeking behaviours and private sector delivery of care for non-communicable diseases in low- and middle-income countries: a systematic review

BACKGROUND

Globally, non-communicable diseases (NCDs) are the leading cause of mortality and morbidity placing a huge burden on individuals, families and health systems, especially in low- and middle-income countries (LMICs). This rising disease burden calls for policy responses that engage the entire health care system. This study aims to synthesize evidence on how people with NCDs choose their healthcare providers in LMICs, and the outcomes of these choices, with a focus on private sector delivery.

METHODS

A systematic search for literature following PRISMA guidelines was conducted. We extracted and synthesised data on the determinants and outcomes of private health care utilisation for NCDs in LMICs. A quality and risk of bias assessment was performed using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

We identified 115 studies for inclusion. Findings on determinants and outcomes were heterogenous, often based on a particular country context, disease, and provider. The most reported determinants of seeking private NCD care were patients having a higher socioeconomic status; greater availability of services, staff and medicines; convenience including proximity and opening hours; shorter waiting times and perceived quality. Transitioning between public and private facilities is common. Costs to patients were usually far higher in the private sector for both inpatient and outpatient settings. The quality of NCD care seems mixed depending on the disease, facility size and location, as well as the aspect of quality assessed.

CONCLUSION

Given the limited, mixed and context specific evidence currently available, adapting health service delivery models to respond to NCDs remains a challenge in LMICs. More robust research on health seeking behaviours and outcomes, especially through large multi-country surveys, is needed to inform the effective design of mixed health care systems that effectively engage both public and private providers.

TRIAL REGISTRATION

PROSPERO registration number CRD42022340059 .

Factors influencing the uptake and utilization of cervical cancer screening services among women attending public health centers in Addis Ababa, Ethiopia: mixed methods study

BACKGROUND

Cervical cancer is the second cause of cancer deaths among Ethiopian women. Despite multifaceted government efforts, the uptake and utilization of cervical cancer screening remain very low. This study aimed to assess factors influencing the uptake and utilization of cervical cancer screening at public health centers in Addis Ababa.

METHODS

A convergent parallel mixed-method study was employed to collect data through eight focus group discussions with 66 women purposively recruited from outpatient clinics, and cross-sectional face-to-face exit interviews with 80 women attending cervical cancer clinics in four high-patient volume health centers. The group interviews were tape-recorded, transcribed in Amharic, translated into English, and a thematic analysis approach was used in the analysis. Exit interview data were collected using a structured questionnaire in the Open Data Kit tool on an android tablet. STATA version 17 was used for descriptive and inferential data analyses. Statistical significance was set at p < 0.05.

RESULTS

The majority of focus group discussion participants had lack of knowledge of cervical cancer and its screening services. The major barriers to the uptake of screening were inadequate public awareness, fear of the procedure, embarrassment, provider's gender, lack of male partner support, and childcare. Women aged 40 years and above were 13.9 times more likely to utilize cervical cancer screening than those under 30 years (AOR = 13.85; 95% CI: 1.40, 136.74). There was a strong preference for a female provider (AOR = 7.07; 95% CI: 1.53, 32.75) among women screened after attending antiretroviral therapy clinics and those screened due to abnormal vaginal bleeding than women referred from family planning clinics (AOR = 6.87; 95% CI: 1.02, 46.44). Safety of screening was negatively associated with women aged 30-39 (AOR = 0.045; 95% CI: 0.003, 0.696), and those who attended primary education, and secondary education and above, (AOR = 0.016; 95% CI: 0.001, 0.262), and (AOR = 0.054; 95% CI: 0.004, 0.724), respectively.

CONCLUSIONS

The study identified low public awareness, inadequate provider preference, safety concerns, and poor male partner support for cervical cancer screening. We recommend the decision-makers enhance public messages, maintain provider choices, ensure safety, and engage males to improve the uptake and utilization of cervical cancer screening.

Cancer signs and risk factors awareness in Addis Ababa, Ethiopia: a population-based survey

BACKGROUND

There is a paucity of data on public awareness of cancer in Ethiopia. This study assessed cancer signs, symptoms, and risk factors awareness among individuals aged 18 and older in Addis Ababa, Ethiopia.

METHOD

A population-based face-to-face interview was conducted applying a validated cancer awareness measure (CAM) tool. A total of 600 adults (315 males and 285 females) were recruited using a multistage sampling technique. One open-ended and ten closed-ended questions were used to assess awareness of cancer signs and symptoms. To assess awareness of cancer risk factors, one open-ended and twelve closed-ended questions were used. Logistic regression analysis was used to test the association between sociodemographic status and awareness of cancer signs, symptoms, and risk factors.

