STRENGTHS AND LIMITATIONS OF THIS STUDY
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This study uses participants from various Nigerian institutions for the baseline needs assessment on the delivery of chemotherapy practices.
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The study uses interdisciplinary involvement to solve a public health issue in the safe delivery of chemotherapy.
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The data for the needs assessment are drawn from a sample comprising of clinicians suggesting a high degree of motivation, so the generalisability of survey finds may be limited.
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The potential for under/overreporting barriers and challenges is possible, given that the responses only reflect that respondent’s experience.
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The ChemoSafe Facility Assessment in this study was given to only one large teaching hospital, and that may mean that the challenges highlighted may not be reflective of the challenges faced across the country.
Introduction
The cancer burden in low-income and middle-income countries (LMICs) is rising, making the development and maintenance of robust systems to deliver oncologic care an urgent priority.1 2 Commonly in Nigeria, physicians, including junior surgeons, are tasked with the responsibility of preparing and administering chemotherapy with support from nurses and pharmacists.3 The majority of healthcare professionals, however, often have no formal training or certification in the preparation and administration of chemotherapy.4–6
The delivery of safe chemotherapy is gaining widespread global attention, but there are barriers to adopting international standards for safe chemotherapy in LMIC settings.5–7 Facilities face challenges related to training personnel, including continuing education and assessment for adherence to safe practices.7 Other challenges directly relate to the financial resources required to build safe infrastructure, including biological safety cabinets with appropriate engineering controls. This includes adopting standardised processes, including standard operating procedures (SOPs) for safe chemotherapy delivery.8 9 Efforts toward overcoming these barriers are nascent, but promising.5
The Allied Against Cancer Group is a coalition of partners seeking to support the African oncology community.10 It is made up of clinical and public health experts from 13 countries across the African continent with founding partners from the African Cancer Coalition, American Cancer Society (ACS), Clinton Health Access Initiative and the National Comprehensive Cancer Network. This group developed ChemoSafe, a training programme focused on safety and quality improvement in handling hazardous drugs in healthcare settings.
Global collaborative healthcare programmes and partnerships have been in existence between developed and developing countries in the past few decades to improve health outcomes, including HIV prevention and health education.11–13 Memorial Sloan Kettering Cancer Centre (MSK), a New York City-based comprehensive cancer centre, has partnered with the Obafemi Awolowo University Teaching Hospital Complex (OAUTHC) for over a decade. In 2013, two surgeons, Dr. Peter Kingham (MSK) and Dr. Isaac Alatise (OAUTHC) founded the African Research Group for Oncology (ARGO).14–16 This group was established to facilitate cancer research and training initiatives in Africa. ARGO is an NCI-recognised consortium that has grown to include 32 medical institutions, 28 from Nigeria and four from the USA and Canada. ARGO has an established research and training infrastructure with biobanks and local scientific partnerships for novel cancer research training and clinical studies. It is a multi-disciplinary initiative that includes stakeholders from environmental health services, medicine, nursing, pathology, pharmacy and radiology. It is within this larger framework that a group of pharmacists, nurses and healthcare professionals joined together to address the challenges associated with the delivery of safe chemotherapy administration.
The objective of this paper is to characterise current chemotherapy practices in Nigeria and identify strategies to improve safe practices.
Methods
Design
A needs assessment survey that was distributed to attendees at the 2019 ARGO Symposium and a ChemoSafe Facility Assessment at OAUTHC that was administered virtually.
Recruitment and sample
For the needs assessment survey, participants were registered attendees of the 2019 ARGO Symposium held in Ile-Ife, Nigeria. The survey was in paper format and was provided to registered attendees in the main auditorium at OAUTHC. This occurred on 23 and 24 April 2019 during symposium hours from 8:30 am to 5 pm West Africa Time. Participants gave verbal informed consent prior to their participation.
For the 2021 ChemoSafe Facility Assessment, interdisciplinary members of the OAUTHC Chemotherapy Task Force engaged in two separate 1 hour virtual meetings to answer assessment questions. The ChemoSafe application tool was accessed electronically online on 17 March and 30 March 2021, from 1 to 2 pm West Africa Time.
Data collection and measurement
2019 needs assessment survey
A 20-question survey on practitioner knowledge, including needs pertaining to safe chemotherapy preparation and administration (Appendix A), was administered to all symposia participants.
