An outcomes evaluation of the Zim-TTECH cervical cancer intervention in Harare Metropolitan Province, Zimbabwe

This report presents the findings of an outcomes evaluation of the Zimbabwe Technical Assistance, Training and Education for Health's (Zim-TTECH) cervical cancer intervention in Harare and Epworth districts (Harare Metropolitan province). This programme seeks to improve access and uptake of cervical cancer screening and treatment among women living with HIV through recruitment, training and mentorship of nurses, procurement of equipment and commodities, providing support for diagnosis and referral for treatment services, and quality assessment of cervical cancer services. The evaluation interrogated the plausibility of the programme theory of the Zim-TTECH intervention and assessed its short- and medium outcomes. Methods The evaluation used a mixed-methods approach with both qualitative and quantitative data collection methods. This comprised a desk review of programme documents and relevant literature, secondary analysis of programme routine data and collection of primary data. Quantative descriptive analysis was conducted to determine coverage (in percentage) of Zim-TTECH cervical cancer services between 2019- 2021. Qualitative analysis was used to complement quantitative data and aid in the interpretation of programme results. Key Results This assessment showed that the Zim-TTECH cervical cancer intervention contributed to the increase in awareness among women living with HIV and health workers. The programme capacitated health workers to conduct effective health education and awareness-raising campaigns for cervical cancer. The evaluation revealed that the Zim-TTECH cervical cancer intervention improved access to cervical cancer services among women living with HIV. Additionally, the intervention did not deny women who were HIV-negative services though the reach for this group is not routinely documented and reported. Results from the evaluation showed that LEEP was the main treatment type used in Harare and Epworth followed by cryotherapy and thermablation techniques. This assessment also showed that the Zim-TTECH cervical cancer intervention contributed positively to the following areas: increasing access to cervical cancer services, early detection of pre-cancers and invasive disease and increased health education and awareness of cervical cancer among women and health workers. The evaluation also revealed some negative implications of the Zim-TTECH intervention on the health system which include the following: the programme‘s screening resulted in the detection of invasive cervical cancer cases which were referred to weak and ill-capacitated public health facilities, and most screening services are offered in HIV clinics which results in some women who are not HIV positive not wanting to screen for fear of stigma and the programme also contributed to staff attrition in public health facilities as they search for better opportunities in the NGO sector and outside the country. The Zim-TTECH cervical cancer programme rapidly adjusted to the new COVID-19 protocols in 2020 to ensure continuity of services though the demand side was affected by protracted lockdowns. The programme has also been keeping in tandem with technological evolutions including the adoption of thermoablative techniques and planning for the rolling out of highly sensitive human papilloma virus (HPV) DNA testing in line with Ministry of Health strategies and WHO guidelines. However, discussions are still ongoing on the adoption of HPV screening as the primary method as it will negate the ‘see and treat' approach. This evaluation showed that cervical cancer services were likely to continue in Harare and Epworth after the cessation of Zim-TTECH support albeit at a lower scale. The Zim-TTECH intervention is based in public health facilities that have been offering cervical cancer services even before partner support came through and these are likely to continue in their absence. Conclusions Findings from this evaluation showed that Zim-TTECH cervical cancer intervention was relatively effective with regards to short-medium term outcomes, although the COVID-19 pandemic saw disruptions of cervical cancer services which affected service delivery/uptake in 2020-2021. However, the key shortfalls of the intervention revealed in this evaluation showed systemic/structural gaps with the design of health interventions in the country as well as the vertical approaches which are also being perpetuated by donors. Additionally, given the huge resource shortfalls in the MoHCC due to protracted underfunding, there is evidence of limited coordination/leadership capacities to guide partners who come up with piecemeal interventions. Despite the revealed shortcomings of the intervention there are opportunities to improve services including treatment of invasive cervical cancer. Overall, better partnerships and coordination among government, NGOs and donors will be a game changer in ensuring continuity of services for cervical cancer in low-resource settings

Health system constraints affecting treatment and care among women with cervical cancer in Harare, Zimbabwe

