Early detection of cervical cancer in western Kenya: determinants of healthcare providers performing a gynaecological examination for abnormal vaginal discharge or bleeding

Differences in influencing mechanism of clinicians' adoption behavior for liver cancer screening technology between the leading and subordinate hospitals within medical consortiums

BACKGROUND

Medical consortiums have been extensively established to facilitate the integration of health resources and bridge the technical gap among member institutions. However, some commonly appropriate technologies remain stagnant in subordinate hospitals, although they have been routinely applied in leading hospitals. Besides, the mechanism underlying differences in clinicians' adoption behavior at different levels of institutions was unknown. Therefore, this study aimed to investigate the differences in influencing mechanisms of clinicians' hepatic contrast-enhanced ultrasound technology (CEUS) utilization behavior between leading and subordinate hospitals within medical consortiums, thus providing clues for expanding effective and appropriate technologies within integrated care systems.

METHODS

A self-designed scale was developed based on the theory of planned behavior (TPB). A multistage sampling method was applied to investigate clinicians who were aware of CEUS and worked in liver disease-related departments within the sampled medical institutions. The final sample size was 289. AMOS 24.0 software was used to construct multi-group structural equation modeling (SEM) to validate the hypotheses and determine the mechanism of hepatic CEUS utilization.

RESULTS

It revealed that behavioral intention significantly influenced adoption behavior, regardless of whether it was in leading hospitals or subordinate hospitals (β = 0.283, p < 0.001). Furthermore, behavioral attitude (β = 0.361, p < 0.001) and perceived behavioral control (β = 0.582, p < 0.001) exerted significant effects on adoption behavior through behavioral intention. However, in leading hospitals, subjective norm had a significant positive effect on behavioral intention (β = 0.183, p < 0.01), while it had a significant negative impact on behavioral intention in the subordinate hospitals (β = -0.348, p < 0.01).

CONCLUSION

To effectively translate the adoption intention into actual behavior, it is recommended to elucidate the demand and facilitators involved in the process of health technology adoption across leading and subordinate hospitals. Additionally, bolstering technical support and knowledge dissemination within subordinate hospitals while harnessing the influential role of key individuals can further enhance this transformative process.

Diagnostic and pre-treatment intervals among patients with cervical cancer attending care at the Uganda Cancer Institute: a cross-sectional study

BACKGROUND

Majority of patients with cervical cancer in the low- and middle-income countries experience long diagnostic and pre-treatment intervals. This study sought to determine the factors associated with the diagnostic and pre-treatment intervals among patients with cervical cancer.

METHODS

This was a cross-sectional study conducted at the Uganda Cancer Institute (UCI) during October 2019 to January 2020. Patients aged ≥ 18 years with histological diagnosis of cervical cancer were consecutively sampled. Data were collected using a pre-tested semi-structured questionnaire and a data abstraction form. Diagnostic intervals, defined as the time between first visit of a patient to a primary healthcare provider to time of getting confirmed diagnosis, of ≤ 3 months was defined as early & >3 months as late. Pre-treatment intervals, which is the time from histological diagnosis to starting cancer chemo-radiotherapy of ≤ 1 month was defined as early and > 1 month as late. Data were analysed using STATA version 14.0. We used modified Poisson regression models with robust variance to determine socio-demographic and clinical factors associated with the intervals.

RESULTS

The mean age of the participants was 50.0 ± 11.7 years. The median diagnostic and pre-treatment intervals were 3.1 (IQR: 1.4-8.2) months and 2.4 (IQR: 1.2-4.1) months respectively. Half of the participants, 49.6% (200/403) were diagnosed early; one in 5 patients, 20.1% (81/403) promptly (within one month) initiated cancer chemo-radiotherapy. Participants more likely to be diagnosed early included those referred from district hospitals (level 5) (aPR = 2.29; 95%CI: 1.60-3.26) and with squamous cell carcinomas (aPR = 1.55; 95%CI: 1.07-2.23). Participants more likely to be diagnosed late included those who first discussed their symptoms with relatives, (aPR = 0.77; 95%CI: (0.60-0.98), had > 2 pre-referral visits (aPR = 0.75; 95%CI (0.61-0.92), and had advanced stage (stages 3 or 4) (aPR = 0.68; 95%CI: 0.55-0.85). Participants more likely to initiate cancer chemo-radiotherapy early included older patients (≥ 60 years) (aPR = 2.44; 95%CI: 1.18-5.03). Patients likely to start treatment late were those who had ≥2 pre-referral visits  (aPR = 0.63; 95%CI: 0.41-0.98) and those that took 3 - 6 months with symptoms before seeking healthcare (aPR = 0.52;95%CI: 0.29 - 0.95).

CONCLUSION

Interventions to promote prompt health-seeking and early diagnosis of cervical cancer need to target primary healthcare facilities and aim to enhance capacity of primary healthcare professionals to promptly initiate diagnostic investigations. Patients aged < 60 years require targeted interventions to promote prompt initiation of chemo-radiation therapy.

