Impact of 10-Day Fulbright Specialist Program and Project Pink Blue Education Sessions on Medical Oncology Knowledge Among Physicians Who Treat Cancer in Nigeria

Despite an estimated population of over 201 million and over 115,950 yearly diagnosed new cases of cancer, Nigeria does not have dedicated medical oncologists. Most oncology care is delivered through surgical and clinical oncologists, who are trained in both radiation and medical oncology and they number fewer than 50 in the country. With a limited number of oncology professionals, cancer patients in Nigeria experience poor health outcomes, with an estimated cancer mortality rate of 75,000 deaths per year. Participants from 15 Nigerian states were selected to attend the medical oncology training. Through the support of Fulbright Specialist Program and Project PINK BLUE, two of the authors delivered 10 days of lectures based on ASCO, ESMO, and NCCN guidelines. Mean scores of both the pre- and post-course tests as well as a 1-year follow-up test were compared using GraphPad Prism 7.0a by paired t-tests. Forty-four clinical oncologists were selected for participation. Twenty-five (57%) completed the pre- and post-course tests. Of the 25 that completed both tests, percentage of correct answers increased from 45 to 59% (2-sided p-value < 0.0001). Improvements were seen in attending doctors 45 to 59% (p = 0.0046) and resident doctors 45 to 59% (0.0007). Eleven doctors responded to the 1-year follow-up test. Although not statistically significant, a numerical pattern for the benefits was maintained 1 year after the program (45% pre-course versus 52% post-course correct answers, Fisher's exact, p = 0.4185). In the short term, the training improved medical oncology knowledge in Nigeria, regardless of the participant's carrier stage. Long-term benefits were not sustained in a small sample of participants, and continuing education strategies are necessary. Similar models may be employed across Africa.

Prevalence and distribution of hypertension in overweight and obese subjects in an urban community in Enugu, South East Nigeria. A post hoc analysis

Background

Most recent studies in Nigeria have documented high prevalence of hypertension, diabetes, and obesity. Several mechanisms may link hypertension and obesity hence the high prevalences of both disorders in Nigeria. There are however no studies on the prevalence of hypertension among the obese in urban settings.

Aims

The aim of this study was to describe the prevalence and pattern of hypertension in overweight/obese individuals in a community.

Methods

We conducted a post-hoc analysis on obese subjects 20 years and above from two urban settlements within Enugu metropolis. For database management and statistical analyses, we used the SPSS version 22.

Results

Data from a total of 301 individuals with obesity who met the selection criteria were re-analyzed. A total of 198 (65.8%) individuals were found to have hypertension most of whom were newly diagnosed 110 (55.6%). The prevalence of hypertension was 65.8% and increased with age and BMI.

Conclusion

Individuals with overweight/obesity have very high rates of hypertension. The prevalence of hypertension also increased with and BMI. Thus, there is need for targeted health education in adults to address the burden of obesity and hypertension to reduce the burden of cardiovascular disease in the community.

Sustaining tuberculosis preventive therapy scale-up through direct supportive supervision

Background

Tuberculosis preventive therapy (TPT) is recommended for tuberculosis (TB) prevention among people living with HIV (PLHIV) and other high-risk groups. The Nigerian Military HIV Program embarked on TPT-specific 'direct supportive supervision' (DSS) in May 2018 to increase TPT initiation and completion rates.

Methods

Interventional approaches included site visits to conduct root cause analysis, didactic teaching approach on the concepts of quality improvement and mentorship to address barriers. The DSS introduced TPT monitoring tools, sticker reminders on clients' folders, and bi-weekly data collection and review for decision making.

Results

TPT initiation increased from a monthly pre-intervention median of 323 clients to monthly medians of 2611 during the 'surge' and 1212 clients during the 'sustained' phases. Due to an isoniazid stock-out, a 'dip phase', with a median of 559 clients was recorded. Overall, 10 463 clients were started on TPT in fiscal year (FY) 2018 and 12 596 in FY2019, with an overall initiation rate of 79%. Completion rates were respectively 73% and 70% for FY2018 and FY2019.

