Provider Barriers and Facilitators of Breast Cancer Guideline-Concordant Therapy Delivery in Botswana: A Consolidated Framework for Implementation Research Analysis

Abstract

Introduction. Systemic treatment for breast cancer in Sub-Saharan Africa (SSA) is cost-effective. However, there is limited real-world data on the translation of breast cancer treatment guidelines into clinical practice in SSA. The study aimed to identify provider factors associated with adherence to breast cancer guideline-concordant care at Princess Marina Hospital (PMH) in Botswana. Methods. The Consolidated Framework for Implementation Research was used to conduct one-on-one semi-structured interviews with breast cancer providers at PMH. Purposive sampling was used, and sample size determined by thematic saturation. Transcribed interviews were double-coded and analyzed in NVivo using an integrated analysis approach.Results. Forty-one providers across eight departments were interviewed. There were variations in breast cancer guidelines used. Facilitators included a strong tension for change and a government-funded comprehensive cancer care plan. Common provider and health system barriers were lack of available resources, staff shortages and poor skills retention; lack of relative priority compared to HIV/AIDS, suboptimal interdepartmental communication and lack of a clearly defined national cancer control policy. Communitylevel barriers included accessibility and associated transportation costs. Participants recommended the formal implementation of future guidelines that involved key stakeholders in all phases of planning and implementation, strategic government buy-in, expansion of multidisciplinary tumor boards, leveraging non-governmental and academic partnerships, and setting-up monitoring, evaluation and feedback processes. Discussion. The study identified complex, multi-level factors affecting breast cancer treatment delivery in Botswana. These results and recommendations will inform strategies to overcome specific barriers in order to promote standardized breast cancer care delivery and improve survival outcomes. The Oncologist 2021;9999:• • Implications for Practice: To address the increasing cancer burden in low-and middle-income countries, resource-stratified guidelines have been developed by multiple international organizations to promote high quality guideline-concordant care. However, these guidelines still require adaptation in order to be successfully translated into clinical practice in the countries where they intend to be used. This study highlights a systematic approach of evaluating important contextual factors associated with the successful adaptation and implementation of resource-stratified guidelines in sub-Saharan Africa. In Botswana, there is a critical need for local stakeholder input to inform country-level and facility-level resources, cancer care accessibility and community-level barriers and facilitators.

Perceived health-related quality of life among patients living with cancer at Kamuzu Central Hospital in Malawi

“…The common barriers or challenges experienced by patients and their caregivers included long distances travelled to seek medical attention and drug unavailability. They were highlighted as barriers to improved quality of life and it was supported by other studies 16,39 . High travel costs negatively in uences stage of diagnosis, appropriate treatment and compliance, outcomes and quality of life among cancer patients 16,40,41 .…”

Prevalence and associated factors of chemotherapy‐related cognitive impairment in older breast cancer survivors

“…Older BCS are more likely to experience negative emotions such as fear, tension, anxiety and depression due to a severe lack of relevant knowledge leading to CRCI. This review underscored the significance of comprehensive geriatric assessment of older BCS, including assessment of emotional status and cognitive function, in line with the recommendations of oncologists and organizations (Habr et al, 2021;Nishijima et al, 2022;Ralefala et al, 2021). And support the potential importance of psychological factors as potentially modifiable and treatable factors that should not be ignored in evaluation, mechanisms and further interventions for older BCS.…”

Cascade Analysis for Women Presenting With Breast Concerns to a Zonal Hospital in Mwanza, Tanzania

“…Health system–level barriers include the unavailability of essential medicines, 16 - 20 staff shortages, and lack of defined national cancer control policies. 21 Individual-level barriers to treatment could consist of barriers in access, low levels of breast cancer knowledge, 7 including the inability to pay, lack of transport, 22 feeling too sick, and stigma, fear, and misconceptions of a cancer diagnosis. 23 Future research to test interventions and implementation strategies to increase treatment initiation (eg, increase targeted community education and awareness campaigns, 7 financial assistance, and requiring that WHO essential medicines be available) is a critical next step to improve care and breast cancer outcomes.…”

“… 23 Future research to test interventions and implementation strategies to increase treatment initiation (eg, increase targeted community education and awareness campaigns, 7 financial assistance, and requiring that WHO essential medicines be available) is a critical next step to improve care and breast cancer outcomes. 21 In addition, barriers to completion of the care cascade at BMC are currently being studied through the implementation of a new patient navigation program. 23 - 25 …”