Jennifer Moodley

Early detection and diagnosis of cancer in African contexts is challenging. Health services should identify people with symptoms suggestive of cancer, refer timeously, and implement diagnostic processes efficiently. This requires the resources and infrastructure to provide these services. This study, the first in Southern Africa, reports on the availability of these services across referral pathways in four provinces of two Southern African countries, South Africa and Zimbabwe. As part of the African Awareness of Cancer and Early Diagnosis (AWACAN-ED) programme, we conducted a quantitative cross-sectional study, from February to September 2023 at primary care (PC), secondary and tertiary (ST) level public sector health facilities. PC’s role is to identify and refer patients, while the definitive diagnosis mostly occurs at ST level. Data were collected on the availability of staff, infrastructure, diagnostic services, referral pathways and community engagement, and analysed descriptively. A total of thirty-four (N = 34) facilities were included. Twenty-two (n = 22) were PC facilities, serving a population of 1,068,177, with a nurse-to-1000-person ratio of 0.46, and doctor-to-1000-person ratio of 0.04. Twelve (n = 12) ST facilities were included, serving a population of 18,750,387, with a nurse-to-1000-person ratio of 0.42, and doctor-to-1000-person ratio of to 0.06. PC and ST facilities differed in availability of adequate communication infrastructure (40% vs 42%); patient transport systems (50% vs 100%); cervical smears/visual inspection (77% vs 100%) and colorectal clinical assessment (9% vs 58%). Mammography was not available at any Zimbabwean facilities. There was low availability of clinical protocols in primary care for cervical (30%) and breast (9%) cancer, and none for colorectal cancer. Community engagement activities focused on breast and cervical cancer. This study identifies areas for improving early cancer diagnosis and provides a baseline for quality improvement interventions in facility infrastructure and referral pathways.

Background: Cancer is an increasing public health problem in South Africa, with breast cancer being the most diagnosed cancer and cervical cancer the leading cause of cancer deaths among women. Despite the complexity of breast and cervical cancer patients’ journeys through the healthcare system, patients’ voices are still predominantly missing from the body of literature. Patient journey mapping, as a qualitative research method, offers an opportunity for centring patients in their care journeys and reimagine healthcare provision for the potential improvement of health systems and patient outcomes. Aim: The aim of this study was to map journeys of breast and cervical cancer patients across the cancer care continuum. Methods: Using patient journey mapping, we conducted six focus group discussions with patients with breast and cervical cancer who had completed treatment in Gauteng, KwaZulu Natal and the Western Cape, South Africa. The process involved three steps: 1.) development of individual maps; 2.) narrative sharing; and 3.) development of a collective map. Results of the study were shared in feedback sessions. Findings: A total of 31 people participated in the focus groups: 23 with breast cancer, 7 cervical cancer and one had both cancers during her lifetime. The participants’ ages ranged between 30 and 69 years old. A patient journey map was developed drawing on the individual and collective maps and participant narratives. The findings of the paper constellate around three themes. The first theme, (de)personalised care, offers an examination of how relational, institutional and structural factors shape and are reshaped through participants lived experiences across the cancer care continuum. The second theme, self-advocacy, explores how participants advocate for their healthcare needs throughout the cancer care continuum. The third theme, intersecting vulnerabilities, explores how intersecting social identities, such as socioeconomic factors, gender, comorbidities and mental health, shape their cancer care journeys. Conclusions: By centring patient with breast and cervical cancer voices, patient journey mapping not only showed where services and systems fall short but also provided guidance for redesigning a more patient responsive health system.

Introduction: Shorter time to diagnosis may lead to better cancer outcomes in Southern Africa. This study measured the time from symptoms to first healthcare visit (patient interval; PI) and diagnosis (diagnostic interval; DI) and associated factors for breast, cervical and colorectal cancer in Zimbabwe and South Africa (SA). Methods: A cross-sectional survey collected data on socio-demographics, cancer awareness, barriers to seeking care, symptoms, healthcare visits and diagnosis after recent cancer diagnosis. Cox regression was used to determine factors associated with PI and DI. Results: This study included 1021 participants (Zimbabwe 396, SA 625). Symptom and risk factor recall was low. Median PIs were shorter than DIs across cancers and regions. For breast cancer, those reporting more health-seeking barriers had longer PIs (Zimbabwe HR 0.801, 95% CI 0.703 to 0.913; SA HR 0.885, 95% CI 0.817 to 0.958), while greater emotional response to symptoms was associated with a shorter PI (Zimbabwe HR 1.194, 95% CI 1.101 to 1.295; SA HR 1.145, 95% CI 1.079 to 1.216). Interpreting a cervical symptom as serious (Zimbabwe) was associated with a shorter PI. DIs were longer in less-resourced regions and increased with number of healthcare visits before diagnosis. Significantly shorter DIs occurred when the first provider was a clinic doctor or specialist compared with a clinic nurse. Conclusions: Efforts to improve timely cancer diagnosis in Zimbabwe and SA should focus on supporting primary healthcare providers in managing and referring symptomatic patients, enhancing cancer symptom awareness and interpretation, and addressing barriers to care.

