Improving knowledge about breast cancer and breast self examination in female Nigerian adolescents using peer education: a pre-post interventional study

Background
Prevention of BC of which the cornerstone is creating awareness and early detection is important in adolescents and young women because of their worse outcomes. Early detection strategies such as mammography are currently beyond the reach of most women in sub-Saharan Africa.. Lack of awareness and late presentation contribute to the poor outcomes. Awareness creation among adolescents may result in modification of some risk factors for BC with adoption of healthy life styles including accessing early detection activities. This study determined the effect of peer education as a strategy to create awareness on BC and breast self examination (BSE) among in-school female adolescents in Benin City.

Methods
This was a pre-post interventional study carried out in October –December 2016 on female students of four secondary schools in Benin City. Pre-peer training, using a pre-tested self-administered questionnaire, knowledge about BC and BSE was assessed in about 30% of each school population. This was followed by training of 124 students selected from the schools (one student per class) as peer trainers. The peer trainers provided training on BC and BSE (the intervention) for their classmates. Within two weeks of peer training knowledge about BC and BSE was reassessed in 30% of each school population. Selection of students for assessment pre and post intervention was by systematic sampling. Correct knowledge was scored and presented as percentages. Chi square test, student t test and ANOVA were used to assess associations and test differences with level of significance set at p < 0.05.

Results
There were 1337 and 1201 students who responded to the pre and post-training questionnaires respectively. The mean BC knowledge score (20.61 ± 13.4) prior to training was low and it statistically significantly improved to 55.93 ± 10.86 following training p < 0.0001 Following peer training, statistically significant improvement (p 0.037- < 0.001) occurred in most knowledge domains apart from symptomatology. Pre-peer training 906(67.8%) students knew about BSE but only 67(4.8%). Significantly more students 1134(94.7%) knew about BSE following peer training.

Conclusions
Peer education strategy can be used to improve BC and BSE knowledge in adolescents. This strategy is low cost and could be very useful in low resource settings.

Needs-led human resource planning for Sierra Leone in support of oral health

Background
In Sierra Leone (SL), a low-income country in West Africa, dental care is very limited, largely private, and with services focused in the capital Freetown. There is no formal dental education. Ten dentists supported by a similar number of dental care professionals (DCPs) serve a population of over 7.5 million people. The objective of this research was to estimate needs-led requirements for dental care and human resources for oral health to inform capacity building, based on a national survey of oral health in SL.

Methods
A dedicated operational research (OR) decision tool was constructed in Microsoft Excel to support this project. First, total treatment needs were estimated from our national epidemiological survey data for three key ages (6, 12 and 15 years), collected using the ‘International Caries Classification and Management System (ICCMS)’ tool. Second, oral health needs were extrapolated to whole population levels for each year-group, based on census demographic data. Third, full time equivalent (FTE) workforce capacity needs were estimated for mid-level providers in the form of Dental Therapists (DTs) and non-dental personnel based on current oral disease management approaches and clinical timings for treatment procedures. Fourth, informed by an expert panel, three oral disease management scenarios were explored for the national population: (1) Conventional care (CC): comprising oral health promotion (including prevention), restorations and tooth extraction; (2) Surgical and Preventive care (S5&6P and S6P): comprising oral health promotion (inc. prevention) and tooth extraction (D5 and D6 together, & at D6 level only); and (3) Prevention only (P): consisting of oral health promotion (inc. prevention). Fifth, the findings were extrapolated to the whole population based on demography, assuming similar levels of treatment need.

