A Hospital-Based Survey Assessing the Health Facility-Level Factors that Contribute to Delayed Diagnosis of Cervical Cancer; Patients Views

doi:10.21203/rs.3.rs-3885643/v1

Download PDF

Research Article

A Hospital-Based Survey Assessing the Health Facility-Level Factors that Contribute to Delayed Diagnosis of Cervical Cancer; Patients Views

https://doi.org/10.21203/rs.3.rs-3885643/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background

In Kenya, Cervical Cancer is the 2nd commonly diagnosed type of cancer and the top cause of cancer-related deaths among women. Globally, over 50% of Cervical Cancer diagnoses are made late, with this proportion rising to 80% in developing countries. Poor Health systems can cause delays in diagnosis, thus, this study focused to determine the health facility level factors that contribute to delayed diagnosis among Cervical Cancer patients at the Kenyatta National Hospital (KNH).

Methods

An analytical cross-sectional mixed method study was adopted to collect data on hospital and referral experiences from 139 Cervical Cancer patients systematically sampled at KNH, using a semi-structured questionnaire. Associations between stage at diagnosis and hospital and referral experiences were tested using logistic regression model at 95% Confidence Interval.

Results

86 (61.9%) were diagnosed at advanced stages III and IV. The risk factors for delayed diagnosis were; more number of referral times (p-value = 0.000), availability of referral challenges (p-value = 0.041), Prolonged diagnosis appointments (p-value = 0.059) and long waiting periods for diagnosis results, (p-value = 0.007), in the bivariate model. Only More number of referral times was significantly associated with delayed diagnosis in the multivariate model (p-value = 0.001). Referral challenges included, misdiagnosis, cost of diagnosis and prolonged diagnosis appointments.

Conclusion

Advanced stage at presentation for most patients due to poor health and referral systems inadequate medical personnel and diagnosis equipment. Improve referral systems and encourage Public Private Partnerships (PPPs) to decentralize diagnostic centers and equipment and train more expertise on Cervical Cancer

Cervical Cancer

Delayed Diagnosis

Kenya

Hospital-based

Health facility-level factors

Leading in fourth place globally, Cervical Cancer records approximately 604,127 new cases and nearly 360,000 deaths worldwide, among all the cancers that affect women. It is proven that about 90% of these cases occur in developing countries(1), with Africa, reporting close to 120,000 new cases annually(2). It is ranked second in causing cancer-related deaths, mostly among women of age between 14–44 years(2). As of 2020, Cervical Cancer comes second after breast cancer as the commonly diagnosed type of cancer among women in Kenya, with 5,236 cases and is the major cause of cancer-related deaths, accounting for 11.9% of all cancer deaths in Kenya(3). Overall literature shows that, the Stage of cancer at the time of diagnosis is a vital prognostic factor that influences cancer treatment outcomes. Delays in cancer diagnosis increases the risk of poor cancer outcomes(4). Early diagnosis (Stages I and II), is associated with a 98% 5-year survival rate, while delayed diagnosis (Stages III and IV), is associated with lower rates (17% 5-year survival rate) (5). Globally, the prevalence of delayed diagnosis among Cervical Cancer is more than 50%(6), with this proportion rising to approximately 80% in developing countries(5). Despite the strategies that have been put in place to enhance early detection such as creating awareness and screening, Cervical Cancer still remains a threat to many sexually active women in Africa(7). Early diagnosis is attributed to functional health systems such as timely patients’ referrals from less equipped facilities to better equipped hospitals where they can access effective services for diagnosis. Poor Health systems cause delays in primary health care causing late-stage cancer presentation(6).Institutional hindrances and referral challenges, create barriers in availability and access of timely and quality medical services, eventually leading to delayed diagnosis(1). Limited access to health care equipment and trained medical personnel, contribute to the delays in diagnosis appointments and results. This further creates challenges such as, misdiagnoses and high cost of diagnosis due to many referrals that burden patients especially those from low socio-economic status(6) (8). Additionally, Resources available in major hospitals are constrained due to congestion of patients(6). Few studies in Kenya have focused on the health facility level factors that contribute to delayed diagnosis of Cervical Cancer, causing high mortality rates due to poor outcomes. This study determined to assess the association between delayed diagnosis and patients experiences at health facility level, at the Kenyatta National Hospital (KNH).

