Passaniti, Anna

School of Public Health - International Health



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 is the ideal setting for this research because of the enormous momentum to build cancer control programs. The region's Bugando Medical Centre (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. Thus, recognizing the importance of evidence to inform action, we will use 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. Over the summer we will be in Phase II of the study which consists of mixed methods KAP surveys with community women and healthcare providers and focus group discussions. 

PI Mentor: Anne Rositch

My research experience has broadened my perspectives on global health by working on a health project within an academic partnership. I had only done global health work through NGO partnerships prior to this experience. My GHEFP project was an implementation research study carried out by Johns Hopkins and Bugando Medical Center in Tanzania. Doing implementation research via an academic partnership allowed our research to be more adaptive to the local context and iterative in our approach than I had previously been exposed to in NGO work. I enjoyed working within this approach. As a result, my perspectives on how global health work can be done effectively yet adaptively have broadened. 

The experiences that most closely met my expectations were those related to challenges that arose with scheduling and coordination survey and interview times over the course of the study. I was working with health care providers at a large referral hospital with a high patient load – therefore, I expected the logistics of data collection and coordination with health care providers to be a challenge. I adapted to this challenge by being flexible with my work hours to best accommodate the availability of study participants. 

The experiences that most defied my expectations were the extent to which I interacted with, and enjoyed interacting with, oncology patients. I worked in an office in BMC’s oncology building where pediatric oncology patients as well as adult patients frequently visited. I also spent a lot of time at a hostel that was set up for pediatric oncology patients and their families to stay as they received care at BMC. I expected to be working primarily with health care providers this summer, largely separated from the patients whom this research was meant to benefit. However, I ended up spending just as much, if not more, time with oncology patients. This direct patient interaction was really gratifying to me, and motivated me throughout my research experience. It also influenced my future career goals in gynecology.

This research experience pushed me out of my comfort zone as I worked in a hospital environment for the first time, and faced challenges related to language barriers throughout my work. I had never worked in a hospital setting with health care providers before. Initially, my role as the researcher with the research participants having much more knowledge about the subject matter of study was intimidating. I did not feel confident in this work environment or in the technical subject matter of the study. Over the course of the study I embraced my role as a learner and built rapport with providers at all three facilities where the study took place. My lack of technical knowledge was actually beneficial in decreasing researcher bias and alleviating any unequal power dynamics that may have existed in my position as researcher. Every survey was a learning opportunity and a genuine exchange of information and perspectives. With the language, I learned as much Swahili as I could by being active in outside-of-work activities in Mwanza. I joined a women’s soccer team and practiced Swahili with my teammates a few times per week. I also spoke Swahili as much as I could at BMC with my colleagues and with patients and their families. Children proved to be some of the best teachers since they spoke slowly and simply. 

This experience made me confident in my ability to success in a health care service provider role. It exposed me to clinical practices related to breast cancer and reproductive health care more broadly. I felt motivated by regularly interacting with cancer patients during the study, and this piqued my career interest in combining public health research with medical practice. 

Conducting the survey with a clinical officer in their office at BMC


Noreen Hynes, MD MPH

Director, Geographic Medicine Center of the Division of Infectious Diseases

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

Yukari C. Manabe, MD

Associate Director of Global Health Research and Innovation

Joanne Katz, ScD MS,BSc

Associate Chair, Director of Academic Programs

Robert Bollinger Jr., MD MPH

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

June 2020



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