Results
To meet the needs of a single year-group of childrens’ needs, an average of 163 DTs (range: 133–188) would be required to deliver Conventional care (CC); 39 DTs (range: 30–45) to deliver basic Surgical and Preventive care (S6P); 54 DTs for more extended Surgical and Preventive care (S5&6P) (range 38–68); and 27 DTs (range: 25–32) to deliver Prevention only (P). When scaled up to the total population, an estimated 6,147 DTs (range: 5,565–6,870) would be required to deliver Conventional care (CC); 1,413 DTs (range: 1255–1438 DTs) to deliver basic Surgical and Preventive care (S6P); 2,000 DTs (range 1590–2236) for more extended Surgical and Preventive care (S5&6P) (range 1590–2236); and 1,028 DTs to deliver Prevention only (P) (range: 1016–1046). Furthermore, if oral health promotion activities, including individualised prevention, could be delivered by non-dental personnel, then the remaining surgical care could be delivered by 385 DTs (range: 251–488) for the S6P scenario which was deemed as the minimum basic baseline service involving extracting all teeth with extensive caries into dentine. More realistically, 972 DTs (range: 586–1179) would be needed for the S5&6P scenario in which all teeth with distinctive and extensive caries into dentine are extracted.

Conclusion
The study demonstrates the huge dental workforce needs required to deliver even minimal oral health care to the Sierra Leone population. The gap between the current workforce and the oral health needs of the population is stark and requires urgent action. The study also demonstrates the potential for contemporary epidemiological tools to predict dental treatment needs and inform workforce capacity building in a low-income country, exploring a range of solutions involving mid-level providers and non-dental personnel.

Qualitative exploration of health system response to COVID-19 pandemic applying the WHO health systems framework: Case study of a Nigerian state

Pandemics can result in significantly high rates of morbidity and mortality with higher impact in Lower- and Middle-Income Countries like Nigeria. Health systems have an important role in a multi-sector response to pandemics, as there are already concerns that COVID-19 will significantly divert limited health care resources. This study appraised the readiness and resilience of the Nigerian health system to the COVID-19 pandemic, using Oyo State, southwest Nigeria, as a case study. This study was a cross-sectional qualitative study involving key informant and in-depth interviews. Purposive sampling was used in recruiting participants who were members of the Task Force on COVID-19 in the state and Emergency Operations Centre (EOC) members (physicians, nurses, laboratory scientists, “contact tracers”, logistic managers) and other partners. The state’s health system response to COVID 19 was assessed using the WHO health systems framework. Audio recordings of the interviews done in English were transcribed and thematic analysis of these transcripts was carried out using NVIVO software. Results show that the state government responded promptly by putting in place measures to address the COVID-19 pandemic. However, the response was not adequate owing to the fact that the health system has already been weakened by various challenges like poor funding of the health system, shortage of human resources and inadequate infrastructure. These contributed to the health system’s sub-optimal response to the pandemic. In order to arm the health system for adequate and appropriate response during major health disasters like pandemics, fundamental pillars of the health system-finance, human resources, information and technology, medical equipment and leadership – need to be addressed in order to have a resilient health system.

Incidence patterns, care continuum and impact of treatment on survival among women with breast cancer in Ghana and the United States

Breast cancer is the most commonly diagnosed cancer among women worldwide. Of the five breast cancer subtypes, triple negative breast cancer (TNBC) is the most aggressive subtype. Black women in the US and Ghana are more likely to be diagnosed with TNBC, at young ages and advanced stages. Combining information from Ghana and the US, this project identified the breast cancer care continuum in Ghana, examined the breast cancer incidence patterns in Ghana and the US and assessed the optimal surgical treatment for TNBC. In the first manuscript, we examined how women in Ghana navigate the healthcare system and factors that influence their decisions and ability to seek and access breast cancer care. We interviewed thirty-one women diagnosed with breast cancer in Kumasi, Ghana. Based on the findings from the interviews, we presented a framework showing specific steps in the pathways and how women transition from one step to another. In the second manuscript, we assessed factors explaining the younger age at breast cancer diagnosis among Ghanaian women compared to women in the US. To achieve these aims we analyzed breast cancer data from the Kumasi Cancer Registry, the only population-based cancer registry in Ghana, and compared it to the US Surveillance, Epidemiology and End Results (SEER) data. Population age structure, screening and cohort effects explain the younger age at breast cancer diagnosis among women in Ghana In the third manuscript, we examined whether the poor prognosis of TNBC warrants a more aggressive surgical approach and whether there is value in expanded use of radiation therapy among women with TNBC who receive mastectomy. We found that breast conserving surgery followed by radiotherapy is an effective treatment for women with early-stage TNBC. Findings from this dissertation are timely due to the rapidly rising burden of breast cancer in sub-Saharan Africa and persistent disparities in the US.