BACKGROUND : Cervical cancer is a major cause of morbidity and mortality among women yet access to treatment and care remains a huge challenge in Zimbabwe. The objective of this study was to investigate health system constraints affecting engagement into treatment and care by women with cervical cancer in Harare, Zimbabwe. METHODS : A sequential explanatory mixed methods design was used for this study. Phase 1 comprised of two surveys namely: patient and health worker surveys with sample sizes of 134 and 78 participants respectively. Validated structured questionnaires programmed in Android tablet with SurveytoGo software were used for data collection during the surveys. Univariate analyses were conducted using STATA® version 14 to generate descriptive statistics. In phase 2, 16 in-depth interviews, 20 key informant interviews and 6 focus groups were conducted to explain survey results. Participants were purposively selected and sample sizes were informed by saturation principle. Participants in phase 1 and 2 were different. English transcripts were manually coded line by line in Dedoose software using the thematic codes that had been established from the survey data. The final codes were used to support and explain the survey data at the interpretation stages. RESULTS : Health system constraints identified in surveys were: limited or lack of training for health workers, weakness of surveillance system for cervical cancer, limited access to treatment and care, inadequate health workers, reliance of patients on out-of-pocket funding for treatment services, lack of back-up for major equipment. Qualitative inquiry revealed the following barriers to treatment and care: high costs of treatment and care, lack of knowledge about cervical cancer and bad attitudes of health workers, few screening and treating centres located mostly in urban areas, lack of clear referral system resulting in bureaucratic processes, and limited screening and treating capacities in health facilities due to lack of resources. CONCLUSION: The results of this study show that health system and its organization present barriers to access of cervical cancer treatment and care among women. Strong political will, mobilization of resources both domestically and from partners in addition to sound policies are imperative to address key health system challenges.Additional file 1. Validated structured questionnaire for healthy women and cervical cancer patients [English & Shona].Additional file 2. Validated structured questionnaire for health workers [English].Additional file 3. In-depth interview guide [English and Shona].The Letten Foundation, Norwayhttps://bmchealthservres.biomedcentral.comam2020Obstetrics and GynaecologySchool of Health Systems and Public Health (SHSPH

Model strategies to address barriers to cervical cancer treatment and palliative care among women in Zimbabwe: a public health approach

BACKGROUND: Cervical cancer treatment and care remains limited in Zimbabwe despite the growing burden of the disease among women. This study was aimed at investigating strategies to address barriers in accessing treatment and care by women with cervical cancer in Harare, Zimbabwe. METHODS: A qualitative inquiry was conducted to generate evidence for this study. Eighty-four (84) participants were purposively selected for interviews and participation in focus group discussions. The participants were selected from cervical cancer patients, caregivers of cervical cancer patients, health workers involved in the care of cervical cancer patients as well as relevant policy makers in the Ministry of Health and Child Care. Participants were selected in such as a way as to ensure different of characteristics to obtain diverse perspectives about the issues under study. Discussion and interview guides were used as data collection tools and discussions/interviews were audio-recorded, transcribed and translated into English. Inductive thematic analysis was conducted using Dedoose software. RESULTS: Salient sub-themes that emerged in the study at the individual patient level were: provision of free or subsi‑ dized services, provision of transport to treating health facilities and provision of accommodation to patients under‑ going treatment. At the societal level, the sub-themes were: strengthening of health education in communities and training of health workers and community engagement. Salient sub-themes from the national health system level were: establishment of more screening and treatment health facilities, increasing the capacities of existing facilities, decentralization of some services, building of multidisciplinary teams of health workers, development and rolling out of standardized guidelines and reformation of Acquired Immunodeficiency Virus (AIDS) levy into a fund that would finance priority disease areas. CONCLUSION: This study revealed some noteworthy strategies to improve access to cervical cancer treatment and care in low-income settings. Improved domestic investments in health systems and reforming health policies underpinned on strong political are recommended.Additional file 1. In-depth interview guide.Additional file 2. Key informant interview guide.Additional file 3. Focus discussion guide.The Letten Foundation, Norwayhttp://www.biomedcentral.com/bmcwomenshealthpm2021Obstetrics and GynaecologySchool of Health Systems and Public Health (SHSPH

Gaps and opportunities for cervical cancer prevention, diagnosis, treatment and care : evidence from midterm review of the Zimbabwe cervical cancer prevention and control strategy (2016-2020)