Seven questions modelled after the Nursing Research Knowledge, Attitudes and Practices survey were used to assess knowledge, attitudes and practice regarding the safe handling and administration of chemotherapy.17 Using a Likert scale (low-medium-high), this tool asked participants to rate their knowledge regarding, willingness to engage, and ability to perform seven tasks related to safe handling.
Thirteen questions adapted from the Organisational Readiness to Change Assessment (ORCA) were used to identify potential areas of improvement in practice with safe handling of chemotherapy.18 Participants rated agreement on a Likert-scale (1 = ‘Strongly disagree’ to 5 = ‘Strongly agree’). The ORCA tool was used previously to identify and monitor organisational strengths and weaknesses to support implementation of evidence-based practices in a variety of healthcare settings.18–20
We scored the instruments according to author guidelines and used descriptive statistics (frequency, median, mode) to characterise the data. Non-parametric univariate testing (Chi-square and Mann-Whitney U) was used to identify and associate professional/educational background with practice barriers. A Spearman correlation matrix was constructed to assess relationships among the subscales of both instruments.
2021 ChemoSafe assessment
Following the 2019 ARGO Symposium, an interdisciplinary task force was established with representation from OAUTHC and MSK. The formation of this task force allowed for joint decision making in prioritising safety practices. The OAUTHC Chemotherapy Task Force members were recruited through the assistance of hospital leadership. Through this recruitment approach, various leaders from the environmental health department, medicine, nursing, pharmacy and hospital administration formed the task force. The task force met monthly between 2019 and 2021 with MSK partners to discuss challenges associated with chemotherapy preparation, administration and disposal. During the meetings, they reviewed results of the needs assessment, and prioritised achievable areas to implement change and improve safe chemotherapy practices.
In March 2021, task force representatives from OAUTHC completed the ChemoSafe Facility Assessment Tool developed by the ACS to provide baseline data on current chemotherapy practices at their hospital.10 The ChemoSafe Assessment Tool is comprised of a total of 169 questions organised into eight domains: 16 questions on facility-wide action items, 28 questions on the receiving department, 39 questions on drug compounding, 21 questions on the patient treatment areas, 5 questions on patient home care, 17 questions on laundry, 22 questions on waste collection and 21 questions on waste disposal. Response options provided nominal categorical data (‘Yes,’ ‘No,’ ‘I don’t know,’), with a ‘Yes’ response indicating that this item is meeting international standard recommendations by ACS. Task force members from OAUTHC filled out the survey together and reached consensus on each response category.
Patient and public involvement
Patients and the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.
Results
2019 needs assessment survey
Symposium attendees (51%) completed the needs assessment survey (n=50 of 98). Most respondents were physicians (74%); 16% were nurses, 2% were social workers and the remaining identified as other (table 1). Practice locations included inpatient (54%), outpatient (52%), the perioperative setting (38%) and paediatrics (6%) (respondents could select more than one option). Years of experience ranged from 0.5 to 35 years, with a median of 14 years.
Demographic characteristics of 2019 needs assessment
Knowledge, attitudes and performance subscales had a theoretical and actual range of 7–21, with high scores indicating positive outcomes. Median knowledge in the sample was 15; median attitude (ie, willingness to engage) was 17; and median ability to perform was 18. All subscales were positively correlated with each other (knowledge-attitude: ρ=0.75, p<0.001; knowledge-performance: ρ=0.70, p<0.001; attitude-performance: ρ=0.84, p<0.001), but there was no association between the subscales and years of experience. Subscale scores did not vary between physicians and nurses (knowledge: U=34, p=0.059; attitude: U=45, p=0.235; performance: U=39, p=0.157).
Results from the modified ORCA scale (figure 1) indicate that 75% of respondents reported that their institution did not have a class for safe chemotherapy handling; 54% noted that they had not been trained well on the use of personal protective equipment (PPE) and safe handling; and 37% reported that cytotoxic contents did not have clear warning labels at their institution.
Safe chemotherapy responses (%), 2019 ARGO needs assessment. ARGO, African Research Group for Oncology.
In general, respondents were dissatisfied with chemotherapy-related processes at their hospitals: 61% felt dissatisfaction with assessment practices for preparing and administering; 52% were dissatisfied with handling procedures; and 44% were dissatisfied with preparation processes. Eighty-two percent of respondents felt an ongoing chemotherapy training programme would be useful, and 74% wanted their hospital to invest in more resources for safe chemotherapy handling and administration.