Medical Brain Drain and its Effect on the Nigerian Healthcare Sector

Nigeria suffers from a huge brain drain issue across different sectors, particularly in the healthcare sector. The WHO assessed that there is a current shortage of 2.8 million physicians in the world A heuristic phenomenological method was used in this study to explore the lived experiences of 12 Nigerian healthcare practitioners that migrated to the United States. The push-pull theory served as the theoretical framework that grounded this study. The central research questions for this study focused primarily on the reasons healthcare practitioners are leaving Nigeria and what the impact of those decisions have on the Nigerian healthcare sector. Qualitative data were collected and analyzed identified three emerging themes: (a) challenges of living in Nigeria; (b) lack of government support; and (c) reality of knowledge gap. The participants were selected by using a purposive and snowball sampling method, and a semi-structure interview was used to collect data from the participants. The study used Moustakas’s heuristic phenomenological approach, which allowed the use of thematic analysis to record and identify passages of the text that fell into categories. The finding from the research puts the brain drain phenomenon on the Nigerian government and its lack of support in rebuilding the healthcare system. Recommendations were made based on the emergent themes on how the government can work with Nigerians in the diaspora to help strengthen the Nigerian healthcare sector and to create worthwhile policies/laws/regulations that will help build the country. Implication for positive social change include the creation of jobs for young Nigerians and creating proper policies and wage scale so that they can be on par with their counterpart

Acute kidney injury among medical and surgical in-patients in the Cape Coast Teaching Hospital, Cape Coast, Ghana: a prospective cross-sectional study

Background: Acute kidney injury (AKI) is a syndrome associated with high morbidity, mortality and high hospital costs. Despite its adverse clinical and economic effects, only a few studies have reported reliable estimates on the incidence of AKI in sub-Sahara Africa. We assessed the incidence and associated factors of AKI among medical and surgical patients admitted to a tertiary hospital in Ghana.

Methods: A prospective cross-sectional study was conducted among one hundred and forty-five (145) consecutive patients admitted to the medical and the surgical wards at the Cape Coast Teaching Hospital (CCTH), Cape Coast, Ghana from April 2017 to April 2018. Socio-demographic and clinical information were collected using structured questionnaires. AKI was diagnosed and staged with the KDIGO guideline, using admission serum creatinine as baseline kidney function.

Results: The mean age of the study participants was 46.6±17.7 years, whilst the male:female ratio was 68:77. The overall incidence of AKI among the participants was 15.9% (95% CI: 10.33 – 22.84%). Stage 1 AKI occurred in 56.5% of the participants, whilst stages 2 and 3 AKI respectively occurred among 4.1% and 2.8% of respondents. About 20% of the participants in the medical ward developed AKI (n= 15) whilst 12% of those in surgical ward developed AKI (n= 8). Among the participants admitted to the medical ward, 60.0%, 26.7% and 13.3% had stages 1, 2 and 3 AKI respectively. Whilst 50.0%, 25.0% and 25.0% respectively developed stages 1, 2 and 3 AKI in the surgical ward. Medical patients with AKI had hyper-tension (40%), followed by liver disease (33.3%); 37.5% of surgical inpatients had gastrointestinal (GI) disorders.

Conclusion: The incidence of AKI is high among medical and surgical patients in-patients in the CCTH, Ghana, with hypertension and liver disease as major comorbidities.