Examining Primary Care Physicians' Intention to Perform Cervical Cancer Screening Services Using a Theory of Planned Behavior: A Structural Equation Modeling Approach

Background

Promoting cervical cancer screening (CCS) is undoubtedly effective in combating severe public health problems in developing countries, but there are challenges to its implementation. Understanding the factors influencing primary care physicians' intentions to provide CCSs to rural women is crucial for the future implementation of screening programs. The aim of this study was to assess the intentions of primary care physicians to provide cervical cancer screening services (CCSSs) to rural women and their determinants.

Methods

This cross-sectional study included 1,308 primary care physicians in rural primary health care, and the data collection tool was developed based on the theory of planned behavior (TPB), which included demographic characteristics, the basic constructs of TPB, and the degree of knowledge of CCSSs as an extended variable of the TPB model. Structural equation modeling was used to analyze the relationships between each factor.

Results

Pathway analysis found that TPB is an appropriate theoretical basis for predicting primary care physicians' intent to provide CCSSs (χ2/df = 2.234 &lt; 3, RMSEA = 0.035, and SRMR = 0.034). Meanwhile, the structural equation model showed that attitude (β = 0.251, p &lt; 0.001), subjective norm (β = 0.311, p &lt; 0.001), perceived behavioral control (β = 0.162, p &lt; 0.001), and knowledge level (β = 0.152, p &lt; 0.01) positively predicted primary care physicians' intention to provide CCSSs.

Conclusions

TPB model, with the addition of knowledge, was useful in predicting primary care physicians' intention to provide CCSSs for rural Chinese women. The findings of this study provide a reference for the government and hospitals to develop strategies to improve the intent of primary care physicians to provide CCSSs.

Inadequacies in service delivery for the diagnosis and treatment of vaginitis and vaginosis in Nairobi, Kenya

Vulvovaginal candidiasis (VVC), a common cause of vaginitis, affects 75% of women in their lifetime. In Kenya, vaginitis/VVC is managed using the vaginal discharge syndrome guidelines. We assessed how frequently healthcare workers consider the diagnosis of vaginitis/VVC in symptomatic women, and adherence to the syndromic guidelines, outpatient records at Nairobi City County health facilities, of non-pregnant symptomatic females aged ≥15 years were abstracted. Descriptive statistics were applied, and analysis of determinants of practice determined using multivariable logistic regression models. Of 6,516 patients, 4,236 (65%) (inter-facility range 11-92%) had vaginitis of which 1,554 (37%) were considered VVC (inter-facility range 0-99%). Vaginitis was associated with facility, adjusted odds ratio (aOR) 2.80 (95% confidence interval (CI) 1.64-4.76) and aOR 0.03 (95% CI 0.02-0.04); and month, aOR 0.33 (95% CI 0.25-0.43). Vaginal examination was in 53% (inter-facility range 0-98%). Adherence to syndromic treatment was 56% (inter-facility range 0-83%), better with older patients (aOR 7.73, 95% CI 3.31-18.07). Vaginitis and VVC are commonly diagnosed in symptomatic patients in Nairobi; adherence to the syndromic guidelines is low and differs across the health facilities. Interventions to improve adherence are needed.

Tweedie Model for Predicting Factors Associated with Distance Traveled to Access Inpatient Services in Kenya

Aim. This study aims to examine which factors influence the distance traveled by patients for inpatient care in Kenya. Methods. We used data from the fourth round of the Kenya Household Health Expenditure and Utilization survey. Our dependent variable was the self-reported distance traveled by patients to access inpatient care at public health facilities. As the clustered data were correlated, we used the generalized estimating equations approach with an exchangeable correlation under a Tweedie distribution. To select the best-fit covariates for predicting distance, we adopted a variable selection technique using the $QI{C}_u$ and $R^2$ criteria, wherein the lowest (highest) value for the former (latter) is preferred. Results. Using data for 451 participants from 47 counties, we found that three-fifths were admitted between 1 and 5 days, two-thirds resided in rural areas, and 90% were satisfied with the facilities’ service. Wealth quintiles were evenly distributed across respondents. Most admissions (81%) comprised $<$ 15, $>$ 65, and 25–54 years. Many households were of medium size (4–6 members) and had low education level (48%), and nine-tenths had no access to insurance. While two-thirds reported employment-based income, the same number reported not having cash to pay for inpatient services; 6 out of 10 paid over 3000 KES. Thus, differences in employment, ability to pay, and household size influence the distance traveled to access government healthcare facilities in Kenya. Interpretation. Low-income individuals more likely have large households and live in rural areas and, thus, are forced to travel farther to access inpatient care. Unlike the unemployed, the employed may have better socioeconomic status and possibly live near inpatient healthcare facilities, thereby explaining their short distances to access these services. Policymakers must support equal access to inpatient services, prioritize rural areas, open job opportunities, and encourage smaller families.