BACKGROUND: Cervical cancer is the fourth most common cancer amongst women globally and it accounts for the majority of cancer deaths among females in Zimbabwe. The objective of this midterm review analysis was to identify the gaps and opportunities for cervical cancer prevention, diagnosis, treatment, and care to inform the next cervical cancer strategy in Zimbabwe. METHODS: A mixed methods approach was used for the midterm review. Secondary data was collected from programme documents, published and grey literature. Primary data was collected in six provinces through key informant interviews with officials and focus group discussions with beneficiaries. After data analysis, a draft report was presented to a technical working group to validate the findings and to fill in any gaps. RESULTS: This midterm review revealed a myriad of gaps of the strategy particularly in diagnosis, treatment and care of cervical cancer and the primary focus was on secondary prevention. There was no data to quantify the level of awareness and advocacy for cervical cancer prevention. Our results revealed that there was no data on the proportion of women who ever tested for cervical cancer which existed nationally. Our findings suggest that some health facilities were screening women above 50 years old using VIAC, which is an inappropriate approach for those women. Quality control of VIAC and treatment of precancers were not part of the strategy. Pathological services were not efficient and effective due to lack of resources and additionally data on investigations were not routinely collected and available at the national level. Other gaps identified were limited funding, human resources, equipment, and commodities as well as lack of leadership at the national level to coordinate the various components of the cervical cancer programme. There are also numerous opportunities identified to build upon some successes realized to date. CONCLUSIONS: Our findings emphasized the importance of effective and holistic planning in cervical cancer screening programmes in low-resource settings. In addition, huge investments are required in cervical cancer programmes and governments need to take centre role in mobilizing the requisite resources.This midterm assessment was funded by OPHID in support of the Ministry of Health and Child Carehttp://www.biomedcentral.com/bmcpublichealth/pm2021School of Health Systems and Public Health (SHSPH

Equity in access and utilization of cervical cancer treatment and palliation services in Harare, Zimbabwe

Background Cervical cancer is one the fastest growing public health challenges in low to middle income countries. About 85% of new diagnoses worldwide are reported in low-income countries and cervical cancer is the fourth cause of mortality in the same contexts. In Zimbabwe in 2018, 3186 new cases of cervical cancer were dignosed accounting for 18.2% of all new cases of cancer reported in that year. However; despite the growing burden of the disease, health systems in countries in the less developing world are too fragile to provide comprehensive treatment and care required by women who need them. This study was aimed at understanding access and utilization of cervical cancer treatment and palliative care and their associated determinants among women with the disease in Harare, Zimbabwe. Methods This study utilized a sequential explanatory mixed methods design, with quantitative study in the form of analytical cross sectional surveys being the major designs. Three surveys were designed and used namely; community, patient and health worker surveys. Qualitative study was used to understand deeper and explain unexpected and surprising results from the surveys. The qualitative data collection methods used in this study comprised of in-depth interviews, focus group discussions and key informant interviews. Data collection tools for the qualitative study were finalized after the analysis of results from surveys to guide the issues that needed exploration using qualitative techniques. The first step of this study was the design and validation of structured questionnaires for the three surveys. The validation process involved factor and principal component analyses to identify meaningful constructs relevant to the research questions. After obtaining the meaningful constructs, Cronbach’s internal consistency coefficient analysis was conducted and constructs with coefficients ≥0.70 were retained in the questionnaires. Data collection of the surveys was conducted in communities selected through a multistage random sampling approach and treatment health facilities in Harare. Findings This research revealed that the designed structured questionnaires for community, patient and health worker surveys to investigate access and utilization of cervical cancer treatment and palliative care services were valid and reliable for use in surveys. This study showed that socio-demographic factors played a minor role in explaining disparities in access and uptake of cervical cancer screening treatment and palliative care in Zimbabwe. Societal and health system determinants played a major role in entrenching inequities to access and utilization of cervical cancer treatment and palliative care. Health system barriers played a key role in influencing access and usage of treatment and care among women with cervical cancer. This research further revealed that while general awareness, knowledge of risk factors, prevention and treatment of cervical cancer were relatively high, knowledge of causes remained relatively low. Utilization of cervical cancer screening and access to regular doctors were relatively high among women with cervical cancer. Some of the major barriers to access and usage of cervical cancer services identified in this study were : limited resources, limited health worker knowledge about cervical cancer, centralized services, limited physical infrastructure, limited human resources especially specialists, limited donor support and competing priorities on the part of the government. This study also revealed a myriad of model strategies that could be considered to improve access and usage of cervical cancer treatment and palliative care services. Conclusions This study revealed a plethora of evidence relevant to cervical cancer programme and policy development in low-income settings affected by the growing burden of cervical cancer. The consideration and implementation of the model strategies reported in this study might go a long way in addressing the majority of the impediments to access and utilization of cervical cancer treatment and care in Zimbabwe and other similar contexts. However, the success of future cervical cancer programmes is hinged on the strengthening of the National Cancer Control Programme and key strategies in the Ministry of Health and Child Care. It is proposed that this lead institution take ownership and stewardship of policies and interventions including coordinating different partners. Furthermore, wider dissemination of relevant research, wider stakeholder engagements and collaborations and strong political will of the government is required to invest and mobilize resources to strengthen non-communicable disease interventions Key words: Cervical cancer, Zimbabwe, equity, access, utilization, sequential explanatory mixed design, determinants, treatment, palliative care.Thesis (PhD)--University of Pretoria, 2019.Letten Foundation, NorwaySchool of Health Systems and Public Health (SHSPH)PhDUnrestricte