Conclusion

With the implementation of a tailored DSS, programmatic barriers to TPT were easily identified and quickly addressed to increase initiation and completion rates.

Evaluation of a School-Based Cervical Cancer Vaccination Awareness Initiative

Background and context: Cervical cancer is the second most commonly-diagnosed cancer among Nigerian women, even though it is one of the most highly-preventable cancers. Worldwide, this most populated country in Africa ranks 10th in terms of cervical cancer mortality and 7 of every 10 Nigerian women diagnosed with cervical cancer annually die annually. With about 47.72 million women aged 15 years and above who are at risk for cervical cancer and median age of first sexual intercourse being 16 years, there is a huge opportunity to prevent cervical cancer deaths through HPV vaccination. Unfortunately, Nigeria has been unable to access GAVI funding for implementation of country-wide HPV vaccination. Hence, most of the HPV vaccination has been by the private sector, NGOs/CSOs and through out-of pocket payments. In spite of this, uptake of HPV vaccines have been reported to be as low as 8% in some studies. Aim: To determine the barriers to uptake of HPV vaccination among mothers of school-age children and opportunities to increase the uptake from the perspective of mothers. Strategy/Tactics: Use qualitative and quantitative methods to gather relevant information about HPV vaccination uptake from all stakeholders including school heads, teachers, school nurses, mothers/guardians and school associations. Program/Policy process: Through funds provided by the American Cancer Society (ACS) and GlaxoSmithkline, Nigeria, we had a one-day HPV vaccination awareness program targeted at school heads, distributed HPV vaccination consent forms, followed-up with awareness in school PTA meetings, gathered data through questionnaires, FGD and KII after a year to determine project effectiveness. Outcomes: Increased understanding of motivators and demotivating factors of HPV vaccination uptake among mothers of school-aged children, increased understanding of strategies to increase uptake and identification of allies in HPV vaccination advocacy. What was learned: 1. There is a need for consistent, “360 campaign” about HPV vaccination as an effective strategy for prevention of cervical cancer targeted at mothers. 2. Since government at federal and state level is unable to access GAVI funding for HPV vaccination, they do have a role to play in validating the effectiveness and safety of HPV vaccines, as well as the efforts of CSOs and NGOs to encourage parents to consent to HPV vaccination for their children. 3. Working in partnership with school associations could be an effective strategy to increasing HPV vaccination uptake among school-aged children. 4. Female teachers are viable advocates for increasing HPV vaccination uptake in schools, if their knowledge is increased and advocacy tools are provided. 5. There is a possibility that reluctance by the government to incorporate awareness of HPV vaccination into its cervical cancer prevention programs is due to its inability to meet the anticipated demand for free HPV vaccination.

Tailoring Therapies: Improving the Outcome of Breast Cancer in a Comprehensive Cancer Center in West Africa—The University of Nigeria Teaching Hospital Experience

Background and context: Early detection and improved treatments are associated with a reduction in breast cancer mortality and morbidity. UNTH is a leading comprehensive cancer center in Nigeria with referrals from the entire southeast and south south regions. Our goal is to offer high quality comprehensive cancer care services across the cancer care continuum from public health awareness campaigns and provision of screening services all the way to palliative care and survivorship. This is the first attempt by any institution in the country to standardize and harmonize available treatment options for breast cancer. Aim: To optimize, standardize and harmonize treatment options and management strategies for breast cancer using a multidisciplinary approach by developing guidelines adapted to our peculiar infrastructure and health system. Strategy/Tactics: The practice guideline was specifically developed for UNTH using a multidisciplinary approach and taking into consideration circumstances peculiar to UNTH, including the following: UNTH's specific patient population; UNTH's services and structure; and UNTH's clinical information. Program/Policy process: The process used recognized methods that are robust, objective, scientifically valid, consistent and adaptable to UNTH and engaged all identified multisectoral and multidisciplinary stakeholders involved in the care of patients with breast cancer. Outcomes: We reviewed substantial evidence on documented and proven strategies for community screening and prevention, less expensive and only marginally less effective diagnostic tools, locoregional and systemic therapies for the management of breast cancer. The team also recommended all patients receive psycho-oncology support through a dedicated team and through the breast cancer support group. It was agreed that palliative care be incorporated within the first 8 weeks of commencing treatment in line with the current ASCO guidelines and receive consultation from the exercise immunology unit. What was learned: Institutionalized care offers better management strategies and standardized treatment in line with best global practices of care for patients with breast cancer across the cancer care continuum which will ultimately translate to better treatment outcomes.