Prevalence and Mortality of Triple-Negative Breast Cancer in West Africa: Biologic and Sociocultural Factors

Key Objective
Triple-negative breast cancer (TNBC) is a malignant breast cancer, lacking targeted therapy, which would benefit from further research to understand its nature and the observed variation in its malignancy between women of differing ancestries. This large-scale systematic literature review examines the current and emerging biologic and nonbiologic factors, which have been shown to influence TNBC disease outcomes among indigenous West African (WA) females while discussing some prospective steps that could be adopted by health care systems for the reduction of this burden.

Knowledge Generated
WA women are the most burdened populations in relation to TNBC. Biologic and economic factors have been shown to significantly influence the TNBC disease outcomes. Women’s education initiatives, specialist training, and accessible health care are needed in WA countries.

Relevance
The determination of WA-specific biologic, cultural, and socioeconomic TNBC factors could align efforts in developing treatment options and physician recommendations to cancer-burdened women.

Public Awareness Knowledge of Availability And Willingness to Use Neurosurgical Care Services in Africa: A CrossSectional ESurvey Protocol

Background: Barriers to care cause delays in seeking, reaching, and getting care. These delays affect low-and middle-income countries (LMICs), where 9 out of 10 LMIC inhabitants have no access to basic surgical care. Knowledge of healthcare utilization behavior within underserved communities is useful when developing and implementing health policies. Little is known about the neurosurgical health-seeking behavior of African adults. This study evaluates public awareness, knowledge of availability, and readiness for neurosurgical care services amongst African adults.

Methodology: The cross-sectional study will be run using a self-administered e-survey hosted on Google Forms (Google, CA, USA) disseminated from 10th May 2021 to 10th June 2021. The Questionnaire would be in two languages, English and French. The survey will contain closed-ended, open-ended, and Likert Scale questions. The structured questionnaire will have four sections with 42 questions; Sociodemographic characteristics, Definition of neurosurgery care, Knowledge of neurosurgical diseases, practice and availability, and Common beliefs about neurosurgical care. All consenting adult Africans will be eligible. A minimum sample size of 424 will be used. Data will be analyzed using SPSS version 26 (IBM, WA, USA). Odds ratios and their 95% confidence intervals, Chi-Square test, and ANOVA will be used to test for associations between independent and dependent variables. A P-value <0.05 will be considered statistically significant. Also, a multinomial regression model will be used.

Dissemination: The study findings will be published in an academic peer-reviewed journal, and the abstract will be presented at an international conference.

Highlights

The burden of neurosurgical diseases is enormous in low- and middle-income countries, especially in Africa.
Unfortunately, most neurosurgical needs in Africa are unmet because of delays in seeking, reaching, and getting care.
Most efforts aimed at reducing barriers to care have focused on improving the neurosurgical workforce density and infrastructure. Little or no efforts have been directed towards understanding or reducing the barriers to seeking care.
We aimed to understand public awareness, willingness to use, and knowledge of the availability of neurosurgical care in Africa.
The study findings can inform effective strategies that promote the utilization of neurosurgical services and patient education in Africa.

Health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa: a systematic review

Background
Breast cancer patients in sub-Saharan Africa experience long time intervals between their first presentation to a health care facility and the start of cancer treatment. The role of the health system in the increasing treatment time intervals has not been widely investigated. This review aimed to identify existing information on health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa to contribute to the reorientation of health policies in the region.

Methods
PubMed, ScienceDirect, African Journals Online, Mendeley, ResearchGate and Google Scholar were searched to identify relevant studies published between 2010 and July 2020. We performed a qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Related health system factors were extracted and classified according to the World Health Organization’s six health system building blocks. The quality of qualitative and quantitative studies was assessed by using the Critical Appraisal Skills Program Quality-Assessment Tool and the National Institute of Health Quality Assessment Tool, respectively. In addition, we used the Confidence in the Evidence from Reviews of Qualitative Research tool to assess the evidence for each qualitative finding.

