Cancer Screening Programs in Low- and Middle-Income Countries: Strategies for Success

Cancer is a leading global health problem and, as of 2020, accounts for 10 million deaths per year.1 The World Health Organization (WHO) estimates that between 30 and 50% of cancer deaths can be prevented by avoiding risk factors, early detection via screening, and proper treatment. The majority of cases occur in low- and middle-income countries (LMIC).2 Despite awareness of the magnitude of this problem by the global health community and the large-scale efforts to implement screening programs, very few programs are successful and, more importantly, sustainable. Although there are several barriers to implementation of a cancer screening program, the critical barriers are lack of awareness and acceptance of the screening programs by the people residing in the specific geographic regions. In the article by Pak et al. entitled Cancer Awareness and Stigma in Rural Assam India: Baseline Survey of the Detect Early and Save Her/Him (DESH) Program, the authors highlight the cultural and psychosocial barriers to cancer screening.3

The DESH program is a well-organized screening program with multiple components that consists of an initial baseline survey followed by implementation of mobile cancer screening and subsequent follow-up of patients regarding final diagnosis and treatment. The DESH program in Assam, India, focuses on breast, oral, and cervical cancers due to the high incidence of these cancers in this region and the availability of validated screening tests. The baseline survey was validated in a smaller cohort (n = 20) of local participants before widespread implementation to nearly 1000 participants. The survey consisted of multiple sections that focused on areas such as awareness of the carcinogenic effects of certain lifestyle choices, i.e., consumption of betel nuts and smoking, spiritual/religious beliefs, stigma around cancer diagnoses, and knowledge about screening programs and local health care facilities. Through this approach, they found that the majority (92.9%) of participants were not aware of cancer screening availability and had never undergone prior screening. Additionally, over 90% of the survey participants reported consumption of betel nuts, but less than half (46.9%) were aware of the carcinogenic effects of betel nuts. Finally, 42–57% of participants reported negative stigma towards cancer diagnosis. Specifically, more than 30% of participants believed that either cancer is a punishment from God or is caused by bad karma and evil spirits. Furthermore, 20% of participants described fear of cancer screening. These results highlight the complex interplay between knowledge gaps, misconceptions, and cancer stigma that could affect the acceptance, and thereby the success, of a screening program.

Taneja et al. identified similar sociocultural barriers regarding cervical cancer screening in India. Specifically, barriers identified included lack of awareness about screening, poor knowledge about initial symptoms, social stigma, cost, and familial obligations. Hence, it is not surprising that only 5% of eligible women have undergone screening for cervical cancer in India, compared with up to 84% in developed countries.4 This is disconcerting since cervical cancer has the potential for prevention and/or cure due to the length of the premalignant and preinvasive period, emphasizing the importance of a population-based screening program. The benefits of an effective screening program for this disease were demonstrated by Sankaranarayanan et al. in a study of over 130,000 healthy women, in which participants were randomly assigned to undergo cervical cancer screening with either human papillomavirus (HPV) testing, cytologic testing, or visual inspection with acetic acid (VIA). Single-round HPV testing was associated with a significantly reduced number of advanced cases [hazard ratio (HR) 0.47, 95% confidence interval (CI) 0.32–0.69] and mortality5 (HR 0.53, 95% CI 0.33–0.83) compared with the control group. The results of this study highlight that implementation of a successful screening program with the right screening test is associated with decreased mortality, even in low-resource settings. However, the main challenge is to screen enough people for the screening program to be effective. The National Cancer Prevention and Control Program launched in 2010 in Morocco, with augmented and expanded infrastructure and considered an exemplar for screening programs in LMIC, had major challenges with uptake of screening and poor participation in early identification of precancerous lesions.

The embodiment of low-field MRI for the diagnosis of infant hydrocephalus in Uganda

Compared to other parts of the world, theincidence of hydrocephalus in children is very high in subSaharan Africa. Magnetic resonance imaging (MRI) would be the
preferred diagnostic method for infant hydrocephaleus. However, in practice, MRI is seldom used in sub-Saharan Africa due to its high prize, low mobility, and high power consumption.
A low-cost MRI technology is under development by reducing the strength of the magnetic field and the use of alternative technologies to create the magnetic field. This paper describes the embodiment design process to match this new MRI technology under development with the specific characteristics of the healthcare system in Uganda.