BWS Experience in Integrating Cancer Care

Background and context: Nigeria, being the most populous African country has the highest cancer burden. Fragmentation of healthcare services leads to late presentation, inappropriate navigation, delay in diagnosis, intervention and an increased loss to follow-up. Aim: To have a harmonized and fast-tracked cancer diagnosis and management via providing an integrated cancer care and effective navigation to tertiary hospitals, when required. Strategy/Tactics: We set up a center to screen, diagnose and treat cancers in partnership with collaborators, at low cost to patients. Program/Policy process: The BWS (Breast Without Spot) Screening and Wellness Centre was set up in 2016 to offer cancer/NCD education, screening services for cancers and other noncommunicable diseases. A multidisciplinary volunteer team takes care of diagnostic ultrasound, ultrasound-guided biopsies, cryotherapy of premalignant cervical lesions, histopathology and chemotherapy. Where radiotherapy and surgery are indicated, patients are navigated appropriately to our collaborators in tertiary hospitals. Outcomes: 721 persons were seen. 112 men and 609 women, 14 men had PSA/DRE and 411 women had VIA and CBE. 58 women had sonomammography while 9 with suspicious masses had ultrasound-guided biopsies followed by histologic diagnosis and IHC for proven malignancy. In the women with proven breast cancer, 7 underwent chemotherapy while 8 were navigated to radiation therapy and surgery. What was learned: There is improved patient experience and compliance when there is an accessible “one stop” facility for their care. Early detection, prompt diagnosis and facilitated treatment improves prognosis. With prompt access to care, patients feel supported and eager to go through the entire cancer care process.

Bridging the Funding Gap for Oncology Services in LMIC: The BWS Cancer Patient Treatment Intervention Fund Project

Amount raised: #1,627,000 (Nigerian Naira) Background and context: With a large population and very limited resources, the economic burden of cancer in our country is enormous and cannot be tackled solely by the government. A high mortality rate among newly diagnosed patients is a direct result of poverty and lack of an effective health insurance coverage for cancer, among other reasons. Breast cancer accounts for two out of five women cancers, with a 70% mortality. Aim: To alleviate the financial burden of cancer treatment on indigent patients. Strategy/Tactics: We constituted the Cancer Patient Treatment Intervention Fund (CPTIF) board of partners and funders. We also inaugurated a fundraising event, the annual Go Pink Day Ball, and instituted crowd-funding schemes. Program process: Indigent patients diagnosed at BWS and designated health facilities are referred to CPTIF for financial support. The patient is reviewed for eligibility by the medical board. If approved by the CPTIF Board of Directors, the required funds are paid directly to the designated tertiary health facility where patient will be receiving the oncology services. Costs and returns: Between December 2017 and March 2018 a total of #1,627,000 (Nigerian Naira) was raised, a total of #750,950 has been spent on 7 patients at different levels of oncology services. The cost covered included laboratory tests, ultrasounds, biopsies chemotherapy and radiotherapy. What was learned: Financial assistance gave these patients a lifeline and zeal to go through the usually overwhelming cancer treatment process.

