approximately 29 000 of those children are in sub - saharan africa where resources for pediatric cancer are very limited . the overall cure rate is 80% for children with cancer in high - income settings like the united states and europe . in low- and middle - income countries ( lmics ) , where children are often diagnosed too late or one of the many barriers to survival of pediatric cancer in lmics is late presentation . the only services for children with cancer in botswana are offered at princess marina hospital ( pmh ) , the main government referral hospital in the capital of gaborone . since 2007 , baylor college of medicine ( bcm ) and texas children s cancer and hematology centers ( txch ) have maintained a full - time pediatric hematologist - oncologist at pmh . to build local capacity , numerous pediatric cancer training programs have been offered at pmh through bcm / txch , including the development of a comprehensive pediatric hematology - oncology curriculum for a 5-day workshop at pmh to a multidisciplinary group of 30 health care workers in botswana . whereas most training focused on the care of a child with cancer and was based at pmh , training that focused on timely recognition and referral by primary health care workers throughout the country was necessary . therefore , a pediatric cancer awareness training program was developed to reach health care workers at hospitals throughout botswana . botswana is similar in size to the state of texas , with a population of 2.2 million people . it has 25 government medical hospitals , including primary , district , and two of which are referral hospitals . there are also two faith - based mission and government partnership hospitals , and there is one psychiatric hospital . hospitals are strategically located across the country , with district and referral hospitals in the population centers . hospitals and clinics in rural botswana have long relied on outreach from pmh and gaborone for medical education and clinical assistance . the goal of the pediatric cancer recognition program was to visit at least 50% of the hospitals throughout botswana to educate health care workers on warning signs of pediatric cancer and to inform health care workers of pediatric cancer services available at pmh . pediatric cancer recognition training workshops were organized with leadership at each hospital . the full - time bcm / txch pediatric hematologist - oncologist based at pmh developed and delivered the teaching . the teaching format was open - forum didactic sessions , with lectures using pictures of physical exam , radiographic , hematological , and/or pathological findings to illustrate presentations of pediatric cancers . the length of the workshops was determined by hospital leadership and varied from 2 hours to 1 day . all health care workers were welcome to attend with a focus on physicians and nurses who typically have the most patient contact and are the decision makers with respect to clinical care . all attendees of the training sessions were asked to complete a pretest evaluation assessing their knowledge of the burden of cancer in children , survivability of pediatric cancer in ideal settings , and the most common types of cancer in children . additionally , attendees were asked about any training in pediatric oncology either during their preservice and/or clinical training years . finally , attendees were asked to indicate their comfort with caring for children with cancer and their understanding of the referral process to pmh . following the presentations , they were asked to complete the same questions regarding pediatric cancer , their comfort level with pediatric cancer patients , and their ability to refer a child with suspected cancer to pmh as well as an evaluation of the speaker and the presentations . statistical analysis of the questionnaires included expressing responses as percentages , evaluating ordinal data as means , and  analyses of respondents responses by medical specialty . statistical analyses were done using stata , version 11 ( statacorp lp , college station , tx ) . pediatric cancer recognition training workshops were offered at 14 ( 53.8% ) of the 26 government / mission hospitals in botswana , excluding pmh , over a 10-month period ( figure 1 ) . of the 362 health care workers who attended a workshop , 279 ( 77.1% ) completed the pretest , posttest , self - assessment , and evaluation . nurses represented the majority of attendees who identified their profession , at 49.2% ( 178/362 ) , whereas physicians represented 30.1% ( 109/362 ) . only 7.4% ( 20/272 ) of attendees completing the evaluations indicated that they had some formal training in pediatric oncology , including a fellowship , clinical rotation , and/or workshops . most of those who had some formal training were physicians ( at 23.5% [ 12/51 ] ) , whereas only 1.8% were nurses ( 2/114 ; p  .01 ) . when asked if their clinical training program included a pediatric oncology component , 26.8% ( 64/239 ) confirmed that their training program had either clinical or didactic pediatric cancer components , with the most common group being physicians ( 63.8% , 30/47 ) when compared with nurses ( 15.8% , 16/101 ; p  .01 ; table 1 ) . pediatric cancer training by profession before the workshop , the majority of attendees were not familiar with the worldwide incidence of pediatric cancer ( 42.0% , 107/255 , answered correctly ) or the survival percentage of pediatric cancer in an ideal setting ( 43.5% , 113/260 , answered correctly ) . when attendees were asked if they understood how to refer a child with suspected cancer to pmh , only 32.7% ( 84/257 ) answered positively ( 4 - 5 on a likert scale of 1 - 5 where 1 = strongly disagree , 3 = neutral , 5 = strongly agree ) prior to the seminar . physicians were most aware of the process ( at 54.9% 28/51 ) compared with nurses ( 25.9% , 28/108 ) and others / unidentified ( 28.6% , 28/98 ; p  .01 ) . after the workshop , 79.5% indicated that they understood how to refer a child with suspected cancer to pmh ( table 2 ) . attendees were asked to critically evaluate the workshop for clarity and content . on a 1 to 5 likert scale , with 5 denoting strongly agree , all criteria had a mean of 4.49 or greater ( figure 2 ) . pre- and post - test responses by profession evaluation of workshop by health care workers ( mean scores on a 1 - 5 likert scale where 1 = strongly disagree , 3 = neutral , 5 = strongly agree ) . in visiting 50% of government hospitals in botswana , 362 health care workers were trained on how to recognize and refer children with suspected cancer to pmh , the only hospital in the country