A context exploration was performed to identify factors that may affect the design and implementation of the low-field MRI in Ugandan hospitals and Ugandan healthcare environment. The key-insights from the technology- and context-exploration were translated into requirements which were the starting point for the design process. The concept development did have a focus on Cost-effective design, Design for durability & reliability, and Design for repairability. The final design was validated by stakeholders from the Ugandan Healthcare context.

Impact of nursing education and a monitoring tool on outcomes in traumatic brain injury

Introduction
Throughout the world, traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality. Low-and middle-income countries experience an especially high burden of TBI. While guidelines for TBI management exist in high income countries, little is known about the optimal management of TBI in low resource settings. Prevention of secondary injuries is feasible in these settings and has potential to improve mortality.

Methods
A pragmatic quasi-experimental study was conducted in the emergency centre (EC) of Mulago National Referral Hospital to evaluate the impact of TBI nursing education and use of a monitoring tool on mortality. Over 24 months, data was collected on 541 patients with moderate (GCS9-13) to severe (GCS≤8) TBI. The primary outcome was in-hospital mortality and secondary outcomes included time to imaging, time to surgical intervention, time to advanced airway, length of stay and number of vital signs recorded.

Results
Data were collected on 286 patients before the intervention and 255 after. Unadjusted mortality was higher in the post-intervention group but appeared to be related to severity of TBI, not the intervention itself. Apart from number of vital signs, secondary outcomes did not differ significantly between groups. In the post-intervention group, vital signs were recorded an average of 2.85 times compared to 0.49 in the pre-intervention group (95% CI 2.08-2.62, p ≤ 0.001). The median time interval between vital signs in the post-intervention group was 4.5 h (IQR 2.1-10.6).

Conclusion
Monitoring of vital signs in the EC improved with nursing education and use of a monitoring tool, however, there was no detectable impact on mortality. The high mortality among patients with TBI underscores the need for treatment strategies that can be implemented in low resource settings. Promising approaches include improved monitoring, organized trauma systems and protocols with an emphasis on early aggressive care and primary prevention.

Remote Monitoring of Clubfoot Treatment With Digital Photographs in Low Resource Settings: Is It Accurate?

Background: Clinical examination and functional assessment are often the first steps to assess outcome of clubfoot treatment. Clinical photographs may be an adjunct used to assess treatment outcomes in lower resourced settings where physical review by a specialist is limited. We aimed to evaluate the diagnostic performance of photographic images of patients with clubfoot in assessing outcome following treatment.

Methods: In this single-centre diagnostic accuracy study, we included all children with clubfoot from a cohort treated between 2011 and 2013, in 2017. Two physiotherapists trained in clubfoot management calculated the Assessing Clubfoot Treatment (ACT) score for each child to decide if treatment was successful or if further treatment was required. Photographic images were then taken of 79 feet. Two blinded orthopaedic surgeons assessed three sets of images of each foot (n = 237 in total) at two time points (two months apart). Treatment for each foot was rated as ‘success’, ‘borderline’ or ‘failure’. Intra- and inter-observer variation for the photographic image was assessed. Sensitivity, specificity, positive and negative predictive values were calculated for the photographic image compared to the ACT score.

Results: There was perfect correlation between clinical assessment and photographic evaluation of both raters at both time-points in 38 (48%) feet. The raters demonstrated acceptable reliability with re-scoring photographs (rater 1, k = 0.55; rater 2, k = 0.88). Thirty percent (n = 71) of photographs were assessed as poor quality image or sub-optimal patient position. Sensitivity of outcome with photograph compared to ACT score was 83.3%-88.3% and specificity ranged from 57.9%-73.3%.

Conclusion: Digital photography may help to confirm, but not exclude, success of clubfoot treatment. Future work to establish photographic parameters as an adjunct to assessing treatment outcomes, and guidance on a standardised protocol for photographs, may be beneficial in the follow up of children who have treated clubfoot in isolated communities or lower resourced settings.