This was a hospital sited, analytical cross-sectional mixed method study design, conducted in KNH, a National Referral and Teaching Hospital in Kenya. Systematic sampling was used to select Cervical Cancer patients diagnosed and receiving treatment at KNH, aged above 18, and diagnosed within the last one year since time of data collection. The study excluded patients whose medical records did not have clear staging information, those diagnosed with other cancer types, those with recurrent Cervical Cancer, those in palliative care, those with psychotic health issues and those who were unwilling to participate in the study. 139 participants were selected and interviewed using a semi-structured questionnaire, with questions regarding their hospital and referral experiences such as type of medical facility they visited first, Number of hospitals visits they made before diagnosis, if they were referred to KNH, Number of referral times, referral challenges they faced, and period taken to get diagnosis appointments and results. The key outcome of delayed diagnosis was Stage at diagnosis, categorized as either; Early (stages I and II) or Delayed (III and IV) diagnosis using the FIGO staging system. The stage at diagnosis was retrieved as stage of malignancy recorded by the doctor in the patients’ files using abstraction forms. Qualitative data was collected from 8 Key Informants including Medical and Radio Oncologists, Nurses and Social Workers in audio recorded sessions, to provide in depth information. Statistical analysis was done via Stata 14.2. The association between delayed diagnosis and health facility level factors was determined by bivariate and multivariate logistic regression tests, at 95% Confidence Interval and Odds Ratios and P-Values were reported. Audio recordings for qualitative data were transcribed in verbatim, transcripts verified then deductive thematic analysis conducted using NVIVO 14.

Sociodemographic characteristics

Table 1

Socio demographic characteristics
Variable	Frequency(n = 139)	Percent (%)
Age in years
< 40	22	15.83
40–59	91	65.47
60 and above	26	18.71
Ethnicity
African	139	100
Religion
Christian	139	100
Marital Status
Single	23	16.55
Married	88	63.31
Divorced/Widowed	28	20.14
Residence
Urban	59	42.45
Semi-urban	24	17.27
Rural	56	40.29
Residential type
Slum	38	64.41
Upmarket	21	35.59
County of Residence
Nairobi	54	38.85
Other County	85	61.15
Education
Tertiary	10	7.19
High school	34	24.46
Primary school	88	63.31
No formal education	7	5.04
Employment Status
Employed	54	38.85
Not employed	85	61.15
Monthly Income
> 25,000	15	27.78
10,000–25,000	17	31.48
< 10,000	22	40.74

Table 1 shows the distribution of sociodemographic characteristics of the study population. 139 Participants were interviewed in September 2023. The mean age was 51 years. The Inter-Quartile Range was 29–89. Majority 91(65.47%) of the participants were aged between 40–59 years and More than half 88(63.31%) of the participants were married. 7 participants were not formally educated whilst majority of them 88(63.31%), were educated up to primary level. Only 54(38.85%) were reported as employed and earning while more than half 85(61.15%) were not employed. 53 participants (38.1%) were diagnosed early, while 86 (61.9%) were diagnosed at advanced stages.

Health Facility-level factors

Distribution of participants across of health facility factors

Table 2

Distribution of participants across of health facility factors
Variable	Frequency(n = 139)	Percentage (%)
First Medical Care
Private	40	28.78
Public	91	65.47
Other	8	5.76
Hospital visits
Once	29	20.86
Twice	22	15.83
3–4 times	39	28.06
5 times and above	49	35.25
Referred
Yes	125	89.93
No	14	10.07
Referral times
Once	67	53.6
Twice and above	58	46.4
Referral Challenges
Yes	72	57.6
No	53	42.4
Diagnosis Appointment
< 2 weeks	119	85.61
2 weeks − 1 month	12	8.63
> 1 month	8	5.76
Diagnostic Results
< 2 weeks	64	46.04
2 weeks − 1 month	43	30.94
> 1 month	32	23.02