with pediatric oncology services . assessment of attendees found that the majority of health care workers in botswana had no prior training or clinical experience in pediatric oncology . though treatment is available at pmh for children with cancer , recognition of suspected cancer and timely referral are essential to offer curative options for batswana children . delayed presentation and diagnosis of pediatric cancer is a major issue in lmics . the reasons for delay of diagnosis are multifactorial , including the malignancy type , patient / family demographics , and multiple factors within health care systems in lmics . a south african study found that the median time of physician delay , the time from the child s presentation to the health care system until diagnosis of cancer , was 20 days , contrasted with patient delay , the time lapse between onset of symptoms until the first health care encounter , which was 5 days . a turkish study had similar results , with a median physician delay of 28 days versus 3 days for the patient / parent delay . this study also found that the physician delay was longer when the first patient contact was with a general practitioner instead of a pediatrician and even longer if the first contact physician was a nonpediatric specialist . of the 109 workshop attendees in botswana who identified as physicians , only 10 ( 9.2% ) identified as a pediatrician . because of the late presentation of childhood cancers in south africa , the southern african children s cancer study group ( saccsg ) developed the saint siluan warning signs of childhood cancer . the warning signs were distributed throughout the johannesburg area , with a catchment area population of 6 million , over a 6-month period , through lectures ( 610 attendees ) and posters . public awareness was also included through a multimedia campaign . compared with the 12 years that preceded the awareness campaign , new referrals and new cancer diagnoses increased in the 6 years following the program from a mean of 78.4/year to 109.3/year . in botswana , the pediatric hematology - oncology program at pmh has primarily relied on 1 bcm / txch pediatric hematologist - oncologist to serve the entire country , including a busy hematology service with the country s only comprehensive hemophilia program for adults and children . because of the addition of a second physician through the baylor international pediatric aids initiative ( bipai)/texas children s hospital global health corps and a txch project manager / care coordinator based at pmh , the full - time pediatric hematologist - oncologist was able to engage in nationwide outreach for the first time since the program s inception in 2007 . with limited time and resources , more than 50% of government hospitals were reached , with 362 health care workers attending the training . the long - term impact on referral patterns and new cancer diagnoses remains to be seen , but the short - term impact can be seen in the respondents increased awareness of basic pediatric cancer knowledge and the services available at pmh for children with cancer . although this cancer recognition program met its goals , limitations of the program emerged that will inform future pediatric cancer education initiatives . expenses for this training program included travel costs for the physician , educational materials , and catering at some sites . the overall cost of the program was $ 4054.02 or $ 11.20 per health care worker trained . with limited full - time staffing in botswana , it is not possible for the pmh oncologist to engage in prolonged educational initiatives while maintaining the quality of the clinical service . future training models may involve intensively training representatives from hospitals and clinics throughout botswana to serve as a local resource for their colleagues and as a direct link to the pediatric hematology - oncology service at pmh . txch is also currently developing a web - based didactic teaching model to include both physician and nurse education . with only 26.8% of attendees of the pediatric cancer recognition workshops indicating that their clinical training program had a pediatric oncology component , there is a tremendous need to incorporate pediatric cancer training into preservice training programs for physicians , nurses , and all health care workers in botswana . engaging the government and other stakeholders to promote pediatric cancer modules in training programs will be paramount . there are many challenges to improving diagnosis and survival of pediatric cancer in lmics . even where programs exist to treat children with cancer , such as the program at pmh , successful treatment is dependent on children being appropriately recognized and urgently referred to advanced care by health care workers in the primary care setting . despite significant deficiencies in human resources , a pediatric cancer recognition program was presented at half of all government / mission hospitals throughout botswana . sustained efforts are necessary to maximize the impact of such programs to lead to improved survival of pediatric cancer patients in lmics . jss contributed to the conception and design ; contributed to acquisition , analysis , and interpretation of data ; drafted the manuscript ; critically revised the manuscript ; gave final approval ; and agrees to be accountable for all aspects of work ensuring integrity and accuracy . ei contributed to the conception and design ; critically revised the manuscript ; gave final approval ; and agrees to be accountable for all aspects of work ensuring integrity and accuracy . psm contributed to the conception and design ; critically revised the manuscript ; gave final approval ; and agrees to be accountable for all aspects of work ensuring integrity and accuracy .
delayed presentation of children with cancer is a significant barrier to improving the survival from children s cancer in low- and middle - income countries ( lmics ) . 
 botswana , a country of approximately 2 million people in southern africa , has only 1 pediatric cancer treatment program , based at princess marina hospital ( pmh ) in the capital of gaborone . 
 a pediatric cancer recognition training program was developed that reached 50% of the government hospitals in botswana teaching 362 health care workers how to recognize and refer children with cancer to pmh . through evaluation of attendees , limitations in pediatric cancer training and general knowledge of pediatric cancer 
 were identified . 
 attendees demonstrated improvement in their understanding of pediatric cancer and the referral process to pmh following the workshop .