Abstract
Purpose
The incidence of colorectal cancer (CRC) in Ghana has increased eightfold since the 1960s. In 2011, national guidelines were set forth recommending all patients aged 50–70 years old undergo annual CRC screening with fecal occult blood testing (FOBT), but adherence to these guidelines is poor and screening rates remain low for unclear reasons.
Methods
We performed semi-structured interviews with 28 Ghanaians including physicians (n = 14) and patients (n = 14) from the Komfo Anokye Teaching Hospital in Kumasi, Ghana, to better understand the factors driving screening adherence and perceived barriers identified in an earlier quantitative study.
Results
Participants reported sociocultural factors such as reliance on alternative medicine or religion, lack of education, and financial burden as community-level barriers to CRC screening. At the system level, screening was limited by insufficient access to FOBT as well as a perceived lack of national prioritization. This was described as inadequate efforts from the Ministry of Health regarding national education as well as lack of incorporation of CRC screening into the National Health Insurance Scheme.
Conclusion
Several community- and system-level barriers exist to widespread screening of CRC in Ghana. A multi-level approach will be required to improve rates of CRC screening and ultimately reduce the burden of CRC in Ghana.
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Introduction
Colorectal cancer (CRC) is the third most commonly diagnosed cancer globally [1, 2]. In 2020, approximately 1.9 million people were diagnosed with colorectal cancer [3]. Traditionally, CRC has been primarily considered a disease of developed countries, but rates are now rising in developing countries [3,4,5,6]. In Ghana, the incidence of CRC remains low at 3.9 cases per 100,000 (compared to 25.6 cases per 100,000 in the United States), but has increased several fold since the 1960s. Moreover, the incidence of CRC in Ghana is expected to continue to climb given Ghana’s aging population, rising life-expectancy, and ongoing adoption of Western habits [7,8,9]. Unfortunately, most patients present late in their disease course resulting in a 16% overall 5-year survival rate [10]. The comparative estimate for 5-year survival in the United States (US) for all stages combined is 65% [3]. Early detection of CRC is critical for Ghanaians given the dramatic decrease in survival rates from Stage I (90%) to Stage IV (0%) [10]. As such, to address the increasing burden of CRC in Ghana, in 2011, the Ministry of Health targeted CRC as an area for improvement and set forth a recommendation that all patients aged 50–70 years old were screened for CRC using fecal occult blood testing (FOBT) with subsequent endoscopy for positive FOBT tests [11].
Despite the national guidelines, adherence is rarely observed. As reported in our earlier work, physicians from Komfo Anokye Teaching Hospital (KATH), Ghana’s second largest tertiary facility, vary widely in their screening habits and only one of 39 surveyed physicians practiced in concordance with the national guidelines [12]. Perceived barriers to CRC screening at the physician level included inadequate time, training, and a lack of equipment and facilities. Separately, among patients, knowledge of cancer and cancer screening in Ghana is generally low, even for more prevalent cancers such as breast, prostate, and cervical cancers [13,14,15]. Increasing CRC screening rates will require coordinated efforts between communities and health systems and a better understanding of the existing barriers.
In this context, we designed an exploratory qualitative study using semi-structured interviews to develop a deeper understanding of community- and system-level barriers to CRC screening in Kumasi, Ghana. The study was designed as a follow-up to our previous quantitative study in which we surveyed physicians at KATH regarding their CRC screening practices and perceived barriers to screening [12]. The results of this study will be able to help inform tailored, multi-level interventions aimed at increasing CRC screening rates in Ghana.
Methods
Study design
In order to understand barriers to CRC screening from multiple perspectives, we interviewed both patients and physicians. The interviews sought to obtain a broader understanding of the perceived barriers to CRC screening in Ghana at the community and system levels. Interview guides were loosely based on the seven domains from the Tailored Implementation in Chronic Disease (TICD) framework [16, 17]. Separate interview guides were created for physicians and patients but were largely similar. Both interview guides were shared with team members who were culturally familiar to ensure relevancy among Ghanaian participants [GK, CKD, DD, BKO]. Approval for the study was obtained from the Institutional Review Board at KATH as the primary site and additionally at the University of Michigan.
Interview participants
Participants were recruited by convenience sampling in order to not place undue burden on our local physician partners. KATH physician participants were included if they screened patients for CRC as part of their practice. Patient participants were either surgical inpatients or being seen in consultation as outpatients. Demographics outside of gender were not recorded in order to protect participants’ privacy and our local partners’ concern for potential retribution. For example, physicians at KATH are employed by the Ghanaian government and did not want to risk loss of their job if identified which was a possibility given the limited number of physicians at KATH. In total, 14 physicians and 14 patients completed interviews. Participants did not receive any compensation for their participation.
