Barriers and recommendations for colorectal cancer screening in Africa

Figures & data

Figure 1. Schematic representation of the article selection process.

Table 1. Barriers and recommendations for CRC screening in Africa.

Ref. [#], 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 collection for FOBT, stigma associated with diagnosis of cancer, financial burden, lack of medical education related to CRC and CRC screening; Provider: lack of education/training, not emphasizing importance of screening and fatality of cancer	Leverage mobile health platform for physicians, community, and religious leaders to educate community members; utilise electronic tools such as WhatsApp (90% of information flow)/Qualtrics to train community health works to administer FOBTs at home and to locate nearest endoscopy center; reduce financial burden; systematic change to improve access and national support
[19]; Egypt; intervention mapping, literature review, focus groups, interviews	58 patients, 17 physicians (primary care, gastroenterology, oncology)	Systematic: cost, lack of accessibility, inadequate training among laboratory providers; Patient: CRC knowledge deficit, fear/anxiety regarding testing and cancer diagnosis; Provider: belief that CRC testing should only be performed for high-risk individuals, concerned about the invasiveness of colonoscopy and how patients perceived screening and their fear of a cancer diagnosis, inadequate training among laboratory providers	One-on-one education by health care professionals about the benefits of screening; train health care professionals in basic CRC knowledge and patient engagement and behavior change methods; involve medical students in educating patients on awareness of risk factors, mortality rates, and how to prevent CRC with healthy lifestyle choices; address cost (low cost or free), availability of screening tests, and time spent on the process (convenience)

CRC, colorectal cancer; FIT, faecal immunochemical test; FOBT, faecal occult blood test.

Table 2. Interventions for CRC in Africa.

