{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,11]],"date-time":"2026-11-11T16:10:38Z","timestamp":1794413438550,"version":"4.9.1"},"reference-count":28,"publisher":"BMJ","issue":"9","license":[{"start":{"date-parts":[[2025,9,2]],"date-time":"2025-09-02T00:00:00Z","timestamp":1756771200000},"content-version":"unspecified","delay-in-days":1,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000024","name":"Canadian Institutes of Health Research","doi-asserted-by":"crossref","award":["479608"],"award-info":[{"award-number":["479608"]}],"id":[{"id":"10.13039\/501100000024","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2025,8,15]]},"published-print":{"date-parts":[[2025,9]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Childhood cancer accounts for a significant proportion of global childhood mortality, especially in low-income and middle-income countries (LMICs). Unlike many adult malignancies, primary prevention of childhood cancers is not possible. Improving survival requires a two-pronged strategy: earlier diagnosis and effective treatment. Our study aims to establish the feasibility, clinical and implementation effectiveness of an adapted early warning signs and symptoms (EWSS) intervention in Cameroon and Kenya. It will equip healthcare workers, Ministry of Health (MOH) representatives and National Cancer Institute leaders with evidence-informed guidance on implementing context-adapted interventions to improve the early detection and referral of childhood cancers in these countries.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods and analysis<\/jats:title>\n                    <jats:p>The study is a quasi-experimental, hybrid type 2 implementation effectiveness study based on a Ghanaian adaptation of the \u2018Saint Siluan\u2019 EWSS campaign. Our protocol proposes context-specific adaptation and evidence-based implementation of the EWSS intervention through iterative engagement with country-level implementation teams to train healthcare workers and improve referral pathways for earlier childhood cancer diagnoses in each study country. Training effectiveness will be measured through pretraining and post-training tests of knowledge and application, as well as training satisfaction surveys. Clinical effectiveness will be assessed by using a REDCap database to track the number of newly diagnosed childhood cancer cases in the study regions and counties, healthcare timelines and paths to diagnosis, and the stage and proportion of metastatic disease at diagnosis. Implementation effectiveness will be evaluated through interviews with senior and mid-level health system partners and clinicians, tracking fidelity to the implementation process as laid out in The Implementation Roadmap Workbook, and analysis of meeting minutes from monthly local implementation team meetings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Ethics and dissemination<\/jats:title>\n                    <jats:p>This study has received ethical approval from The Hospital for Sick Children (REB # 1000080092) and all participating sites. We have received National Ethical Clearance from the Cameroon Ethical Board (#1699) and Regional Administrative Authorizations from our piloting regions (Centre and West). We have also received ethical clearance from Kenyatta National Hospital (KNH) (ERB# KNH-ERC\/RR\/955) and our National Commission for Science, Technology and Innovation in Kenya licence from the counties we are piloting in Kenya. As clinical data will be collected from existing health registries and patient charts, patient consent will not be required; however, we will obtain consent from all members of the leadership implementation teams and operational implementation teams for their participation in the implementation meetings and from all individuals participating in the semistructured interviews. We will disseminate findings to build awareness and share findings among various target audiences: (1) key county and regional parties (eg, clinical societies, advocacy groups, country MOHs and regional bodies such as the East African Community, Economic Community of West African States); (2) international bodies such as the WHO; and (3) the academic community.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2024-094502","type":"journal-article","created":{"date-parts":[[2025,9,2]],"date-time":"2025-09-02T14:40:11Z","timestamp":1756824011000},"page":"e094502","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Feasibility and clinical and implementation effectiveness of an adapted early warning signs and symptoms intervention for the early detection of childhood cancer in Cameroon and Kenya: protocol for a quasi-experimental, hybrid type 2 implementation effectiveness study"],"prefix":"10.1136","volume":"15","author":[{"given":"Hayle","family":"Noh","sequence":"first","affiliation":[{"name":"SickKids Research Institute, Toronto, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-2756-6177","authenticated-orcid":false,"given":"Melinda Piriyanca","family":"Chelva","sequence":"additional","affiliation":[{"name":"SickKids Research Institute, Toronto, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Glenn","family":"Mbah Afungchwi","sequence":"additional","affiliation":[{"name":"World Child Cancer, Surrey, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ang\u00e8le","family":"Pondy","sequence":"additional","affiliation":[{"name":"University of Yaounde I, Yaounde, Cameroon"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessie","family":"Githanga","sequence":"additional","affiliation":[{"name":"University of Nairobi, Nairobi, Kenya"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fongang","family":"Landis","sequence":"additional","affiliation":[{"name":"EWSS, Bamenda, Cameroon"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maureen","family":"King\u2019e","sequence":"additional","affiliation":[{"name":"University of Nairobi, Nairobi, Kenya"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexandra LC","family":"Martiniuk","sequence":"additional","affiliation":[{"name":"University of Sydney, Glebe, New South Wales, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nathan","family":"Ward","sequence":"additional","affiliation":[{"name":"World Child Cancer, Surrey, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2478-604X","authenticated-orcid":false,"given":"Melanie","family":"Barwick","sequence":"additional","affiliation":[{"name":"SickKids Research Institute, Toronto, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sumit","family":"Gupta","sequence":"additional","affiliation":[{"name":"Hematology\/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0039-0742","authenticated-orcid":false,"given":"Avram","family":"Denburg","sequence":"additional","affiliation":[{"name":"Hematology\/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,9,2]]},"reference":[{"key":"2025090207400803000_15.9.e094502.1","doi-asserted-by":"crossref","DOI":"10.1002\/pbc.28761","article-title":"Interventions to improve early detection of childhood cancer in low- and middle-income countries: A systematic review","volume":"67","author":"Zabih","year":"2020","journal-title":"Pediatr Blood Cancer"},{"key":"2025090207400803000_15.9.e094502.2","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2014.60.6376"},{"key":"2025090207400803000_15.9.e094502.3","doi-asserted-by":"publisher","DOI":"10.1016\/S1470-2045(18)30909-4"},{"key":"2025090207400803000_15.9.e094502.4","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2019-001825","article-title":"Cost and cost-effectiveness of childhood cancer treatment in low-income and middle-income countries: a systematic review","volume":"4","author":"Fung","year":"2019","journal-title":"BMJ Glob Health"},{"key":"2025090207400803000_15.9.e094502.5","unstructured":"Gupta S , Howard SC , Hunger SP , et al . 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