Background: Despite improvements in early cancer diagnosis worldwide, morbidity and mortality in Southern Africa continue to rise owing to challenges with funding, sociocultural beliefs, and health care access. Digital health (“eHealth”) has the potential to expand access to health care, particularly to remote communities. However, few studies explored the use of eHealth to support symptomatic cancer diagnosis in Southern Africa. Objective: This study explored the barriers and facilitators to eHealth use by health care workers (HCWs) to support the management of people with symptoms of possible breast, cervical, or colorectal cancer in South Africa and Zimbabwe. Methods: We conducted semistructured in-depth interviews with HCWs (n=56) who managed people with symptoms of possible cancer. Interviews explored the barriers and facilitators to eHealth use and attitudes toward further adoption of eHealth. Interview schedules were guided by the sociotechnical theory, a model “designed to address the socio-technical challenges involved in design, development, implementation, use, and evaluation of eHealth.” The interviews were audio-recorded and transcribed. We used the framework method to analyze the data and developed themes that encompassed patterns and meaning in the data to answer the research question. Results: The median age of participants was 44 (IQR 34‐53) years, 38 (68%) were female, and most were nurses (n=34, 61%) or doctors (n=18, 32%). Four core themes were developed: (1) “the lack of reliable infrastructure hindered eHealth use among HCWs”; (2) “the use of personal mobile devices increased eHealth access at the expense of patient privacy and personal cost”; (3) “information, workflow integration, and access”; while eHealth improved access to information, many tools were already in use, were poorly integrated into workflow, and disrupted consultations; and (4) “digital health is expanding whether we like it or not,” which describes a spectrum of attitudes toward digital health, ranging from enthusiasm to resistance but willingness to adapt to those completely against its use. Themes from the workshops were concordant with the in-depth interview findings. Conclusions: To capitalize on the potential benefits of eHealth use among HCWs, such as to support early cancer diagnosis, infrastructural challenges must be addressed, and tools designed to meet user needs and be integrated into clinical workflow. As in many other resource-constrained settings, significant improvements in development are required for the value of eHealth to be realized in Southern Africa. Additionally, where resources such as electricity are limited, their use for eHealth needs to be weighed against use for other priorities such as operating ventilators. Furthermore, energy production in these regions is largely reliant on burning fossil fuels, and thus, the use of eHealth tools risks contributing negatively to climate change. The findings of this study can be used to guide future eHealth design or implementation strategies that are more contextually suitable.

Background: For early detection and diagnosis of cancer to become a reality in African contexts, health services should identify people with symptoms suggestive of cancer, refer timeously, and implement diagnostic processes efficiently. This requires health facilities to have the necessary resources and infrastructure to provide these services. This study, the first in Southern Africa, reports on the availability of these services across referral pathways in four provinces of two Southern African countries, South Africa (SA) and Zimbabwe. Methods: As part of the African Awareness of Cancer and Early Diagnosis (AWACAN-ED) programme, we conducted a quantitative cross-sectional study, from February to September 2023 at primary, secondary and tertiary level public sector health facilities. Data were collected on the availability of staff, infrastructure, diagnostic services, referral pathways and community engagement, and analysed descriptively. Results: A total of thirty-four (N=34) facilities were included. Of these, twenty-two were primary care facilities, serving an estimated population of 1,068,177, with a nurse-to-people ratio of 0.46 per 1000 people, and doctor-to-people ratio of 0.04 per 1000 people. Twelve (n=12) secondary/tertiary (ST) facilities were included, serving a population of 18,750,387, with a nurse-to-people ratio of 0.3 per 1000 people, and doctor-to-people ratio of to 0.06 per 1000 people. There were differences between primary care versus secondary/tertiary facilities in availability of adequate communication infrastructure (29% vs 42%); patient transport systems (50% vs 100%); cervical smears/visual inspection (77% vs 100%) and colorectal clinical assessment (9% vs 58%). Mammography was not available at any Zimbabwean facilities. There was low availability of clinical protocols in primary care for cervical (30%) and breast (9%) cancer, and none for colorectal cancer. Community engagement activities focused on breast and cervical cancer. Conclusion: This study identifies areas for improving early cancer diagnosis and provides a baseline for quality improvement interventions in facility infrastructure and referral pathways.