Limited knowledge and access to palliative care among women with cervical cancer: an opportunity for integrating oncology and palliative care in Zimbabwe

BACKGROUND : Cervical cancer is mostly diagnosed at advanced stages among the majority of women in low-income settings, with palliative care being the only feasible form of care. This study was aimed at investigating palliative care knowledge and access among women with cervical cancer in Harare, Zimbabwe. METHODS : Sequential mixed methods design was used, consisting of two surveys and a qualitative inquiry. A census of 134 women diagnosed with cervical cancer who visited two cancer treating health facilities and one palliative care provider in Harare between January and April, 2018 were enrolled in the study. Seventy-eight health workers were also enrolled in a census in the respective facilities for a survey. Validated structured questionnaires in electronic format were used for both surveys. Descriptive statistics were generated from the surveys after conducting univariate analysis using STATA. Qualitative study used interview/discussion guides for data collection. Thematic analysis was conducted for qualitative data. RESULTS : Mean ages of patients and health workers in the surveys were 52 years (SD = 12) and 37 years (SD = 10,respectively. Thirty-two percent of women with cervical cancer reported knowledge of where to seek palliative care. Sixty-eight percent of women with cervical cancer had received treatment, yet only 13% reported receiving palliative care. Few women with cervical cancer associated treatment with pain (13%) and side effects (32%). More women associated cervical cancer with bad smells (81%) and death (84%). Only one of the health workers reported referring patients for palliative care. Seventy-six percent of health workers reported that the majority of patients with cervical cancer sourced their own analgesics from private pharmacies. Qualitative findings revealed a limited or lack of cervical cancer knowledge among nurses especially in primary health care, the existence of stigma among women with cervical cancer and limited implementation of palliative policy. CONCLUSIONS : This study revealed limited knowledge and access to palliative care in a low-income setting due to multifaceted barriers. These challenges are not unique to the developing world and they present an opportunity for lowincome countries to start considering and strategizing the integration of oncology and palliative care models in line with international recommendations.The Letten Foundation, Norwayhttps://bmcpalliatcare.biomedcentral.comam2020School of Health Systems and Public Health (SHSPH

Factors Associated with COVID-19 Vaccine Intentions in Eastern Zimbabwe: A Cross-Sectional Study