Table 2 shows the frequencies of participants across of health facility factors assessed. Over half 91(65.47%) of the participants first sought medical care from public health facilities, while 49 (35.25%) of the participants visited the hospital 5 times and more before being diagnosed with Cervical Cancer. Most 125(89.93%) participants were referred to KNH, with 58(46.4%) of them reporting that they were referred two times and more. More than half 72 (57.6%) of those who were referred, reported to have faced referral challenges that have been a hindrance in accessing appropriate and proper medical care thus delaying their diagnosis. Most patients who faced challenges reported lack of finances as the major challenge they faced, followed by misdiagnosis and prolonged appointments among other challenges. See Fig. 1. Those who reported misdiagnosis reported to have been diagnosed with Urinary Tract Infections (UTIs), Sexually Transmitted Infections (STIs), postmenopausal bleeding, hormonal contraceptive side effects, fibroids, among other health issues. Less than half 32(23.32%) of participants reported to have received their diagnostic results in over a month.

Association between health facility level-factors by delayed Cervical Cancer diagnosis

Table 3

Association between health facility level-factors by delayed Cervical Cancer diagnosis
Variable		Early (%)	Delayed (%)	Crude Odds Ratio (95% Confidence Interval)	P-value
		n = 53	n = 86
First Medical care
	Private	15(37.50)	25(62.50)	Ref
	Public	36(39.56)	55(60.44)	0.917(0.426–1.971)	0.824
	Other	2(25.00)	6(75.00)	1.800(0.321–10.088)	0.504
Hospital visits
	Once	12(41.38)	17(58.62)	Ref
	Twice	10(45.45)	12(54.55)	0.847(0.277–2.591	0.771
	3–4 times	14(35.90)	25(64.10)	1.261(0.470–3.382	0.646
	5times and above	17(34.69)	32(65.31)	1.329(0.517–3.417)	0.555
Referred
	Yes	46(36.80)	79(63.20)	Ref
	No	7(50.00)	7(50.00)	0.582(0.192–1.765)	0.339
Referral times
	Once	35(52.24)	32(47.76)	Ref
	Two and above	11(18.97)	47(81.03)	4.673(2.073–10.535)	0.000*
Referral Challenges
	Yes	21(29.17)	51(70.83)	2.168(1.034–4.550)	0.041*
	No	25(47.17)	28(52.53)	Ref
Diagnosis Appointment
	< 2 weeks	48(40.34)	71(59.66)	Ref
	2 weeks- 1 Month	1(8.33)	11(91.67)	7.437(0.929–59.504	0.059*
	I Month and above	4(50.00)	4(50.00)	0.676(0.161–2.835)	0.592
Diagnostic Results
	< 2 weeks	31(48.44)	33(51.56)	Ref
	2 weeks- 1 Month	16(37.21)	27(62.79)	1.585(0.720–3.490)	0.252
	I month and above	6(18.75)	26(81.25)	4.071(1.477–11.222)	0.007*

*Statistically significant at P-value of less than 0.05

Table 3 summaries the relationship between delayed diagnosis and health facility level factors assed using the bivariate logistic regression test. The most type of facility visited first was mostly public and most patients visited the hospital 5 times and more before being diagnosed. Both of these factors did not have statistical significance. However, the differences in referred were not statically significant, majority (63.20%) of the referred patients were diagnosed at advanced stages. The risk factors for delayed diagnosis were; more number of referral times (p-value = 0.000), availability of referral challenges (p-value = 0.041), Prolonged diagnosis appointments (p-value = 0.059) and long waiting periods for diagnosis results, (p-value = 0.007), in the bivariate model.

Only one factor; more number of referral times, was statistically significantly associated with delayed diagnosis in the multivariate model (p-value = 0.001).

