Project structure - Reducing Cancer Delays in Sub-Saharan African

We implemented in Kenya the survey conducted in our Nigerian sites (Diagnosis of cancer in the South and North of Nigeria: duration and causes of delay) to calibrate delays at each stage of the patient pathway and describe barriers at each stage. This research was conducted at Kenyatta National Hospital. This was for two purposes: first, to gain information on the transferability of our tool to a new setting; and second, to gain a deeper understanding of access by stage in Kenya. We completed this work in June 2025 and conducted 212 interviews with patients in total. The study team are in the process of writing up the paper.

Read more about the study and access the protocol

WP2 involves conducting knowledge tests with clinicians who consult with patients in our 25 sampled clinics in Kiambu, Ibadan and Kano. The knowledge test has three purposes: 1) identify common knowledge gaps to be addressed in the clinic/education intervention (WP4); 2) function as an outcome measure in the evaluation (WP5); and 3) provide a tool for others to use. Each clinician conducted two knowledge tests (where it was possible to make contact with the clinician on the second occasion). 505 knowledge tests were conducted across the three sites in total for the first test and 439 for the second test. The knowledge test comprised 15 Very Short Answer Questions and 4 Vignettes where a scenario was presented to the clinician and they were scored based on how they responded. The test covered the seven different cancer types we are studying in this project (uterus, colon, breast, lung, stomach/oesophagus, bladder/prostate/kidney, and head/neck) and three control cases (asthma, arthritis, and hyperthyroidism). The study team are in the process of writing this paper.

Read more about the study and access the protocol

Members of the study team from University of Birmingham and University of Ibadan

WP3 involved visits by standardised patients (SPs) to health facilities to measure the quality of care they received. While vignettes test knowledge in a hypothetical scenario, SPs test practice to which the patient is exposed. Together they are used to estimate the knowledge-practice gap. In addition, SPs enable us to test for other important clinical attributes, patient centeredness, knowledge of local facilities, and personal discrimination. Standardised patients are 'mystery shoppers' who visit the same clinics as knowledge tests were conducted in. The study team are in the process of writing this paper.

Read more about the study and access the protocol

We developed an intervention designed to reduce delays within the formal health sector between the initial presentation of symptoms and the commencement of treatment. The intervention was delivered in 25 facilities within each study site. These facilities were intentionally selected to differ from those used in WP2 and WP3.

The intervention consists of two key components:

1. Education – focused on enhancing the recognition and referral of individuals with potential cancer symptoms.
2. Clinic Strengthening, clinic navigation and peer navigation – aimed at supporting individuals with possible cancer symptoms in accessing timely and appropriate care.

Following the implementation of the intervention at participating clinics, we conducted a formative study. The aims of this study are to:

1. Test whether the intervention is acceptable and feasible in its entirety and in its components.
2. To support the design of a full-scale evaluation by estimating key statistics, including the referral and follow-up rates of patients in the study.

This study consisted of three components:

1. Retrospective review of clinic records to ascertain referral rates.
2. A process evaluation of intervention implementation in clinics.
3. Prospective, mixed-methods cohort study of referrals from clinics to specialist care (pathway analysis).

WP4 is now complete in all study sites, and the study teams are working on analysing the results and writing the paper.

Our research is having a positive societal impact on the communities that we are working with. So far, we engaged with a wide range of stakeholders to understand the local, national, and international policy contexts and to secure support for the study. At each research site, we established engagement networks comprising key decision-makers—including community leaders, NGO representatives, provincial and county policymakers, and officials from local and national government. These networks have played an active role in co-developing the educational, clinical strengthening, and peer navigation interventions through a series of focused sub-group meetings. Their contributions have ensured that the interventions are contextually relevant and aligned with existing health system priorities and are scalable.

By the end of this contract, we hope we will have generated evidence of effective interventions and policies to influence where future investments are made to reduce late presentation of cancer and more generically improve access and quality of primary healthcare.

Read more about the study and access the protocol

We hypothesise that the clinic strengthening intervention will lead to an enduring improvement in both the knowledge and practice of primary care clinicians, and this, along with the peer navigation support intervention, will lead to referred patients reaching resolution of their case sooner. We also hypothesise that the two interventions may have synergistic effects; however, as we describe below the training intervention may affect which patients are referred, as well as affecting the outcomes of those who are referred. Our proposed trial design aims to estimate these effects, with additional analyses designed to tease apart different explanations for the effects and examine the persistence of any benefits over time. This is the main trial bringing together all the work in the pilot (WP2, WP3 and WP4).

WP5 will operate in different areas from those used in the pilot. A total of 225 facilities, 75 in each study site, will participate, allocated evenly across three trial arms.

WP5 began in Spring of 2026.

WP6 is the synthesis of qualitative and quantitative findings. We will synthesise findings from WPs 4 & 5 to examine system factors such as the potentially debilitating effects of workforce shortages, provider burnout, weak health system governance and leadership and inter-professional rivalries. There is also a operations research and health economics aspect to this WP. We will carry out a cost-effectiveness analysis from a health systems perspective in the first instance, using a state-transition Markov model to simulate the evolution of disease. Clinical outcomes (cases and deaths) contingent on reduced delay will be modelled from observed trial outcomes (such as time to diagnosis and time to treatment) allowing for lead-time bias.

Literature review

We will keep our review of interventions to reduce delay in access to cancer care up to date. We are doing this through our research team conducting systematic reviews including:

- Interventions to reduce delay in cancer diagnosis in low- and middle-income countries: a systematic review PROSPERO

Use of Large Language Models in Primary Care in Low- and Middle-Income Countries: A Systematic Living Review PROSPERO

Contacts:

Jen Knight, Project Manager – j.knight.2@bham.ac.uk

Jo Sartori, Programme Manager – j.m.sartori@bham.ac.uk