2021 Chemosafe assessment
The Assessment tool was completed by 1010 task force members and focused on hospital safety and quality at the administrative, engineering and personnel levels. Of the 169 items, zero questions went unanswered and there were eight responses of ‘I don’t know.’ Thirty-three (19.5%) items received a ‘Yes’ response (ie, met compliance with international standards). Table 2 illustrates the proportion of ‘yes’ responses per domain. The patient home care (60%) and laundry (41.2%) domains received the highest endorsement. The remaining domains received a ‘yes’ response on less than 25 percent of items. Facility-wide action items received the lowest endorsement, with only a single ‘yes’ response in this domain (6.25%). This domain includes questions which address overall safety across the institution, and focuses on the existence and use of policies, standard operating procedures, training, education and management of exposures and spills of hazardous drugs (table 3). The low endorsement of this domain indicates that the institution is not currently meeting international standards for safety. ChemoSafe Assessment results also indicate that only 7 of the 24 (29%) items categorised as ‘High Cost’ were endorsed by participants (table 4). The high-cost items were those which assessed infrastructure to secure safety with hazardous drugs, indicating that this is an area of urgent need.
ChemoSafe Facility Assessment Tool—the number of questions with a ‘Yes’ response of meeting international safety standards and cost range
ChemoSafe survey questions addressing the ‘Facility Wide’ component of the assessment and corresponding responses by the OAUTHC Chemotherapy Task Force
Questions that addressed items with a cost category labelled ‘high’
Discussion
Our findings demonstrate that in Nigeria, safe chemotherapy handling and delivery is uneven, but providers are striving to meet international standardised practices. Barriers highlighted in our assessments include (1) limited resources to design safe infrastructure to prepare, deliver and dispose of drugs within institutions; (2) limited training available to the health professionals involved in the handling and delivery of chemotherapy drugs; (3) limited access to PPE; and (4) the absence of institutional guidelines for the implementation of standardised safety measures related to handling, delivery, accidental exposures and spills. Our work highlights collaborative efforts to improve practices with the safe handling of hazardous drugs in LMICs as well as the need for standardised guidelines that maintain safe environments for patients and employees.
Worldwide chemotherapy standards protect the healthcare worker, the patient and the environment.9 21–23 It is documented that workers have been exposed to hazardous drugs that have the potential to cause harm, including cancer, reproductive toxicity and harm to body organs.22 As a result, engineering controls such as biological safety cabinets and personal protective equipment are recommended and required in the workplace to maintain safety. The results from our 2019 needs assessment demonstrate the need for stronger safety measures and guidelines within the OAUTHC hospital environment, including guidelines, adequate PPE and warning labels identifying hazardous drugs. These findings are consistent with prior work that found considerable variation in chemotherapy preparation and PPE availability and use in LMICs.7 9
The ChemoSafe Facility Assessment Tool provided information on the gaps that need to be addressed at the facility level at OAUTHC. This programme has been created by the American Cancer Society for facilities in Sub-Saharan Africa. The programme has several objectives that include improving infrastructure, proving education to workers involved in cancer care and meeting international standards.10 24 The programme has been adopted for use in a number of countries including Ethiopia, Kenya, Nigeria, Rwanda, Tanzania and Uganda.24
Continuing education can help close the knowledge gap for safe chemotherapy practices. Our teaching strategy comprised of, one of the senior OAUTHC clinicians presenting in partnership with a member of the MSK group. Educational content for each topic is developed using references from professional organisations. These organisations include the American Society of Clinical Oncology, United States Pharmacopoeia, Oncology Nursing Society, National Institute for Occupational Safety and Health, International Society of Oncology Pharmacy Practitioners and American System of Health System Pharmacists. An in-depth understanding of practices is also achieved during these educational opportunities. For example, when the working group was developing the educational content, clinicians from OAUTHC shared insight into systemic practice differences between the USA and Nigeria to ensure content could be feasibly integrated into practice at OAUTHC.
The OAUTHC Chemotherapy Task Force planned a virtual Pan-African Symposium to address safe chemotherapy practices. This symposium received over 180 registered African clinicians. These clinicians practicing in LMIC countries provided feedback during the symposium. The feedback included requests for assistance in adhering to safety standards, a need for education and training in oncology, establishing and maintaining institutional safety standards, and financial assistance.