Data collection
In-person interviews were performed by six resident physicians (EAB, KB, EP, FG, LS, and FY) at KATH between October 2020 and January 2021. Prior to interviewing, interviewers explained the purpose of the study and obtained verbal consent. Interviews lasted 10–15 min and were audio-recorded, transcribed verbatim, and de-identified. Of note, physician interviews were conducted in English and patient interviews were conducted in Twi, the most commonly spoken language in Kumasi. Patient interviews were transcribed from Twi to English. Back-translation was not used due to a limitation of resources.
Data analysis
Transcripts were coded using open coding informed by the iterative steps used in inductive thematic analysis [18]. During the first round of coding, five members of our research team (MB, AV, AL, LJ, and LH) independently reviewed three physician or three patient interview transcripts and annotated them with initial codes. Given the content similarities between the patient and physician interviews, a single codebook was generated using these preliminary codes. Several additional meetings were held to discuss discrepancies, modify the codebook, and adapt code definitions. Once a final codebook was agreed upon, each transcript was then independently coded by one of three members of the research team (AL, LJ, LH). Transcribed interviews were coded in MAXQDA 2020 qualitative analysis software (VEFBI Software, Berlin, Germany).
Results
A total of 28 participants were interviewed in this study: 14 physicians (64% male) and 14 patients (43% male). Previous work has found the majority of physicians at KATH to be male [12]. Barriers were categorized into two groups, community level and system level. At the community level, sociocultural factors, lack of education and financial burden were identified as barriers. At the system level, insufficient access and lack of national prioritization were most commonly reported.
Perceived barriers: community level
Sociocultural
Table 1 describes the range of sociocultural barriers to CRC screening described by patients and physicians. These included health care beliefs, the influence of religion and traditional medicine, perception of stool collection for FOBT, and the stigma associated with the diagnosis of cancer. The idea of physician consultation upon initial symptom presentation and for routine cancer screening was not widely accepted as the norm. Respondents also commented on the prevalence of religion and its role in shaping community members’ medical beliefs and habits. Some physicians noted that patients may seek treatment from their church or a spiritualist before coming to see them. One physician explained his frustration with this phenomena:
In the village…they start the herbs before the operations are planned, various concoctions and leaves, drinking stuff here and there....sometimes, some of these religious bodies or persons sort of hinder the progress of medicine. And also with the traditional medicine people too, preaching false cures to people, grinding all sorts of leaves and herbs for people, they are sort of compounding the problem. -Physician 05
This physician explains that while he also believes in God, religion and traditional medicine may “hinder the progress of medicine,” and prohibit timely access to care and effective medical treatment.
The stigma of having a diagnosis of cancer was noted a few times but overall, infrequently discussed. One patient mentioned that cancer is not stigmatized, unlike diagnoses of human immunodeficiency virus (HIV) or coronavirus disease 2019 (COVID-19) (Patient 01). More often, patients discussed the collection of fecal matter for FOBT. Patient participants rarely said they would be uncomfortable giving a sample of stool, most instead expressed faith in their physician and willingness to undergo any recommended test in order to facilitate diagnosis and treatment. Moreover, they believed their communities would feel the same way. When asked if people would be laughed at for undergoing FOBT, one patient commented:
I can attest to the fact that nothing like this will ever happen. No one will be teased. For instance, if you are unwell and you go to the hospital and the doctor asks you to bring your stool and urine for testing to determine the illness, the person will run to go and bring it to the doctor. – Patient 14
Lack of education
Lack of education was one of the most commonly mentioned barriers to CRC from among patients and physicians (Table 2). Participants believed that improved medical education related to CRC and screening awareness would be beneficial for increasing rates of CRC screening in the community. Further, without understanding the importance of CRC screening, patients felt their community would be unlikely to undergo screening.
If they do not understand what the test is for, they will not see the importance of participating in the screening.—Patient 13
Specifically, patients pointed out that education should not only describe what CRC and CRC screening are but emphasize their importance and how cancer is a “dangerous illness” (Patient 10). Separately, both patient and physician respondents acknowledged the power of community and religious leaders to leverage their platforms to educate community members and promote the importance of CRC screening. One physician highlighted the role clinicians could play to encourage this effort:
…we all need to play a role. There is a role that we as clinicians for instance…help educate religious leaders use their church platforms and mosque and religious setting to preach and to education the people so that people will come our way. – Physician 03
Here, this physician emphasized the unique role they can play in educating key personnel who have highly influential positions in their communities.