The study found out that, most of the participants were diagnosed at late stages of Cervical Cancer. In this study, 90% of participants sought medical help from other facilities before being referred to KNH. Lack of decentralized diagnostic facilities in Kenya, is one of the major barriers to accessing cancer testing especially in local facilities (9), leading to patients being referred to better equipped facilities to access diagnostic services. While assessing referral dynamics, patients referred two times and more, were reported to face referral challenges, and were found to be more likely to have delayed Cervical Cancer diagnosis compared to those who were only referred once with no or less referral challenges. Patients reported to have experienced misdiagnoses with other diseases such as fibroids, postmenopausal bleeding and infections. Medical staff noted that several medical personnel from local facilities are not well trained and lack a high index in suspecting cancer cases, thus, a high number of misdiagnosed cases. These findings were in corroboration with another study, where almost half of its participants were referred more than once and 35% of them blamed medical personnel at local facilities for having misdiagnosed them with other diseases and lack of diagnostic equipment as major referral challenges(6). This could be explained by challenges presented by poor referral systems such as; lack of finances, misdiagnosis, lack of specialized personnel and equipment that may lead to delay in primary health care(6). Availability and accessibility of effective cancer diagnostic equipment is an important hospital factor that improves early diagnosis among cancer patients(6). Inadequate access to screening and diagnostic services and trained medical personnel, especially in rural settings(1) (7), forces patients to travel long distances in sought of better primary health care(9). Qualitatively, patients had to incur extra finance costs at all referral stages as they were required to pay for consultations, tests and treatment. Referrals also led to inconsistencies in medical information, due to misplacement of medical records. This would further cause misdiagnosis and financial burden on the patients. Qualitative findings from a previously done study, reported that inadequate knowledge on Cervical Cancer and patient information by healthcare providers, are factors that may lead to delayed diagnosis(10).

This study also found that longer waiting periods for diagnosis appointments and results also lead to delayed diagnosis. These findings are consistent with that of a study that reports that, delays in diagnosis results, hinders primary healthcare as medical care decisions are dependent on them (6). Centralization of diagnostic and treatment equipment in major government hospitals, causes congestion of patients due to a higher patient to medical personnel ratios and few equipment for diagnosis(9). Needy patients are required to travel long distances to seek the diagnostic services(9). Due to high cancer patient numbers at KNH, patients take longer to get diagnosis appointments and close to two months or more to get scanning or biopsy results. During this waiting period, the disease progresses further with worsening of symptoms, especially for late stages patients. These delays, could implicate more treatment financial burden to the late patients. Diagnosis results delays, also hinder primary healthcare as medical care decisions are dependent on them(6). This study found that, patients who are able to afford private facilities are able to fast track this process and get early diagnosis and treatment, because private facilities experience less congestion as only patients who can afford their services visit them.

The study identified gaps in the organization of health systems as Referral challenges and systemic delays in appointments and results were the Health facility related factors that were associated with delayed Cervical Cancer diagnosis. With these gaps, poor health systems are a major hindrance in the access and availability of quality medical care leading to delayed diagnosis. Public Private Partnerships (PPPs) should be encouraged to support the increase and equitable decentralization of diagnostic centers, equipment and specialized medical personnel, so as to lessen referral challenges and improve access of diagnostic services whilst targeting timely diagnosis.

ERC- Ethical Review Committee
JKUAT – Jomo Kenyatta University of Agriculture and Technology
KNH- Kenyatta National Hospital
NACOSTI- National Commission for Science, Technology & Innovation
PPPs- Public Privates Partnerships
STIs- Sexually Transmitted Infections
UON- University of Nairobi
UTIs- Urinary Tract Infection
TICH-Tropical Institute of Community Health and Development

Ethics Approval and Consent to Participate

The Research ethical clearance and approval was obtained from the JKUAT and KNH-University of Nairobi (UON) Ethical Review Committees (ERCs), under approval numbers JKU/ISERC/02316/0818 and P522/06/2023 simultaneously, and a Research permit obtained from the National Commission for Science, Technology & Innovation (NACOSTI), under license number, NACOSTI/P/23/24644. A study certificate was also issued from the KNH Medical Research Department, to allow registration of the research project and data collection. All participants gave oral informed consent to participate in the study. Authorization to access and use patient contact information for telephone interviews and hospital medical records was sought from the KNH hospital administration. Participants were interviewed in privacy and data collected was handled with confidentiality, through the use of identity codes to conceal the patient identities and limiting access to the raw data collected to the Principal Investigator only.

