Eberhart, Lindsay

School of Public Health

MHS / MA

Tanzania

Time to ACT: Implementing strategies for breast cancer control in Africa

Breast cancer is the most common cancer in women in both high- and low-resource settings. Although widely recognized as a significant public health concern in developed nations, breast cancer is becoming an increasingly urgent health issue in low and middle-income countries (LMICs). Both incidence and mortality in LMICs continue to increase, and the majority of breast cancer deaths now occur in developing nations. Global disparities in breast cancer mortality persist due to inequities in access to early detection and curative treatment.
The Mwanza region of Tanzania has enormous momentum to build cancer control programs. The region's Bugando Medical Center (BMC) is being developed as the nation's second private cancer hospital, serving approximately 13 million people and yet there is currently no coordinated plan to engage the target population, shift the focus to early detection, and overcome barriers along the breast cancer control continuum.
Recognizing the importance of evidence to inform action, we are using research methods from the emerging field of implementation science to Assess (local context), Couple (strategies to context), and Test (implementation strategies) within a larger effort to scale-up breast cancer programs in Tanzania. The overarching goal of the multidisciplinary "Time to ACT" study is to reduce breast cancer morbidity by developing a toolkit to design and implement contextually appropriate, evidence-based programs for breast cancer control. To achieve this objective, we specifically aim to:


Aim 1. Assess multi-level contextual factors affecting successful implementation of breast cancer control programs in Mwanza, Tanzania.
A. Describe patients seeking care for breast concerns, breast cancer burden and characteristics, and clinical care and outcomes in the catchment area of Bugando Medical Center.
B. Identify facilitators and barriers associated with both prior cancer prevention programs in Mwanza and those perceived for new breast cancer control programs from key stakeholders.
Aim 2. Develop and test the implementation of consensus-selected strategies for breast cancer control that are responsive to the local context of the Mwanza region.
A. Identify promising strategies through stakeholder consensus that overcome barriers and capitalize on key themes related to successfully reducing breast cancer morbidity.
B. Assess the feasibility, reach, and adoption of the selected implementation strategies using a pre/post-test design to demonstrate the ability of the strategies to ultimately reduce breast cancer morbidity.

This is a mixed method, multi-stage implementation science study which started in August 2017. 
 

PI Mentor: Anne Rositch

Before leaving for my project in Tanzania, details surrounding my project were still being worked out and I was unsure about what to expect. This was also my first time in a developing country and I was not sure how I would be able to handle adjusting to such a new and different environment. When I got to Tanzania, however, I was immediately comforted by how welcoming the research team was as well as my neighbors and even strangers. I was truly surprised by how much the Tanzanians I met wanted to share their culture with me and make me feel welcome.

My project involved working at a hospital to help establish standardized pathways of care for patients with a breast concern. This meant going to the hospital every day and meeting with different stakeholders throughout the hospital to understand how they currently handle a breast concern. It was eye-opening to see that there was not a procedure in place to triage breast concerns or ensure that patients all had the appropriate tests ordered. Although doctors did their best, many that were the first point of contact for patients were just out of medical school and did not have experience handling breast cases. It was clear that the providers we worked with cared a lot about their patients, and we were able to find many doctors that would take time out of their busy schedules to explain to us how the hospital worked and where they thought it could use some improvement.

The project involved working with many departments and staff from nurses to doctors. To our surprise, one of the biggest challenges we faced was navigating the inter and intradepartmental hierarchies. We quickly learned to be careful of stepping on toes and to always ask the head of the department before you talk to anyone within their department. When working with different departments, we learned that the departments frequently disagreed over how the hospital should work and who should see the patients when.

Despite running into some challenges on the project, I learned a lot about how to work within other cultures and how to bring together people with differing opinions. I found it was important to make clear that we were not there to impose a workflow on the doctors but rather to work with them to develop a standardized operating procedure that the doctors want and that will help them do their work more effectively. Although I worked to make the project reflect the will of the doctors at Bugando hospital, I still occasionally battled with a feeling that we were the wrong people to be doing this job. We didn’t know how the hospital worked, we didn’t speak the language and we didn’t know the culture. We were constantly discovering new things about the way the hospital worked that were likely obvious to those that worked there. Upon working with the staff more I came to realize that the doctors and nurses did not have time to think about the flow of the hospital because they were constantly seeing patients. Furthermore, it was almost helpful to be an outsider because we could work outside the pre-established hierarchy that frequently kept departments from coordinating. I still sometimes wonder if we were really the right people for the job, but in the end, we at least got people thinking about the issue and working together toward a solution.

When I was not in the hospital, I spent my time getting to know the city of Mwanza by walking through the crowded markets or getting a smoothie at the local bakery. I found that I had a lot more time to enjoy my surroundings and came to appreciate the joys of sitting outside enjoying a sunset or watching the leaves rustle in the wind. I learned that I can actually go for two months without watching Netflix and be perfectly happy. Now that I am back in America, I hope to continue to take time for myself and perhaps cut down on my screen time.

People

Robert Bollinger Jr., MD MPH

Director, Johns Hopkins Center for Clinical Global Health Education (CCGHE); Associate Director, Johns Hopkins Center for Global...

Joanne Katz, ScD MS,BSc

Associate Chair, Director of Academic Programs

Yukari C. Manabe, MD

Associate Director of Global Health Research and Innovation

Caitlin Kennedy, PhD MPH,BA

Co-Director, MPH concentration in Social and Behavioral Sciences in Public Health; Associate Director, Center for Qualitative...

Stefan Baral, MD MPH,MBA,MSc

Director, Key Populations Program

Noreen Hynes, MD MPH

Director, Geographic Medicine Center of the Division of Infectious Diseases
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November 2019

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