Financial burden
Several patients and physicians reported cost as a barrier to CRC screening (Table 2). Many alluded to a general state of poverty in their community resulting in lack of funds to cover the costs of screening as well how they “don’t have the money to go to the hospital” (Patient 08). Additionally, a few patients reported that despite having health insurance, not all of their medical bills were covered.
Perceived barriers: system-level
Access
Although the majority of patients reported having a local hospital where they could seek medical care, they were not always able to receive what they needed (Table 3). Some noted local hospitals did not always have physicians available resulting in exceedingly long wait times for general medical care and at times, resources for diagnosis and treatment were frequently lacking. Separately, physicians noted that FOBT was not always available at every hospital and in particular highlighted the need for easy access at all medical system levels: community, sub-district, and district.
If these so called fecal blood tests can be made available especially for those of us coming or working in the sub-district. If these test kits are not available and then they always have to come to these CT, or what they are about to get, will be a big problem, they will lose interest in doing it. So I think they, the point should be available right down to the district level and sub-district level, so that it can easily be picked from there.—Physician 03.
This physician notes that if FOBT is not widely accessible, physicians will lose interest in recommending the screening test.
Lack of national prioritization
CRC screening was generally not perceived to be a national priority in Ghana (Table 3). To address this, participants suggested that: (1) the Ministry of Health (MOH) increases pertinent cancer education and public awareness of CRC and (2) FOBT financial coverage is incorporated into the National Health Insurance Scheme (NHIS), Ghana’s national insurance policy that was designed to provide basic healthcare services [19]. Although the NHIS was designed to cover over 95% of disease conditions in Ghana, including treatment for breast and cervical cancers, it notably does not over CRC screening or treatment [20]. One physician commented:
The Ministry of Health needs to really invest a lot of time and create more public awareness of cancers...public education is very necessary. Also…the government and Ministry of Health entirely should also invest in cancer care, invest in providing health facilities resources for the management of these patients, and also if they could factor it in to the national health insurance scheme. -Physician 09
This physician believed that given the increasing prevalence of CRC in Ghana, investment from the MOH to “create more public awareness,” increase education, and advocate for insurance coverage of FOBT would have significant impact on Ghanaians.
Discussion
The results of this study highlight several barriers to CRC screening in Ghana at both the community and system levels. At the community level, sociocultural factors included reliance on alternative medicine or religion and limited use of hospitals for medical care. Respondents simultaneously noted that lack of education regarding CRC and CRC screening was widespread and without addressing this issue, patients would be unlikely to undergo screening. At the system level, screening was limited by insufficient access to FOBT and a lack of national prioritization. Efforts from the Ministry of Health to promote awareness and education as well as incorporation of FOBT into the National Health Insurance Scheme were cited as opportunities to improve rates of CRC screening. Our results build on our previous work identifying barriers at the physician level including lack of equipment, personnel shortages, and limited training and, within this context, underscore the need for a multi-pronged approach to improving CRC screening rates in Ghana in order to ultimately reduce the burden of CRC [12].
As our respondents highlighted, improved education, garnering support from the community, and reducing the financial burden of CRC screening will be required to make substantial impact. Mobile health platforms are effective means of communication and education and can help provide timely medical care within the confines of low resource settings [21,22,23]. As such, mobile health platforms may be an innovative way to address CRC screening and may be particularly effective in Ghana, where WhatsApp accounts for 90% of information flow [24]. Prior studies have shown the success of mobile health platforms in improving the conduction of cervical cancer screening [25]. Our team is currently working on the development and implementation of ConqueringCRCancer, a mobile health platform that leverages pre-existing electronic tools such as WhatsApp [26] and Qualtrics [27] and trains community health workers in Ghana to bring and administer FOBT for patients in their homes. Further, use of this tool will facilitate localization of the nearest endoscopy center should more invasive testing be required and will serve as a longitudinal tracking system for CRC screening.