Consent for publication

Not applicable

Available of Data and Materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing Interests

The authors declare that they have no competing interests.

Funding

This Research project was funded by the Second European and Developing Countries Clinical Trials Partnership (EDCTP2), supported by the European Union (EU).

Authors Contributions

MKZ conceptualized and designed the Research, collected patient data, analyzed and interpreted the data, and developed and revised the manuscript for submission.

JN, SM and CO conceptualized and designed the Research and revised the manuscript for submission.

All authors read and approved the final manuscript

Acknowledgements

We acknowledge, the JKUAT School of Public Health, and the KNH administration and staff, for the approval and support in mobilization and actualization of this project.

Rendle KA, Ramogola-Masire D, Monare B, Ogden SN, Toneff HK, Saia CA, et al. Patient perspectives on delays in Cervical Cancer screening and follow-up care in Botswana: A mixed methods study. 2020; doi:10.1186/s12905-022-01777-z
Globocan. Africa https://gco.iarc.fr/today/data/factsheets/populations/903-africa-fact-sheets.pdf Accessed 28 Sep 2022.
Globocan. Kenya https://gco.iarc.fr/today/data/factsheets/populations/404-kenya-fact-sheets.pdf Accessed 28 Sep 2022.
Osok D, Karanja S, Kombe Y, Njuguna E, Todd J. Assessing Factors Associated with Survival Among Cervical Cancer Patients in Kenya: A Retrospective Follow-up Study 2018; doi:10.24248/EAHRJ-D-18-00010
Makena Frida K, Carole Atieno WM, Habtu M. Socio-Demographic Factors Associated with Advanced Stage of Cervical Cancer at Diagnosis in Kenyatta National Hospital, Kenya: A Cross Sectional Study. 2017; doi:10.4172/1948-5956.1000473
Korir Anne Rugutt B. Barriers to Early Diagnosis of Invasive Cervical Cancer Among Patients Receiving Treatment at Kenyatta National Hospital, Nairobi Kenya. 2014. https://ir-library.ku.ac.ke/handle/123456789/11957
Zeleke S, Anley M, Kefale D, Wassihun B. Factors associated with delayed diagnosis of Cervical Cancer in Tukur Anbesa Specialized Hospital,2019: A cross-sectional study. 2021; doi:10.2147/CMAR.S285621
Dereje N, Addissie A, Worku A, Assefa M, Abraha A, Tigeneh W, et al. Extent and Predictors of Delays in Diagnosis of Cervical Cancer in Addis Ababa, Ethiopia: A Population-Based Prospective Study. 2020; doi:10.1200/JGO.19.00242
Makau B, Sandra B, Nicholas A, Stephanie W, Asheley S, Antonia V. Improving Access to Cancer Testing and Treatment in Kenya. 2017; doi:10.1200/JGO.2017.010124
Plaisy MK, Boni SP, Coffie PA, Tanon A, Innocent A, Horo A, et al. Barriers to early diagnosis of Cervical Cancer: A mixed-method study in Côte d’Ivoire, West Africa. 2023; doi:10.1186/s12905-023-02264-9

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

A Hospital-Based Survey Assessing the Health Facility-Level Factors that Contribute to Delayed Diagnosis of Cervical Cancer; Patients Views

Status:

Version 1

Abstract

Figures

Background

Methods

Results

Sociodemographic characteristics

Health Facility-level factors

Distribution of participants across of health facility factors

Association between health facility level-factors by delayed Cervical Cancer diagnosis

*Statistically significant at P-value of less than 0.05

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1