Vaccines are one of the most effective public health strategies to protect against infectious diseases, yet vaccine hesitancy has emerged as a global health threat. Understanding COVID-19 knowledge and attitudes and their association with vaccine intentions can help the targeting of strategies to increase vaccination uptake and achieve herd immunity. The goal of this study was to assess COVID-19 knowledge, attitudes, and behaviors, and identify factors associated with COVID-19 vaccine intentions among heads of households in Manicaland Province, Zimbabwe. A cross-sectional survey was conducted in May 2021 among 551 randomly selected households. Data were collected on socio-demographic characteristics, and knowledge, attitudes, and behaviors regarding COVID-19 and the vaccines. More than half (55.7%) of the respondents reported intending to vaccinate themselves or their households. Multivariate logistic regression indicated that the likelihood of vaccine intentions was most strongly associated with confidence in vaccine safety. Additionally, the odds of intending to get vaccinated were significantly higher among heads of households who were male, had a higher level of education, and identified vaccination and face mask usage as prevention measures. Among perceived motivators to vaccinate, recommendations from the World Health Organization and availability of the vaccine free of charge increased the likelihood of vaccine intentions, while country of vaccine manufacturer posed a barrier to vaccine intentions. As the vaccine rollout in Zimbabwe continues, efforts to increase COVID-19 vaccination coverage and achieve herd immunity should target females and less educated populations and be tailored to address concerns about vaccine safety and country of manufacturer

Design and validation of questionnaires investigating access and utilization of cervical cancer treatment and palliative care

BACKGROUND : Standardized tools to evaluate access and utilization of cervical cancer treatment and care remain scarce in developing countries. The objective of this study was to validate questionnaires to investigate access and uptake of cervical cancer treatment and palliative care. MATERIALS AND METHODS : We designed and validated two questionnaires for patient and community and health worker surveys to determine the main constructs of each of the draft questionnaires. Pilot data was collected randomly amongst 50 patient and community participants and 14 health workers respectively in Chitungwiza, Zimbabwe. Content and face validity were assessed qualitatively from expert evaluations. Construct validity, reliability and internal consistency testing were conducted using exploratory factor analysis and Cronbach’s alpha correlation coefficient respectively. RESULTS : Twelve (12) experienced researchers, based on convenience, reviewed the questionnaires and validated their draft constructs based on experience and literature. Each of the questionnaires was sub-divided into 4 separate mini-questionnaires respectively. All the eight mini-questionnaires were analyzed independently and Kaiser-Meyer-Olkin coefficients ranged from 0.5-0.9 and Bartlett’s sphericity tests were all significant, p<0.001, showing promising good constructs. Patient and community questionnaire had 15 meaningful constructs while the health worker questionnaire had 13. Cronbach’s alpha (α) coefficients for internal consistency reliability testing of all the final constructs were greater than the minimum acceptable threshold of 0.70. CONCLUSION : This analysis revealed the validity and reliability of questionnaires that could be used to evaluate access and utilization of cervical cancer treatment and palliative care in countries affected by the disease.Professor Babill Stray-Pedersen through the Letten Foundation.http://www.ccsenet.org/journal/index.php/gjhs/indexam2020Obstetrics and GynaecologySchool of Health Systems and Public Health (SHSPH

Zimbabwe (2015): Quantitative Study Evaluating Knowledge and Behaviours on Family Planning, Violence against Women and Girls and Cervical Cancer Screening Behaviours among men and women aged 15 - 49 years.

The goal of this study was to add to the body of knowledge on Family Planning, Violence Against Women and Girls and Cervical Cancer Screening. This quantitative study provided evidence for monitoring, segmentation and evaluating the implementation of PSI Zimbabwe's programs and impact of their interventions. This information will be used to develop interventions and communications for the interventions. Study objectives for this study aims to answer three fundamental questions related to segmentation i). What are the levels and trends in knowledge of family planning,VAWG and cervical cancer screening?.ii). Monitoring What are the trends and current levels in family planning, VAWG and cervical behaviors and correlates identified through qualitative studies?, iii). Evaluation is exposure to PSI Zimbabwe communication activities leading to changes in knowledge and behaviors of family planning, VAWG, cervical cancer screening?. This study was conducted among men and women aged between 15-49 years in Zimbabwe. The study was a stratified multi-stage cluster sampling approach. Respondents for this study were selected from 100 enumeration areas (35 in urban and 65 in rural). Data was collected using structured questionnaires and smartphones. Analysis was done using stata version 13. Analyses consisted of descriptive statistics for key program indicators and Analysis of Variance (ANOVA) to examine trends over time. Bivariate analysis was done using place of residence as exposure variables and program indicators as outcome variables.