Barriers and Facilitators to Integrating Clinical Breast Examinations With Cervical Cancer Screening Programs in Outpatient Clinics in Western Kenya

Abstract

PURPOSE Nearly half of Kenyan women with breast cancer present with advanced disease—owing partially to limited patient education and screening limitations in low- and middle-income countries. With increasing access to nurse-led cervical cancer screening (CCS) in government clinics in Kenya, we investigated provider-perceived barriers and facilitators to integrating clinical breast examinations (CBEs) with ongoing CCS programs in Kisumu County, Kenya. METHODS CCS providers within the Ministry of Health Clinics in Kisumu County, Kenya, were recruited to participate in a two-phase, sequential, mixed methods study. Knowledge of CBE guidelines was assessed with a questionnaire. Providers with significant CCS and CBE experience then completed a one-on-one interview discussing barriers and facilitators to integration. RESULTS Sixty-nine providers from 20 randomly selected facilities participated in the survey. Providers all agreed that breast cancer screening was very important. Although 93% said that they routinely offered CBEs, only 22% of these providers screened at least eight of their last 10 patients. Forty-four percent identified four or more of five signs and symptoms of breast cancer, and 33% identified four to five risk factors. Although providers showed enthusiasm for integration of CBEs into their practices, barriers were identified and grouped into four themes: (1) fragmentation of services, (2) staffing shortage and inadequate on-the-job training, (3) limited space and referral system challenges, and (4) limited patient awareness on need for cancer screening. CONCLUSION Addressing providers' concerns by providing routine on-the-job clinical training, improving staffing shortages, strengthening the diagnostic and treatment referral pathway, and increasing patient education are some of the first steps in facilitating integration of CBEs with CCS services in primary care clinics in Kenya.

Integration of cervical cancer screening into healthcare facilities in low- and middle-income countries: A scoping review

“…Integration could lead to a decrease in the number of women screened per day. Fragmentation of services also could be one of the disadvantages if the service is given in a separate room within the health facility [ 62 ].…”

“…Increases the workload for healthcare providers, and fragmentation of services if the service is given in a separate room within the health facility [62]. Feeling empathy/emotional distress for testing positive for both HIV and cervical cancer lesions, decrease in the number of women screened per day, and feeling disrespectful or offensive to their needs due to the prolonged time [25,37,38,45,58].…”

“…A lack of staff, insufficient on-the-job training, poor interpersonal care and counselling skills, and resistance to change [47,62,64]. Increased workloads [48,55], and the prioritization of curative healthcare by health professionals [57].…”

Integrating Breast Cancer Early Detection Into a Resource-Constrained Primary Health Care System: Health Care Workers' Experiences in Rwanda

“…Our findings complement a study in which Kenyan clinicians were interviewed about barriers and facilitators to integrated breast and cervical cancer screening before the launch of any formal integrated approach. 9 Rwanda's WCEDP addressed many of the barriers envisioned by the Kenyan clinicians, such as the need for training. However, our study demonstrates that important challenges remained, providing lessons for Rwanda and other countries seeking to integrate women's cancer early detection services into primary care.…”

“…1 University of Global Health Equity, Burera District, Rwanda 2 Hailemariam and Roman Foundation, Addis Ababa, Ethiopia 3 Partners In Health/ Inshuti Mu Buzima, Burera District, Rwanda 4 Dell Medical School, University of Texas, Austin, TX 5 Brigham and Women's Hospital, Boston, MA 6 Rwanda Biomedical Centre, Kigali, Rwanda 7 Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 8 Dana-Farber Cancer Institute, Boston, MA 9 Palladium Group, Kigali, Rwanda…”