BWS Effort in Cancer Screening in Rural Communities

Background and context: Nigeria, being the most populous African country has the highest cancer burden. Most of the population reside in rural areas where there are no functional health centers. Life in these communities is marked by profound ignorance, superstition and stigma, concerning cancers. There is no cancer control plan in place in the country. Aim: BWS aims at increasing awareness of the need for prevention and early detection of cancers. Strategy/Tactics: Three-pronged approach of education, screening and vaccination, with navigation where required. Monthly education and cancer screening in rural communities. Provision of a navigation system of medical follow-up for patients with a positive screening result; establishing treatment and support care for patients and recruiting and training volunteers and local advocates for cancer awareness campaigns. Program/Policy process: Monthly education/enlightenment activities in various rural communities in southeast Nigeria. Dissemination of information on screening activities is done via church and other community groups; town criers, WhatsApp, radio and banners at strategic locations. Outcomes: A total of 1990 participants (1388 females and 602 males) were screened from January 2016 to December 2017. 1342 women had CBE, 96 were referred for mammography. 105 out 1041 females who had VIA with colposcopy were positive and 26 of them had cryotherapy. 426 girls and young women (9-26 years) received HPV vaccination. 12 out of 204 men who had PSA tests were positive and referred to urologists. Since the launch of project Rid Nigeria of Late Cancer Detection in 2016, BWS has acquired a physical infrastructure for daily screening and continued her monthly rural screening services. What was learned: Women need to take permission from their husbands to even get screened, therefore involvement of traditional rulers, local government chairmen, opinion molders, leaders of faith-based organizations, and local cancer advocates from the community, is helping to increase awareness and reduce stigmatization. Taking the screening to the community is helping combat “late presentation syndrome”. However, financing rural awareness and screening is quite a challenge without financial support.

Improving Community Health Workers Knowledge of and Attitude Toward Breast Cancer in Rural Communities in Eastern Nigeria

Background and context: Nigeria presently grapples with a high burden of all forms of cancers with breast cancer being the most common and most lethal with estimated 27,304 new cases and 13,960 deaths annually. Poor knowledge of breast cancer and the wrong perception about its treatment is pervasive among many Nigerian women particularly those in rural communities leading to late presentation and poor treatment outcomes. Community health workers (CHWs) are at the forefront of closing the knowledge gap and improving on attitude toward breast cancer and its treatment in these rural settings through provision of an effective cancer patient care and support. Against this backdrop, the University of Nigeria Teaching Hospital-Breast cancer support group (UNTH-BCSG) was established by a group of health professionals involved in caring for cancer patients in the eastern parts of the country. The consortium provides education and supports to breast cancer patients, training support to community health workers for early detection and prompt referral, carry out community outreach and education in both urban and rural communities, free cancer screening services to communities, as well as creating and supporting systems that effectively links cancer patients from the community level to the treatment centers. Aim: To implement a training program aimed at improving community health workers knowledge of and attitude toward breast cancer in selected rural communities in eastern Nigeria. Strategy/Tactics: A cross-sectional study design was used to select total of 521 health workers drawn across the 7 randomly selected local government areas in Enugu state, southeastern Nigeria. Respondents' level of knowledge and attitude toward breast cancer was assessed before and after the training. Data were collected using self-administered questionnaire, while data analysis was done with Statistical Package for Social Sciences (IBM-SPSS) version 20. Program/Policy process: Advocacy and campaign on breast cancer screening. Outcomes: Out of a total 521 CHWs with a mean age of 37.71 ± 8.789 years, majority of the workers were females (92.9%), married (74.1%) received formal trainings in community health education (67.3%). Prior to training, only 18.4% of respondents had ever screened for breast cancer, while 68.3% practice breast self-examination. T-test analysis showed that the mean knowledge score of breast cancer (6.86 ± 2.48), mean knowledge of risk of breast cancer (5.69 ± 3.15) and the mean attitude toward breast cancer score (5.98 ± 3.04), significantly improved with the training program to 7.56 ± 2.29, 10.62 ± 3.09, and 7.21 ± 2.69 respectively ( P < 0.01). What was learned: Community health worker still need more sustained training as they operate at the grass root of health care system. Every little assistance will be translated to reduced cancer morbidity and a lot of lives being saved through early detection.