No matter how effective an intervention, sustainable impact will require change at the system level, including improved access and national support. The system-level barriers identified in our study are similar to other work evaluating the barriers to breast and cervical cancer screening and despite increased national attention, screening rates for breast and cervical cancer in Ghana remain low at 12% and 3.4%, respectively [13, 14, 28]. Strategies employed as part of the response to the HIV/AIDS epidemic may be especially helpful in designing efforts aimed at improving screening for all three cancers. Ghana’s multi-sector, coordinated approach to fighting the HIV/AIDS epidemic has allowed for the successful implementation of interventions within the decentralized Ghanaian health care system. This has resulted in improved physician awareness, increased testing and treatment access, prevention of mother-to-child transmission, and universal precautions to prevent infection [29, 30]. Such an approach may additionally encourage communication between the government, hospitals, and physicians and ultimately align priorities to more effectively improve CRC screening rates. Another helpful tactic from Ghana’s management of HIV/AIDS was early creation of the HIV Sentinel Surveillance (HSS) system, and later the Ghana Demographic and Health Survey, which allowed for estimation of the extent of HIV infection and the linkage of HIV results to key demographic, social, and behavioral factors [31]. These data repositories—which are lacking for CRC—were critical in understanding the burden of HIV/AIDS, tracking progress, and identifying where needs were highest. As a marker of Ghana’s success, HIV screening is now widely available at the national, regional, district, and subdistrict levels [30].
Our study must be interpreted in light of its limitations. We used convenience sampling which may limit the generalizability of our results in two ways. First, we sampled from only one institution; however, KATH is the second largest tertiary facility in Ghana and receives referrals from 12 of 16 regions of Ghana [32]. It receives a diverse set of patients representative of almost the whole country. Second, by interviewing individuals who were patients at KATH, our sample may be biased as it is comprised from a population willing to seek care at a hospital. Therefore, these participants may not share the same health beliefs as the Ghanaian population at large. However, several patients acknowledged their community’s hesitancy in seeking hospital care; we believe community views were broadly represented. Lastly, our study was conducted during the COVID-19 pandemic which limited our sample size, resources, and ability to train interviewers as intensively as originally planned. Despite these limitations, we found our collected data to be incredibly informative and our local partners perceive it to be in line with their experiences. Future studies are needed to understand barriers to CRC screening in a broader Ghanaian population and to investigate the most appropriate method for CRC screening in Ghana.
Data availability
The dataset generated during this study are not publicly available but are available from the corresponding author on reasonable request.
Code availability
Not applicable.
References
Keum NN, Giovannucci E (2019) Global burden of colorectal cancer: emerging trends, risk factors and prevention strategies. Nat Rev Gastroenterol Hepatol 16(12):713–732
Fitzmaurice C, Abate D, Abbasi N et al (2019) Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 29 cancer groups, 1990 to 2017: a systematic analysis for the global burden of disease study. JAMA Oncol 5(12):1749–1768
Colorectal Cancer: Statistics. Published 2020. Accessed April 20, 2021. https://www.cancer.net/cancer-types/colorectal-cancer/statistics#
Center MM, Jemal A, Ward E (2009) International trends in colorectal cancer incidence rates. Cancer Epidemiol Biomarkers Prev 18(6):1688–1694
Favoriti P, Carbone G, Greco M, Pirozzi F, Pirozzi REM, Corcione F (2016) Worldwide burden of colorectal cancer: a review. Updates Surg 68(1):7–11
Arnold M, Sierra MS, Laversanne M, Soerjomataram I, Jemal A, Bray F (2017) Global patterns and trends in colorectal cancer incidence and mortality. Gut 66(4):683–691
Dakubo J, Naaeder S, Tettey Y, Gyasi R (2011) Colorectal carcinoma: an update of current trends in Accra. West Afr J Med. https://doi.org/10.4314/wajm.v29i3.68218
Yeboah FA, Yorke J, Obirikorang C et al (2017) Patterns and presentations of colorectal cancer at Komfo-Anokye teaching hospital Kumasi Ghana. Pan Afr Med J 28:1–10
Global Cancer Observatory. World Health Organization. Published 2022. Accessed March 24, 2022. https://gco.iarc.fr
Agyemang-Yeboah F, Yorke J, Obirikorang C et al (2018) Colorectal cancer survival rates in Ghana: a retrospective hospital-based study. PLoS ONE 13(12):1–15
MoH. National Strategy for Cancer. Minist Heal Ghana. Published online 2016:1–8.