One of the goals of the Interdisciplinary Task Force is to work on developing practical and achievable solutions to ensure safe chemotherapy practices at OAUTHC. These solutions suggest standardised SOPs for safe chemotherapy delivery including storage, preparation, administration, monitoring and disposal.
Given budget limitations at OAUTHC, the current short-term goal of the task force is focused on tackling items that are categorised as low-cost. This includes creation of a list of hazardous drugs, implementation of an annual review of the hazardous drugs lists and accessible safety data sheets for each hazardous drug used at OAUTHC. In addition, implementation of a policy that permits expectant mothers to be temporarily excluded from work (such as in the preparation or administration of antineoplastic agents).21
The findings of this work must be interpreted with some caution due to several limitations. The data are drawn from a sample comprised of clinicians attending a symposium and a group of physicians and public health professionals participating in a joint task force, suggesting a high degree of motivation toward continuing education and a specific interest in the topic. As such, the generalisability of the survey findings may be limited. Physicians were overrepresented in the sample completing the needs assessment, and thus the findings may be similarly limited in their generalisability. Additionally, the potential for under/overreporting barriers and challenges is possible, given that the responses only reflect that particular respondent’s experience. The ChemoSafe Assessment was given to only one large teaching hospital in Nigeria; therefore, it is unclear how the challenges highlighted may be reflective of the challenges other hospitals across the country encounter. At the same time, further investigation is required because based on audience feedback obtained during the 2021 virtual Pan-African Symposium, the main sentiment expressed by healthcare workers seemed to align with some of the challenges presented in the ChemoSafe Assessment.
The key to achieving short and long-term goals is working with hospital administration to support and encourage their commitment to achieving a safe environment at OAUTHC. In addition to local support and collaboration, the interdisciplinary task force will seek to secure both local and international resources. This will assist in addressing medium to high-cost materials. These include the creation of an externally ventilated, negative-pressure room, refrigeration of antineoplastic hazardous drugs in a dedicated refrigerator, and creating separate rooms for sterile and non-sterile compounding.21
Future steps
This study discusses a collaboration that continues with plans for both virtual and in-person meetings moving forward. Using technology and venues such as WhatsApp, Zoom and project ECHO (Extension for Community Health Outcomes) allows for on-going review and discussion of goals and objectives identified at the various fora.25 The shared knowledge of best practices and support for educational training is creating better working environments for employees, patients and the community at large. Based on the strong engagement and collaborative efforts over the last number of years, we believe that using a systems-thinking approach, particularly the utilisation of an interdisciplinary team, is optimal.26 This will allow us to address the challenges encountered and to solve some of these complex problems and develop long-term and sustainable solutions.27 28 It is one example of a global collaboration that has been developed through mutual respect and trust that seeks to create safe environments for healthcare workers and patients.
Supplemental material
Data availability statement
Data are available upon reasonable request. Data are available upon reasonable request. The data generated from this study are analysed as stated. The original data supporting all the findings will be made available upon request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants but The Exempt protocol was provided because our research included interactions involving the use of survey procedures and the information obtained was in such a manner that the identity of the human subjects cannot be readily ascertained, directly or through identifiers linked to the subjects. Additionally, any disclosure of the human subject’s responses outside the research would not reasonably place the participant at risk of criminal or civil liability or be damaging to the subjects’ financial standing, employability, advancement or reputation. Memorial Sloan Kettering Cancer Center Institutional Review Board approved this study. The reference number is X19-017A, exempted this study. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We thank Ronke Ogunbameru, MD for helping to organize our initial efforts to engage all disciplines on the WhatsApp platform. Oluwaseun Abosede Agboola, BNSc, RPON, RN for her assistance with 2019 ARGO Symposium efforts.Raphael Roman, CPhT for creating the online demonstration video in 2019 ARGO Symposium for OAUTHC staff and for his lecture during the virtual 2021 Pan African Symposium. Rivka Khan, M.S. for assistance with the virtual 2021 Pan African Symposium planning and execution. The following for their assistance with lectures during the virtual 2021 Pan-African Symposium – Larry Buie, PharmD, BCOP, FASHP, Brian Del Corral, Pharm.D., R.Ph., Meagan Mulawka, RN, ACNP-BC, CCRN, Ray Muller, M.S., R.Ph., FAHSP, and Amy Winn, BSN, RN, OCN and Paul Zel, M.S.
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