Exploratory Use of Cloud Computing and Social Media for Prostate Cancer Advocacy in Nigeria

Background and context: Prostate cancer is the commonest cancer affecting Nigerian men, with worse outcome compared with men from the developed world. There is limited public awareness about prostate cancer in Nigeria. Oga Blue 4 Prostate Awareness (OB4PA) was created by a consortium of Nigerian nonprofits for prostate cancer advocacy (PCA). Aims: -Design PCA using videos, printed brochure and social media -Implement PCA in five Nigerian states -Evaluate the reach and impact of PCA campaign Program/Policy process: Community-based participatory process, involving the medical community, prostate cancer survivor, and the public was used. Multimedia teaching was used to enhance learning and retention; social media was used to engage groups and individuals. Content development involved iterative consultation among project leaders, medical experts and target audience, often on social media. High-quality teaching videos were recorded in English and Nigerian Pidgin languages. Videos ensured consistency and ease of broadcast. Videos were accessed by OB4PA partners through cloud computing (OneDrive). Facebook was used to promote the campaign, engage local audience, and for Facebook Live presentation. Local health professionals projected the video in appropriate language to audiences in religious and community groups. Brochure detailing clinical features and local service providers was distributed. Audience evaluation was obtained following each interaction. Outcomes: In 6 weeks, 20 presentations were made to 1800 persons. The Facebook Live presentation had 1500 views, reached 9302 people and was shared 107 times. A total of 25 Facebook posts were made, resulting in 628 like, 1908 video views, 160 shares, and reached 14,222 people. Almost all participants had positive feedback on the free and detailed advocacy. Most questions focused on the causes and prevention of prostate cancer, especially on the use of nutritional supplements. What was learned: Cloud computing enabled us to have one presenter; this eliminated the need to find a presenter for each organization. Audience appreciated simplified videos used in explaining the disease process and need for personalized early detection. Facebook live presentation attracted the most reactions on social media, with most comments showing that people liked the intervention. Audience feedback showed that adding advocacy cellphone video by a survivor helped demystify prostate cancer. Having the main presentation video in different file formats and sizes enhanced sharing on social media, as most Nigerians access the Internet on cell phones. Reliable access to projectors was challenging, especially in remote areas. Overall, use of cloud computing and social media were crucial in the success of the PCA project. Lessons from OB4PA informed the design of the current We Can, I Can Conquer Cervical Cancer Awareness project in Nigeria.

Impact of Support Group Intervention on Quality of Life of Patients With Advanced Breast Cancer

Background: Health-related quality of life is an important end point in breast cancer care. Assessing quality of life in breast cancer patients could contribute to improved treatment outcome and could even serve as monitor along with medical parameters. The need for psychosocial support is well established among breast cancer patients with levels of psychological distress and depression, particularly after diagnosis and treatment. Cancer support helps patients to cope with cancer by adjusting their attitudes, knowledge, and expectation about the disease. Aim: To determine the impact of support group intervention on quality of life of patients with advanced breast cancer To create awareness, educate, counsel and support as well as to mediate in the weaknesses of the medical care system in dealing with breast cancer patients. Methods: A prospective cohort study involving breast cancer patients using a system of breast cancer support group that organizes a two month period meeting for all breast patients in University of Nigeria Teaching Hospital Enugu. Educational information on breast cancer, nutritional needs, exercise and the need for regular follow-up in breast cancer care were given to them as well as the means of overcoming the psychosocial burden in cancer. QOL assessment evaluating the four domains (physical, social, psychological and environmental) on selected patients with advanced breast cancer using WHO BREF was administered. Results: A total of 113 breast cancer patients were involved in this study. At the end of the intervention, 14 women (12.4%) were censored due to death, while postassessment was carried out for only 99 women. Postintervention analysis showed that there was a significant positive correlation between availability of social support to respondents (FS score) and the four quality of life domains ( P < 0.05). Further analysis also showed that respondents' quality of life significantly increased across all domains at postintervention ( P < 0.05). Conclusion: Patients receiving support group intervention all had improved quality of life.