RESULTS

Based on the responses for the open-ended questions, unexplained bleeding (23.16%) and smoking (24.17%) were the most frequently recalled cancer sign and risk factor, respectively. Based on the responses for the closed questions, the majority of respondents identified tiredness all the time (80.7%) as a cancer symptom and alcohol use (82.5%) as a cancer risk factor.  The odds of cancer signs and symptoms awareness was higher in those with primary (AOR = 4.50, 95% CI, 1.72-11.79, p = 0.02), secondary (AOR = 4.62; 95% CI 1.86-11.43; p = 0.001), and tertiary (AOR = 7.51; 95% CI 3.04-18.56; p < 0.001) education than those who were illiterate. The odds of awareness about cancer signs and risk factors was 0.28 (95% CI 0.12-0.65; p = 0.003) and 0.22 (95% CI 0.83-0.58; p = 0.002) times lower, respectively, among individuals aged 60 and older than those aged 18 to 29.

CONCLUSIONS

Young adults who attended formal education of primary or higher level may have a better cancer signs and symptoms awareness. Future education interventions to increase awareness of the society in Addis Ababa may target illiterate and the elderly.

Patient delay and related influencing factors in Chinese women under 35 years diagnosed with cervical cancer: A cross-sectional study

Objective

Patient delay was defined as an interval between the discovery of the initial symptoms and diagnosis, which was longer than 90 days. This study aimed to determine the patient delay rate and related factors in women with cervical cancer in Hunan province, South-Central China.

Methods

A cross-sectional study was conducted among 140 women with cervical cancer aged <35 years from October, 2019 to March, 2021. Assumptions in Andersen Behavioral Model of Health Services Utilization were used to measure the factors influencing patient delay. Logistic regression models were used to identify factors associated with patient delay. A P-value of <5% was considered significant.

Results

A total of 57 (40.71%) young women with cervical cancer had patient delay, with an average delay time of 178.70 (307.90) days. Predisposing factors, such as religion, unemployment, health beliefs related to cancer screening, and a history of cervical cancer screening within 2 years or more (P ​< ​0.05), were associated with patient delay. Enabling factors, such as distance to the nearest medical facility and type of the nearest medical facility, were associated with a reduced likelihood of patient delay. With the need-for-care factor, young women who experienced vaginal pain after or during intercourse had a higher risk (adjusted odds ratio, 33.48; 95% confidence interval, 3.22-348.68, P ​= ​0.003) of patient delay.

Conclusions

These findings reinforce the need for programs to enhance knowledge and awareness about cervical cancer screening and the importance of early diagnosis in women to help eliminate cervical cancer in China by 2050.

Barriers and facilitators to chemotherapy initiation and adherence for patients with HIV-associated Kaposi’s sarcoma in Kenya: a qualitative study

Background

Kaposi sarcoma is one of the most prevalent HIV-associated malignancies in sub-Saharan Africa and is often diagnosed at advanced stage of disease. Only 50% of KS patients who qualify for chemotherapy receive it and adherence is sub-optimal.

Methods

57 patients > 18 years with newly diagnosed KS within the AMPATH clinic network in Western Kenya were purposively selected to participate in semi-structured interviews stratified by whether they had completed, partially completed, or not completed chemotherapy for advanced stage KS. We based the interview guide and coding framework on the situated Information, Motivation, Behavioral Skills (sIMB) framework, in which the core patient centered IMB constructs are situated into the socioecological context of receiving care.

Results

Of the 57 participants, the median age was 37 (IQR 32–41) and the majority were male (68%). Notable barriers to chemotherapy initiation and adherence included lack of financial means, difficulty with convenience of appointments such as distance to facility, appointment times, long lines, limited appointments, intrapersonal barriers such as fear or hopelessness, and lack of proper or sufficient information about chemotherapy. Factors that facilitated chemotherapy initiation and adherence included health literacy, motivation to treat symptoms, improvement on chemotherapy, prioritization of self-care, resilience while experiencing side effects, ability to carry out behavioral skills, obtaining national health insurance, and free chemotherapy.

Conclusion

Our findings about the barriers and facilitators to chemotherapy initiation and adherence for KS in Western Kenya support further work that promotes public health campaigns with reliable cancer and chemotherapy information, improves education about the chemotherapy process and side effects, increases oncology service ability, supports enrollment in national health insurance, and increases incorporation of chronic disease care into existing HIV treatment networks.