Results
From 14,184 identified studies, this systematic review included 28 articles. We identified a total of 36 barriers and 8 facilitators that may influence diagnostic and treatment intervals in women with breast cancer. The principal health system factors identified were mainly related to human resources and service delivery, particularly difficulty accessing health care, diagnostic errors, poor management, and treatment cost.

Conclusion
The present review shows that diagnostic and treatment intervals among women with breast cancer in sub-Saharan Africa are influenced by many related health system factors. Policy makers in sub-Saharan Africa need to tackle the financial accessibility to breast cancer treatment by adequate universal health coverage policies and reinforce the clinical competencies for health workers to ensure timely diagnosis and appropriate care for women with breast cancer in this region.

Community engagement and involvement in Ghana: conversations with community stakeholders to inform surgical research

Background: Involving patients and communities with health research in low- and middle-income countries (LMICs) contributes to increasing the likelihood that research is relevant in local context and caters to the needs of the population, including vulnerable and marginalised groups. When done right, it can also support empowerment of wider communities in taking ownership of their own health, lead to increased access and uptake of health services and generally improve the wellbeing of individuals. However, the evidence base of how to undertake successful community engagement and involvement (CEI) activities in LMICs is sparse. This paper aims to add to the available literature and describes how the Global Health Research Unit on Global Surgery’s (GSU) team in Ghana worked collaboratively with the Unit’s team in the UK and a UK-based Public Advisory Group to involve community stakeholders in rural Ghana with surgical research. The aim was to explore ways of reaching out to patients and community leaders in rural Ghana to have conversations that inform the relevance, acceptability, and feasibility of a clinical trial, called TIGER.
Methods: As this kind of larger scale involvement of community stakeholders with research was a novel way of working for the team in Ghana, a reflective approach was taken to outline step-by-step how the GSU team planned and undertook these involvement activities with 31 hernia patients, two Chiefs (community leaders), a community finance officer and a local politician in various locations in Ghana. The barriers that were experienced and the benefits of involving community stakeholders are highlighted with the aim to add to the evidence base of CEI in LMICs.
Results: GSU members from the UK and Ghana planned and organised successful involvement activities that focused on establishing the best way to talk to patients and other community stakeholders about their experiences of living with hernias and undergoing hernia repairs, and their perceptions of the impact of hernias on the wider community. The Ghanaian team suggested 1:1 conversations in easily accessible locations for rural patient contributors, creating a welcoming environment and addressing contributors in their local dialects. A UK-based Public Advisory Group helped in the initial stages of planning these conversations by highlighting potential barriers when approaching rural communities and advising on how to phrase questions around personal experiences. Conversations mainly focused on understanding the needs of hernia patients in rural Ghana to then incorporate these in the design of the TIGER trial to ensure its relevance, acceptability and feasibility. When talking to patient contributors, the GSU teams found that they were more likely to open up when they knew members of the team and the opportunity to speak to local leaders only arose because of the Ghanaian team members being well-respected amongst communities. The experiences of the patient and community contributors led to changes in the study protocol, such as including women in the patient cohort for the trial, and allowed the GSU teams to confirm the relevance and acceptability of this trial. These conversations also taught the team a lot about perceptions of health in rural communities, allowed the Ghanaian team to establish relationships with community leaders that can be utilised when future studies need input from the public, and has changed the minds of the Ghanaian research team about the importance of involving patients with research.
Conclusion: This paper contributes to the evidence base on successful CEI activities in LMICs by providing an example of how CEI can be planned and organised, and the benefits this provides. The conversations the teams had with patient contributors in Ghana are an example of successful patient consultations. Even though there are certain limitations to the extent of these involvement activities, a solid foundation has been built for researchers and community stakeholders to establish relationships for ongoing involvement.