Background: In 2018, approximately 60,000 Ugandans were estimated to be suffering from cancer. It was also reported that only 5% of cancer patients access cancer care and 77% present with late-stage cancer coupled with low level of cancer health literacy in the population despite a wide coverage of primary healthcare facilities in Uganda. We aimed to contribute to reducing the unmet needs of cancer prevention and early detection services in Uganda through capacity building. Methods: In 2017, we conducted two national and six regional cancer control stakeholders’ consultative meetings. In 2017 and 2018, we trained district primary healthcare teams on cancer prevention and early detection. We also developed cancer information materials for health workers and communities and conducted a follow-up after the training. Results: A total of 488 primary healthcare workers from 118 districts were trained. Forty-six health workers in the pilot East-central subregion were further trained in cervical, breast, and prostate cancer early detection (screening and early diagnosis) techniques. A total of 32,800 cancer information, education and communication materials; breast, cervical, prostate childhood and general cancer information booklets; health education guide, community cancer information flipcharts for village health teams and referral guidelines for suspected cancer were developed and distributed to 122 districts. Also, 16 public and private-not-for-profit regional hospitals, and one training institution received these materials. Audiovisual clips on breast, cervical, and prostate cancer were developed for mass and social media dissemination. A follow-up after six months to one year indicated that 75% of the districts had implemented at least one of the agreed actions proposed during the training. Conclusions: In Uganda, the unmet needs for cancer control services are enormous. However, building the capacity of primary healthcare workers to integrate prevention and early detection of cancer into primary health care based on low-cost options for low-income countries could contribute to reducing the unmet needs of cancer prevention and early detection in Uganda.
This capacity building efforts to integrate primary prevention and early detection of cancer into the existing PHC facilities involved stakeholders’ consultative meetings, development and distribution of cancer reference IEC materials for health workers and communities, training of district PHC workers and follow‐up. We targeted all the 122 districts in Uganda based on number of districts in Uganda as in 2017. The participants were sampled purposively with specified inclusion criteria. Invitation letters were emailed to the district health officers to mobilize the specified category of district leaders who were willing to participate in the regional level consultation meetings. Invitation letters were also emailed to the district health officer to identify four health workers who were willing to be trained. In 2017, we mobilized and conducted one‐day 6 regional cancer control stakeholders’ consultative meetings with representation from 118 out of the planned 122 districts (Table (Table11 and Figure Figure1).1). A maximum of 4 participants per district were invited. The stakeholders included were the District health officers (DHOs)‐head of district health services, Chief administrative officers (CAOs)‐head of district technical services, Chairperson district local council V (CPLCV)‐political head of the district local government, and member of the civil society organizations (CSOs)‐Non‐governmental health related program implementers and advocates. This was done to get input on what is needed and to advocate for their local leadership support for the inclusion of primary prevention and early detection of cancer in their district health work plans. The narrated view points and recommendations of the stakeholders were captured “as said” through note taking and audio‐recording to inform the subsequent capacity building process and interventions. Regional cancer control stakeholders’ consultative meetings, 2017, Uganda. No. of districts Represented Map of Uganda showing the regions, subregions, and districts where the district stakeholders’ meetings and training of PHC workers were conducted. Adapted from: Uganda Bureau of Statistics (UBOS). In this map, Western region = Western and South Western, Northern = Acholi, West Nile and Lango, Eastern region = East‐central, Elgon, Teso and Karamoja. During the capacity building activities, Acholi, Lango, and Karamoja were zoned as Northern region and North‐western districts zoned with West Nile. We developed print and audiovisual cancer education, information and communication (IEC) materials on prevention, early detection and referral based on the commonest types of cancer in Uganda. We reviewed published literatures including World health organization (WHO) publications to guide the development of these IEC materials. These materials were developed to provide reference information for the health workers and community village health teams (VHTs) with priority on the most common types of cancer in Uganda‐especially cervical, breast, and prostate cancer. In 2017 and 2018, a maximum of four PHC workers per district were invited for training. The district health teams included were the assistant district health officer‐in‐charge maternal and child health, medical officer or clinical officer, nursing officer and health educator per district and were selected by the district health management from 122 planned districts. The districts were zoned into 6 regions: West Nile, Central, East‐central, Eastern, Western, and Northern Uganda (Figure (Figure11). The district PHC workers were intensively trained for five days on cancer primary prevention and early detection including raising cancer awareness in the communities, promotion of human papillomavirus and hepatitis B vaccination, early detection through early diagnosis and screening strategies, referral and community‐based care. Emphasis was put on the most common types of cancer in Uganda: cervical, breast, prostate, Kaposi sarcoma, esophageal, liver, lymphoma, leukemia, colo‐rectal, and childhood cancers. In cancer screening pilot districts in East‐central subregion, 46 health workers from 10 health facilities were further intensively trained for 10 days and equipped to provide routine cancer screening for the most common types of cancer in Uganda. The early detection training component focused on low‐cost options for low‐ and middle‐income countries. For cervical screening, we emphasized visual inspection with acetic acid (VIA) or Papanicolaou (Pap) smear test and pre‐cancer treatment using cryotherapy or thermocoagulation based on “see and treat” or “see and see and treat” approaches. VIA screening is still the most feasible option in low‐income countries and could still be conducive to the future introduction of HPV screening. 18 Prostate screening methods were based on prostate‐specific antigen (PSA) blood test and digital rectal examination (DRE) technique for most at risk men. 19 , 20 The affordable option for breast screening at district PHC facilities in Uganda was clinical breast examination (CBE) and demonstrating to women self‐breast examination (SBE) technique as part of early diagnosis strategy—not screening. Clients with abnormal or suspicious findings in their breast were to be recommended for or referred for breast ultrasound scan or mammography where applicable. However, it is crucial to reiterate that mammography screening option is complex and resource‐intensive, thus may not be feasible in health‐resources constrained countries. 17 , 18 , 21 Mammography is also reported as being less sensitive in young African women and other women with dense breast tissue. 3 For all types of cancer amenable by early detection, we focused on public health education on early warning cancer symptoms and signs to facilitate seeking early diagnosis and treatment. During the training, in early detection of cancer we emphasized the application of a low‐cost options of raising cancer awareness and early detection in the communities from lowest level community health facilities through the health service delivery hierarchies, similar to the recent “step‐wise five components” model that was tested in Peru in the context of low‐ and middle‐income countries. 17 This involves 1‐health education to raise awareness on risk factors, early warning symptoms and signs, and need for screening; 2‐clinical or laboratory‐based screening in a primary healthcare setting; 3‐triage for imaging or laboratory test for detected or suspected lesions or other abnormality during a clinical examination; and 4‐referral of clients with positive or cancer suspicious findings for further management in tertiary hospitals. 17 We used interactive lectures, demonstration and returned demonstration, role plays and group discussion as the main teaching and learning methods. We assessed learning progress through pre‐ and post‐tests based on a set of questions that covered the entire training content. We also conducted a follow‐up in the districts after six months to approximately one year after the training—as part of process evaluation.
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