Contextual Barriers and Facilitators to Implementing Ultrasound-Guided Fine-Needle Aspiration and Rapid Onsite Evaluation in a Resource-Limited Setting

Abstract

PURPOSE: Fine-needle aspiration (FNA) is an inexpensive, minimally invasive tissue sampling method that is often the primary diagnostic procedure in low- and middle-income countries. Although FNA can yield highly accurate diagnostic samples when performed by skilled practitioners, inadequate training frequently leads to indeterminate, nondiagnostic, or false-negative results. The adequacy and accuracy of FNA can be significantly improved by using image guidance and rapid onsite evaluation (ROSE). This study assessed the barriers to and facilitators of ultrasound-guided FNA (USFNA) and ROSE at a national referral hospital in Tanzania. METHODS: We conducted situational analysis using semistructured interviews with multiple key stakeholders involved in cancer care, including pathologists, surgeons, interventional radiologists, laboratory scientists, and administrators. The prompts included questions about barriers and facilitators for implementing the USFNA and ROSE. The interviews were recorded, transcribed, translated, and coded using thematic context analysis, and major themes were identified. RESULTS: A total of 23 stakeholders were interviewed. Major barriers include the lack of standardized training for cytopathology, the need for new equipment and supplies, and the need to establish a new procedure payment structure for patients. Facilitators included access to global academic partnerships for subspecialty training, availability of cytotechnology training programs, and institutional motivation for change. Participants suggested establishing systematic training in cytopathology, an integrated patient referral pathway for USFNA, appointing an intervention champion, strengthening the cytopathology infrastructure and quality, and modifying payment structures. CONCLUSION: Multidisciplinary stakeholder involvement, development of rigorous training programs, capacity strengthening of cytopathology infrastructure, and ability to bill for procedures will be critical for the successful adoption of USFNA and ROSE.