Increasing Cancer Awareness Through BWS Social Media Activities

Background and context: Information is key. The Nigerian Communications Commission released a statement in December 2017 that 98.3 million people in Nigeria use the Internet. The increasing number of people that use social media and the unlimited access is a reason to do some level of awareness on these platforms. A huge opportunity to pass information and save lives in the process will be missed by not engaging social media. Aim: To increase awareness for prevention and early detection of cancer via social media and forming an online community in the process. Strategy/Tactics: Creation of cancer-related engaging contents with words, pictures and videos such as general information about cancer, preventive measures among others to get the attention of the audience and consistent posting of these contents. Informing the general public of our free screening exercises and activities. Program/Policy process: Creation of a content calendar for our posts on specific days and times, targeting of online audience through age, sex and location among others considering the campaign we want to push at a given time. Outcomes: After 3 months, we had 48,765 reach and 17,223 impressions on Facebook, 47,599 impressions on Twitter and 15,177 impressions on Instagram from 30 posts each. A very significant increase in the number of people that showed up to our vaccinations, screenings and other activities/programs. Positive response from people who were reached via social media, they were thankful for the basic information they got which they had no idea about. Dozens of people volunteered to work for our organization to help get rid of cancer. What was learned: Social media enabled us to reach a good number of people easily. Our target audience was very grateful for the information they got. In summary, the use of social media in raising awareness and passing information was very effective.

A qualitative study of young Nigerian family physicians’ views of their specialty

Background: In Nigeria, the specialty of family medicine (FM) has endured its own share of identity crises. This study was aimed at generating hypotheses about what describes a practising family physician (FP) and the specialty, according to young Nigerian FPs. Methods: Using the online platform for young African FPs alongside text messages and emails from volunteer research assistants over an eight-week period (March 3 to April 30, 2015), a purposive sample of young Nigerian FPs were asked to describe their favourite aspect of FM in a single word/phrase. Responses were provided in English/individual’s mother tongue. Translation of the words was performed by respondents and additional collaborators fluent in these languages. Thematic analysis using the grounded theory approach was performed. Results: Twenty-four responses were received consisting of four themes: Scope, Family, Skills/Feelings/Values, and Professional Fulfilment. The resulting data portrayed the FP as one who possesses a unique skill-set, enjoys fulfilment in the profession, deals with undifferentiated diseases and is able to provide holistic care for patients (irrespective of age and gender) from a family-centred perspective. When compared with accepted domains of FM for Africa and Europe, roles of the FP in community-oriented care and primary care management were absent. Conclusion: While this showcases the young Nigerian FPs’ acceptance of their role in providing comprehensive primary care, it suggests a lesser acceptance of their role in community-oriented primary care as well as primary care management. This study provides a basis for future, quantitative research describing attitudes and competence in these areas. (Full text of the research articles are available online at www.medpharm.tandfonline.com/ojfp) S Afr Fam Pract 2017; DOI: 10.1080/20786190.2017.1292694

Regional cancer control in south-eastern Nigeria: a proposal emanating from a UICC-sponsored workshop

There is an impending cancer epidemic in Africa. In Nigeria, this disease is causing untold devastation, and control measures are desperately needed. Breast, cervical, prostate, and liver cancers are the most common types in Nigerian adults. In children, the predominant malignant diseases are Burkitt's lymphoma, acute lymphoblastic leukemia, neuroblastoma, and Wilm's tumor (nephroblastoma). The focus of efforts to control cancer in Nigeria should be directed at prevention with adequate attention to planning/policy making, early detection, accurate diagnosis, treatment and palliative care. National and regional allocation of sufficient resources is required, accompanied by measurable objectives and appropriate emphasis on accountability.