Ref. [#], location and article type/study design	Sample size, patient demographics	Intervention	Result and patient feedback	Barriers	Recommendations
[24]; Nigeria; prospective review	422 (1 male:2.2 female); mean age, 62 yr; most participants had college-level education	FIT (50 ng/ml)	FIT complete, 375 (88.9%); FIT positive, 38 (10.1%); colonoscopy, 28.9% (11/38)	FIT nonadherent: 11.1% (misplaced kit, traveled out of town, lost to follow-up); priority to manage index illness before CRC; discouraged by friends/family; limited capacity/acceptability of colonoscopy; unwilling to undergo invasive procedure when asymptomatic	Make more FIT kits available, link screening option to generic family health programs, educate people on importance of evaluation after positive screening; need additional studies of barriers to uptake of screening colonoscopy
[22]; Egypt; quasi-experimental design	60 (76.7% female); mean age, 68.1 yr (range: 60–83 yr); married, 56.7%; education: university, 60%; secondary, 33%; positive medical history, 96.7%; no tumor, 66.7%	Nurse-led intervention on knowledge and perceptions regarding CRC among older adults	Significant differences (p < 0.001) before and after intervention: ‘good’ knowledge of CRC: before (61.7%), after (96.7%), and 4 weeks later (88.3%); good CRC screening practices before (3.3%) and after (63.3%); perceived confidence to perform CRC screening before (39.0%) and after (98.3%)	Lack of interest from older adults in searching for information; seeking medical help when asymptomatic not a common practice nor a welcomed idea in this culture	Design health-related educational leaflets/posters using simple familiar words about CRC prevention and screening procedures and make them available at clubs, at different health care settings, and via mass media and social media; Replicate the study with a larger sample from different geographical areas to achieve more generalised results
[10]; Egypt; quasi-experimental design	140; mean age, 54.3 yr (study group) and 52.1 yr (controls)	Nurse-led intervention on adults’ health beliefs and screening behaviors toward CRC	Significant improvement of total awareness score in study group (9.39 ± 4.31) vs. controls (5.01 ± 2.93); Significant differences (p < 0.001) in total mean health belief score pre- and postintervention		Design effective nursing strategies to address barriers of CRC screening and improve CRC knowledge/awareness to achieve greater adherence
[23]; Nigeria; prospective, single-arm study	379; median age, 51 yr; university education, 64.7%; history of prior cancer screening, 45%; previously discussed CRC screening with physician, 6.6%	FIT (50 ng/ml)	FIT complete, 332 (87.6%); FIT positive, 68 (20.5%); colonoscopy, 89.7% (61/68); those who completed FIT found it easy to use (82%), will recommend to family/friends (100%), and will undergo colonoscopy if free (100%)	FIT positive yet nonadherent to colonoscopy: 7 (10.3%) declined or lost to follow-up	Before implementing FIT, need targeted approach to account for low positive-predictive value in average-risk individuals, also need prospective evaluation of FIT-based screening among individuals with known first-degree relative with CRC in Nigeria; develop multi-tiered risk stratification including positive family history, sex, age, cigarette use; obtain more data on natural history of CRC, molecular profile
[25]; Tunisia; quantitative/qualitative review with interviews	5856	FOBT	FOBT complete, 5865 (100%); FOBT positive, 390 (6.7%); colonoscopy, 18.6% (72/390)	Variable adherence from health care professionals; lack of awareness in general population regarding CRC screening; no acceptability of colonoscopy without sedation; problem of affordability; long appointment delays in public sector	Involve the national health insurance fund in CRC screening tests and colonoscopy reimbursement; establish a performance-based payment modality for health care plan
[21]; Nigeria; cross-sectional study	2330 (958 males, 1,372 females) median age, 57 yr; secondary-level education, 68%; even spread across wealth quintiles	FIT (50 ng/ml)	FIT complete, 2109 (90.5%); FIT positive, 432 (20.5%); colonoscopy, 66% (285/432); patients who completed FIT would pay to undergo FIT (out-of-pocket cost $3.65) (73%) or would undergo FIT if free (89%), found the kit easy to use (89%), and will recommend to family/friends (90%)	Level of education: FIT incomplete more in younger (45–54 yr), poorer, less educated participants; higher education level significantly associated with higher rate of colonoscopy attendance; cost: colonoscopy cost equivalent to half of the median monthly household income reported; paucity of endoscopic resources	Higher threshold to account for many false-positive FIT results, design, delivery, and financing of any formal screening program in Nigeria; formal cost-effectiveness analyses and comparative cost-effectiveness analysis are needed for screening programs
[26]; Morocco; demonstration project	9908; age range, 50–75 yr; 10 primary care health centers in 2 providences	FIT (40 ng/ml)	FIT complete, 9763 (98.5%); FIT positive, 460 (4.7%); colonoscopy 62.6% (288/460); patients who completed FIT will recommend the test to family/friends (99%) and found it easy to complete (82%) but messy (52%)	FIT positive but nonadherent to colonoscopy: competing life priorities (15.4%), other health problems (13%), fear of getting cancer diagnosis (12.3%), perception of a low risk of CRC (11.1%); 63% unaware colonoscopy free of charge at research site; increased colonoscopy referral led to increased waiting time and drop in adherence	Media campaign, health education, readiness to get screened for those who feel at risk; train physicians in doctor-patient communication, CRC risk factors, screening, diagnosis, and treatment; promote screening tests in clinics, ensure tests are affordable, provide adequate equipment and training for clinic and laboratory staff, and implement compulsory screening programs; train nonphysician providers to perform the test and to use qualitative FIT (avoids the need for a lab setup)

CRC, colorectal cancer; FIT, faecal immunochemical test; FOBT, faecal occult blood test.

Nawwar A, Brand Bateman L, Khamess S, Fouad MN, Arafat WO, Abdelmonem SE, et al. Using intervention mapping to develop a theory-based intervention to promote colorectal cancer screening in Egypt. Asian Pac J Cancer Prev. 2022;23:1975–1981. Epub 20220601. PubMed PMID: 35763639.

 PubMedGoogle Scholar

Lussiez A, Dally CK, Boateng EA, Bosompem K, Peprah E, Hayward L, et al. Barriers to colorectal cancer screening in Ghana: a qualitative study of patients and physicians. Cancer Causes Control. 2022;33:951–958. Epub 20220412. PubMed PMID: 35415797; PubMed Central PMCID: PMC9005024.

