Access to Palliative Care in Patients with Advanced Cancer of the Uterine Cervix in the Low- and Middle-Income Countries: A Systematic Review

Access to Palliative Care in Patients with Advanced Cancer of the Uterine Cervix in the Low- and Middle-Income Countries: A Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Access to Palliative Care in Patients with Advanced Cancer of the Uterine Cervix in the Low- and Middle-Income Countries: A Systematic Review Francis Ooko, Tebogo Mothiba, Peter Van Bogaert, Johan Wens This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2412007/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Sep, 2023 Read the published version in BMC Palliative Care → Version 1 posted 8 You are reading this latest preprint version Abstract Background Women with advanced uterine cervical cancer suffer from a combination of moderate to severe physical, psychological, social, and spiritual distress due to their disease and are in need of palliative care to improve their quality of life. Approximately 85% of the women live in the low- and middle-income countries. Whether these women and their families access palliative care is not known. Objectives To understand the geographic accessibility, availability, financial accessibility, and acceptability of palliative care by patients with advanced cervical cancer and their families. Methods We conducted a Systematic review following PRISMA guidelines in CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE, PsychINFO, PubMed and Scopus for the core concepts: palliative care, access, advanced uterine cervical cancer. Eligible articles were published in English, contained original data on experiences of patients and/or caregivers including symptoms management, and discussed available resources, communication, satisfaction, and healthcare utilization. Results Overall there was limited access to palliative care with insufficient facilities located in cities away from the rural areas where most women lived. Pervasive poverty was common with poor affordability of healthcare, travelling, accommodation, and subsistence expenses. Misconceptions and poor knowledge of the disease, cultural beliefs and attitudes, and other health system insufficiencies also presented challenges for access. Conclusion Concerted effort should be made to improve availability of palliative care facilities. Health education to address misconceptions and other cognitive barriers that limit access among cervical cancer patients and their families should be urgently undertaken in the LMICs. Cervical cancer access palliative care low and middle-income countries Figures Figure 1 Figure 2 Introduction And Background Cervical cancer is the second most prevalent cancer in women in South Africa. Recent data reveal that 6945 cases of cervical cancer were diagnosed in 2019 being 15.85% of all histologically diagnosed cancers (Cancer Statistics NICD, 2022: https://www.nicd.ac.za ), with an estimated mortality of 19.6 per 100000 population (Global Cancer Observatory, 2022: https://gco.iarc.fr ). Therefore, cervical cancer is a public health problem in South Africa. Although cervical cancer is a preventable disease, it still causes significant morbidity and mortality in women, particularly in the low- and middle-income countries (LMICs) where up to 88% of all global cervical cancer related deaths occur ( 1 , 2 ). High prevalence of symptoms such as vaginal discharge, vaginal bleeding, and spiritual distress are found in women living with or who die from cervical cancer ( 2 ). Clinically evident anxiety, depressed mood, sexual dysfunction, and abandonment are common among these patients ( 3 ) in addition to financial distress particularly among patients and their families living in less developed countries ( 4 ). Globally, approximately 2.6 million patients living with and 250 000 who died from cervical cancer in 2017 reported a combination of moderate to severe physical, psychological, social, and spiritual distress of whom 85% were in the LMICs ( 5 ). Nevertheless, many other studies worldwide report significant unmet physical, psychosocial, and spiritual needs among cervical patients and their families ( 6 – 8 ). Such report exemplify the need to provide palliative care (PC) alongside specific cancer therapy in patients with advanced cancer of the uterine cervix to alleviate distress and achieve for them good quality of life (QoL). Therefore, access to PC according to an individual’s need is critical in patients with cervical cancer and their families throughout the disease trajectory. Palliative care is “the active holistic care of individuals across all ages with serious health-related suffering due to severe illness and especially of those near the end of life. It aims to improve the quality of life of patients, their families, and their caregivers”( 9 ). Earlier studies provide evidence that provision of PC alongside usual oncologic care significantly improves QoL of patients and their families ( 10 – 12 ). However, access to PC is not universally guaranteed for all in need due to complex factors such as poor referral system, lack of physical facilities, poor general public awareness, negative beliefs, and other sociocultural factors ( 13 – 16 ). Furthermore, lack of PC knowledge and skills have been reported among a large number of healthcare professionals in many LMICs ( 17 ). Other factors known to affect access include geographic distance from health facilities, lack of medicine, poor affordability of services, lack of information on the specific disease, and poor healthcare professionals’ attitude, knowledge and skills ( 18 ). Disparities in access to PC by women with cervical cancer from different resource settings have been studied ( 18 , 19 ). We conducted this systematic review to gain a better understanding of barriers, facilitators, and measurable factors that can act as basis of remedial