Barriers to colorectal cancer screening in Ghana: a qualitative study of patients and physicians

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.

Barriers and recommendations for colorectal cancer screening in Africa

“…[#], location, and article type/study design Sample size Barriers Recommendations [ 20 ]; Kenya; perspectives paper Systematic: limited endoscopic capabilities (training, infrastructure), limited no. of trained pathologists (turnaround time, 2–6 weeks) Train nonphysician endoscopists; use high-resolution micro-endoscopy to improve detection of neoplasia; expand insurance coverage [ 18 ]; Africa; editorial Systematic: infrastructure, provider availability, cost of screening procedure; Patient: acceptance of screening; Provider: pathologic services, endoscopic training Consider FIT for CRC screening; consider flexible sigmoidoscopy or serologic blood tests; in-person and virtual training from other specialties and nonphysician providers to increase endoscopic capacity by health care professionals and endoscopic equipment manufacturers [ 16 ]; Egypt; qualitative study, 1-h semi-structured interview 17 physicians (8 specialists, 9 primary care) Systematic: lack of test availability, cost of screening procedure; Patient: Socio-economic status, fear, cost, cultural belief (only see doctor when symptomatic); Provider: lack of emphasis on prevention, belief that only high-risk patients should be screened, lack of confidence to perform and interpret test, inadequate training for lab technicians and providers Implement a media campaign emphasising early detection, curability, and prevention; educate physicians and elicit physical engagement; make screening tests widely available; provide well-trained providers; lower cost [ 12 ]; Ghana; qualitative study 39 physicians Systematic: lack of equipment/facilities, high screening costs/lack of insurance coverage; Patient: lack awareness of early screening benefits, not perceiving CRC as a serious health threat, poor adherence; Provider: not recommending CRC screening for asymptomatic average-risk patients, lack of training/personal adherence to screening Government to make sustained commitment and financial investment for CRC screening; further studies on true incidence of CRC and individual and societal cost of CRC screening to motivate stake holders to support CRC prevention on a national scale; further studies to understand the exact beliefs and level of knowledge held by the Ghanaian population [ 17 ]; Ghana; qualitative study, interview to understand factors driving screening adherence 14 patients, 14 physicians Systematic: access to healthcare, lack of national prioritisation; Patient: sociocultural factors, reliance on alternative medicine/religion, perception of stool co...…”

“…Another barrier to CRC screening in Africa was the lack of patient knowledge [ 13 , 17 , 18 , 20 , 26 , 27 ]. Lussiez et al [ 13 ] reported that 86.2% of physicians interviewed in Ghana identified patients’ lack of awareness of screening, specifically patients not perceiving CRC as a serious health threat, as a barrier to CRC screening.…”

“…Furthermore, 65.6% of those physicians noted that primary care physicians do not actively recommend screening in their practices and 10% would not recommend CRC screening for asymptomatic average-risk patients, even if their age was in the range specified in the national guidelines. Three other nonintervention studies listed in Table 1 reported the lack of emphasis and education on preventive screening by health care professionals as a barrier [ 17 , 18 , 20 ]. Brand Bateman et al [ 17 ] found that only a few participants mentioned doctors as an information source, likely because Egyptians do not regularly visit physicians.…”

“…Some of the significant cultural factors influencing CRC screening in Ghana were patients’ beliefs about health care, religion and traditional medicine and the stigma associated with the diagnosis of cancer [ 18 ]. Most (~75%) of interviewed physicians reported the perception of stool collection for FOBT and the invasive nature of colonoscopy as barriers [ 17 , 18 ].…”

Experiences and coping strategies of colostomy patients in Ghana: A Phenomenological study

“…Like most SSA countries, Ghana lacks a national colostomy registry, however, institutional-based data indicate increasing incidence for colostomy due to recent increases in colorectal cancers and diverticular diseases [9]. For instance, recent data points to the fact that about 33 percent new cases of colorectal cancer out of every 100,000 persons are recorded yearly [10,11]. These statistical evidences indicate that the problem of colorectal cancers is no longer uncommon among the indigenous people of Ghana.…”