 PubMed Web of Science ®Google Scholar

Saluja S, Alatise OI, Adewale A, Misholy J, Chou J, Gonen M, et al. A comparison of colorectal cancer in Nigerian and North American patients: is the cancer biology different? Surgery. 2014;156:305–310. Epub 20140619; PubMed PMID: 24953266; PubMed Central PMCID: PMC4589271.

 PubMed Web of Science ®Google Scholar

Winawer MC S, Lambert R, Fried M, Dite P, Goh KL, Guarner F, et al. World Gastroenterology Organisation/International digestive cancer alliance practice guidelines: colorectal cancer screening 2007. Available from: https://www.worldgastroenterology.org/guidelines/colorectal-cancer-screening/colorectal-cancer-screening-english.

 Google Scholar

Brand Bateman L, Khamess S, Abdelmoneim SE, Arafat W, Fouad MN, Khamis Y, et al. Designing an effective colorectal cancer screening program in Egypt: a qualitative study of perceptions of Egyptian primary care physicians and specialists. Oncology. 2020;25:e1525–31. Epub 20200224. PubMed PMID: 32091658; PubMed Central PMCID: PMC7543238.

 Google Scholar

May FP, Anandasabapathy S. Colon cancer in Africa: primetime for screening? Gastrointest Endosc. 2019;89:1238–1240. PubMed PMID: 31104752.

 PubMed Web of Science ®Google Scholar

Knapp GC, Alatise O, Olopade B, Samson M, Olasehinde O, Wuraola F, et al. Feasibility and performance of the fecal immunochemical test (FIT) for average-risk colorectal cancer screening in Nigeria. PLoS ONE. 2021;16:e0243587. Epub 20210112; PubMed PMID: 33434195; PubMed Central PMCID: PMC7802943.

 PubMed Web of Science ®Google Scholar

Alatise OI, Dare AJ, Akinyemi PA, Abdulkareem FB, Olatoke SA, Knapp GC, et al. Colorectal cancer screening with fecal immunochemical testing: a community-based, cross-sectional study in average-risk individuals in Nigeria. Lancet Glob Health. 2022;10:e1012–22. PubMed PMID: 35714629; PubMed Central PMCID: PMC9400038.

 PubMed Web of Science ®Google Scholar

El Sayad HE, Ramzy Ahmed Atalla H, Mostafa Amer H. Effectiveness of nurse-led intervention on adults’ health beliefs and screening behaviors toward colorectal cancer. Egypt J Health Care. 2021;12:96–113.

 Google Scholar

Hafez S, Taha E, Abd El Fattah N, Mohsen H, Mohsen H, Sayed E, et al. Effect of nursing interventions on health practices and perceptions regarding colorectal cancer among community-dwelling older adults in Alexandria, Egypt. Port Said Sci J Nursing. 2020;7:175–190.

 Google Scholar

Labaeka EO, Irabor AE, Irabor DO. Fecal immunochemical test as a screening method for colorectal cancer in University College Hospital Ibadan, Nigeria. JCO Glob Oncol. 2020;6:525–531. PubMed PMID: 32216652; PubMed Central PMCID: PMC7113128.

 PubMedGoogle Scholar

Parker RK, Ranketi SS, McNelly C, Ongondi M, Topazian HM, Dawsey SM, et al. Colorectal cancer is increasing in rural Kenya: challenges and perspectives. Gastrointest Endosc. 2019;89:1234–1237. Epub 20181211. PubMed PMID: 30543780; PubMed Central PMCID: PMC7476216.

 PubMed Web of Science ®Google Scholar

Rejaibi S, Mahfoudh Mchirgui R, Ben Mansour N, Barbouch F, Kaddour N, Mrabet A, et al. Colorectal cancer mass screening, Tunisia 2019. Evaluation of a pilot program in the Tunis region (Tunisia, 2019). Tunis Med. 2021;99:158–167. PubMed PMID: 33899183).

 PubMedGoogle Scholar