Lussiez A, Dualeh SHA, Dally CK et al (2021) Colorectal cancer screening in Ghana: physicians’ practices and perceived barriers. World J Surg 45(2):390–403
Binka C, Nyarko SH, Awusabo-Asare K, Doku DT (2019) Barriers to the uptake of cervical cancer screening and treatment among rural women in Ghana. Biomed Res Int 2019:1–8
Opoku SY, Benwell M, Yarney J (2012) Knowledge, attitudes, beliefs, behaviour and breast cancer screening practices in Ghana, West Africa. Pan Afr Med J 11:28
Baratedi WM, Tshiamo WB, Mogobe KD, McFarland DM (2020) Barriers to prostate cancer screening by men in sub-saharan Africa: an integrated review. J Nurs Scholarsh 52(1):85–94
Flottorp SA, Oxman AD, Krause J et al (2013) A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implement Sci. https://doi.org/10.1186/1748-5908-8-35
Wensing M (2017) The tailored implementation in chronic diseases (TICD) project: introduction and main findings. Implement Sci 12(1):10–13
Terry G, et al (2017) Thematic analysis. The Sage Handbook of Qualitative Research in Psychology
Blanchet NJ, Fink G, Osei-Akoto I (2012) The effect of Ghana’s National Health Insurance Scheme on health care utilisation. Ghana Med J 46(2):76–84
Benefits Package. National Health Insurance Scheme. Published 2022. https://www.nhis.gov.gh/benefits.aspx. Accessed 27 Feb 2022
Woods J, Moorhouse M, Knight L (2019) A descriptive analysis of the role of a WhatsApp clinical discussion group as a forum for continuing medical education in the management of complicated HIV and TB clinical cases in a group of doctors in the Eastern Cape, South Africa. South Afr J HIV Med 20(1):1–10
Bervell B, Al-Samarraie H (2019) A comparative review of mobile health and electronic health utilization in sub-Saharan African countries. Soc Sci Med 232(April):1–16
Amoakoh HB, Klipstein-Grobusch K, Amoakoh-Coleman M et al (2017) The effect of a clinical decision-making mHealth support system on maternal and neonatal mortality and morbidity in Ghana: study protocol for a cluster randomized controlled trial. Trials 18(1):1–11
Ahiabenu K. Ghana runs on whatsApp. Published 2018. https://www.graphic.com.gh/features/opinion/ghana-runs-on-whatsapp.html. Accessed 30 Mar 2021
Asgary R, Cole H, Adongo P et al (2019) Acceptability and implementation challenges of smartphone-based training of community health nurses for visual inspection with acetic acid in Ghana: mHealth and cervical cancer screening. BMJ Open. 9(7):e030528
WhatsApp. Published 2020. https://www.whatsapp.com/. Accessed 30 Mar 2021
Qualtrics. Published 2020. https://www.qualtrics.com. Accessed 1 July 2020
Ayanore MA, Adjuik M, Ameko A et al (2020) Self-reported breast and cervical cancer screening practices among women in Ghana: predictive factors and reproductive health policy implications from the WHO study on global AGEing and adult health. BMC Womens Health 20(1):1–10
WHO. GHANA. Summary Country Profile for HIV/AIDS Treatment Scale-Up.; 2005. https://www.who.int/hiv/HIVCP_GHA.pdf. Accessed 27 Feb 2022
AyisiAddo S, Abdulai M, Yawson A et al (2018) Availability of HIV services along the continuum of HIV testing, care and treatment in Ghana. BMC Health Serv Res 18(1):739
Akwara PA, Fosu GB, Govindasamy P, Alayón S, Hyslop A (2005) An in-depth analysis of HIV prevalence in Ghana: further analysis of demographic and health surveys data. Calverton: ORC Macro. http://dhsprogram.com/publications/publication-FA46-Further-Analysis.cfm
Komfo Anokye Teaching Hospital - About Us. Published 2019. http://www.kathhsp.org/about-us/. Accessed 22 Feb 2022
Acknowledgments
The authors are deeply indebted to Dr. Anne Sales and Dr. Jennifer Ervin for their guidance and support in the creation and execution of this study.
Funding
AL is supported by the National Cancer Institute (T32CA009672).
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All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by AL, EB, KB, EP, LH, LJ, AV, MB, AD, CV, LM, DD, FA, KG-S, and BO. The first draft of the manuscript was written by AL and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
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Lussiez, A., Dally, C.K., Boateng, E.A. et al. Barriers to colorectal cancer screening in Ghana: a qualitative study of patients and physicians. Cancer Causes Control 33, 951–958 (2022). https://doi.org/10.1007/s10552-022-01578-7
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DOI: https://doi.org/10.1007/s10552-022-01578-7