PURPOSE: Human papillomavirus (HPV) testing on self-collected samples may increase coverage of cervical cancer screening, but previous studies have observed lower specificity of HPV testing in self- versus clinician-collected samples. Here we investigate strategies to improve the sensitivity-specificity balance of a round of HPV testing on self-collected samples. MATERIALS AND METHODS: Women living with and without HIV, age 30-65 years, were recruited in South Africa. Self-collected vaginal samples and clinician-collected cervical samples were tested with Xpert HPV, an assay that detects the 14 high-risk HPV types in five separate channels: (P1) HPV 16; (P2) HPV 18, 45; (P3) HPV 31, 33, 35, 52, 58; (P4) HPV 51, 59; and (P5) HPV 39, 56, 66, 68. All women underwent colposcopy with histology sampling, and diagnosis of cervical intraepithelial neoplasia grade 2 or greater (CIN2+) was determined by adjudicated pathology. The AUC and related performance parameters were calculated using logistic regression with the cycle threshold (Ct) values of the channels as predictors. RESULTS: HPV prevalence in women without and with HIV was higher in self-collected (25.1% v 61.5%) than in clinician-collected samples (16.2% v 48.4%). The optimal model to predict CIN2+ used Ct values from the three channels that detect HPV 16, 18, 45, 31, 33, 35, 52, and/or 58. AUC was superior for testing on clinician-collected (0.908) than on self-collected samples (0.878; P = .0261) in women without HIV, as well as for women living with HIV (0.868 v 0.819; clinician v self; P = .0002). Alternate approaches to handling multiple types and sequential testing approaches did not allow self-testing to achieve equivalent performance to testing on clinician-collected samples. CONCLUSION: Using more stringent Ct cutoffs on the three channels that detect the eight highest-risk HPV types can improve the sensitivity-specificity balance of a round of screening in both self- and clinician-collected samples. Although performance of HPV testing on self-collected samples is excellent, performance parameters are better on clinician-collected samples.

Background: A reduction in communicable diseases in sub-Saharan Africa (SSA) over recent decades has led to an increased life expectancy and non-communicable diseases such as cancer. However, cancer services in SSA remain inadequate. With increasing mobile use, mobile health (mHealth) has the potential to expand healthcare access. Aim: This systematic review aims to synthesise literature reporting on barriers and facilitators to the implementation and use of mHealth tools by patients or the public to support symptomatic cancer diagnosis in SSA. Method: A comprehensive literature search was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Two researchers independently conducted title and abstract screening, full-text review and data extraction. Extraction templates were compared and data were synthesised. Quality was assessed using the Mixed Methods Appraisal Tool. Results: Of 7695 records identified, three quantitative and two mixed-methods studies were included, published between 2016 and 2022. The studies focused on Kaposi’s sarcoma, cervical cancer, breast cancer and any cancer. Three inter-related themes describe the barriers and facilitators: (1) user or population-related factors including access to mobile devices and connectivity, and language literacy; (2) mHealth tool-related factors such as tool accessibility and language translation; and (3) structural, societal or systemic factors such as sociocultural significance and stigma. Conclusion: Although SSA countries experienced similar challenges to mHealth tool use as high-income nations, some barriers such as limited mobile devices and connectivity were more severely evident. Contribution: The study findings can be used to guide future mHealth tool design and implementation strategies that are relevant to SSA.

BACKGROUND Despite improvements in early cancer diagnosis globally, morbidity and mortality in Southern Africa continue to rise. Challenges with funding, sociocultural beliefs, and healthcare access underlie the evolving cancer burden in the region. The increasing global use of digital health has the potential to expand healthcare access, particularly to remote communities, and expand support for healthcare workers (HCWs). However, there is limited research exploring the readiness to use digital health to support symptomatic cancer diagnosis in Southern Africa. OBJECTIVE This study explored the barriers and facilitators of digital health use by HCWs to support the management of people presenting with symptoms of possible breast, cervical or colorectal cancer in South Africa (SA) and Zimbabwe. METHODS We conducted semi-structured in-depth interviews (IDIs) with HCWs (n=56) across all levels of healthcare in SA and Zimbabwe who managed patients with symptoms of possible cancer. Conducted in English or local languages, interviews were audio-recorded, translated into English, and transcribed. Data were analyzed using framework analysis. To check the credibility of results, early findings were shared at four clinical advisory group workshops with 26 participants. RESULTS Median age of IDI participants was 44 years, 38 (68%) were female, and most were nurses (n=34, 61%) or doctors (n=18, 32%). Four themes were developed: 1) the lack of reliable infrastructure (e.g., access to electronic devices, internet, and electricity) hindered technology use among HCWs; 2) the use of personal mobile devices increased digital health access at the expense of patient privacy and personal cost; 3) Information, workflow integration, and access: while digital health improved access to information, many tools were already in use, were poorly integrated into workflow, and use disrupted consultations; 4) Digital health is expanding whether we like it or not, describes a spectrum of attitudes toward digital health, ranging from enthusiasm to resistance but willingness to adapt to those completely against its use. Themes from the workshops were concordant with the IDI findings. CONCLUSIONS To capitalize on the potential benefits of digital health use among HCWs to improve early cancer diagnosis, infrastructural challenges must be addressed, tools designed to meet user needs and be integrated into clinical workflow. For the value of digital health to be realized in Southern Africa, as in many other resource-constrained settings, significant improvements in development are required. In addition, where resources such as electricity are limited, its use for eHealth needs to be weighed against its use for other priorities such as operating ventilators. Furthermore, energy production in these regions is largely reliant on burning fossil fuels and use of eHealth tools risks contributing negatively to climate change. The findings of this study can be used to guide future digital health design or implementation strategies that are more contextually suitable. CLINICALTRIAL NA