actions for improving access to PC by cervical cancer patients and their families living in the LMICs. In particular, this review aims to identify the physical availability of PC facilities and the enablers and barriers to utilization of these services guided by the conceptual model of access to quality healthcare in developing countries (Fig. 1 ). The review question, PICOTS, and inclusion/exclusion criteria are presented in Table 1 Table 1 Study eligibility criteria Review question: What factors are important for access to palliative care by women with advanced cancer of the uterine cervix in the low- and middle-income countries? Population : Women diagnosed with advanced cancer of the uterine cervix (advanced cancer being defined as any of the following: FIGO stage IB to IV; or presence of distant metastasis; or cancer that is life limiting; or cancer with prognosis of 6 to 12 months); Age 19 years and older (this age group defines and adult); and/or family or caregiver of the patient Intervention(s), exposure (s ):Any care given to relieve distressing symptoms, – physical or otherwise, before, alongside, or after the disease specific treatment, such as pain management, vaginal bleeding, vaginal discharge, and psychosocial support Comparator : Palliative care in any form is not provided Outcome : Specified or unspecified aspects of palliative care outcomes and/or associated outcomes such as problems or facilitators of access; physical or psychosocial needs; cultural factors; communication of needs – with family, healthcare staff, or other patients; underserved/minority groups – ethnic or socio-economic factors Outcome measures : Qualitative and/or quantitative with regard to availability, affordability, physical accessibility and acceptability of the care; primary palliative care use - access, provision, implementation, integration Setting : Home, hospice facility, outpatient oncology setting, outpatient non-oncology setting, in-patient oncology setting, and inpatient non-oncology setting Inclusion criteria : • Original research involving data on adult women with advanced stage uterine cervical cancer, and/or their caregivers • Studies of cancer patients, or gynecological cancer patients with an arm including patients with cervical cancer • Any care intended to relieve distressing symptoms • Outcome includes qualitative or quantitative measures • Published anytime from inception of database • Study design can include experimental studies (randomized controlled trials, other types of trials), observational studies (cohort studies, case-control studies, controlled and uncontrolled pre/post studies), retrospective studies, cross-sectional studies, qualitative, quantitative, mixed-method studies Exclusion criteria : • Trials of medications or medical procedures related to primary cancer therapy • Case reports, editorials, letters to the editor, commentaries, historical perspectives, reviews, gray literature including guidelines and protocols, newspaper articles, social media • Review articles (not systematic review) • Diseases other than cancer of cervix • Studies reporting factors not expressed by patients or caregivers • Papers published in any language other than English Methods The study proposal is registered in the International Prospective Register of Systematic Reviews ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022310163 ) Search strategy The updated Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) 2020 statement guideline for systematic reviews ( 21 ) was followed to standardize the search and reporting process. Literature search was conducted in six electronic databases (Cumulative Index of Nursing and Allied Literature [CINAHL], Cochrane Central Register of Controlled Trials [CENTRAL], MEDLINE, PubMed, PsychINFO and Scopus) in May 2022. Advanced Boolean search strategy with at least the following terms using controlled vocabulary and free text was used: (((woman OR women OR female*) AND (neoplasm* OR oncology OR cancer OR tumo?r or malignanc*)) AND (palliative care OR end of life care OR terminal care OR hospice care OR palliati*) AND (cervi*)). Second line of search among records after screening of titles and abstract done using search terms: access* OR availability OR available OR barriers OR utilization OR utilize*. Additional hand searches of the reference lists of the included studies was also done to identify relevant articles not initially picked up by electronic search. Overview of the search strategy is shown in Fig. 2 . Study selection Search results were uploaded onto EndNote™20 to identify and remove duplicates, and perform further screening. The remaining articles after deduplication were screened for eligibility based on the criteria in Table 1 . Two authors (F.O. and P.B) screened the titles, abstracts, and full-text articles for eligibility, and reached a consensus on the included articles. Quality appraisal Due to heterogeneity of the selected articles, different methods were used to assess the methodological quality of the included studies. The Strengthening Reporting of Observational Studies in Epidemiology (STROBE) statement ( 22 ) was used for observational studies, whereas Standards for Reporting Qualitative Research (SRQR) checklist ( 23 ) was used for qualitative studies. Studies that scored at least 75% in the respective checklists were considered of good methodological quality and included in the final analysis. Data extraction Selected articles were heterogeneous with both quantitative and qualitative designs thus not allowing either meta-analysis of the quantitative studies or meta-synthesis of the qualitative studies. A textual narrative approach was used to synthesize the different types of research evidence for qualitative, quantitative, and mixed-method studies ( 24 ). For each included article, the first author (F.O) extracted data into a preformatted table. Data fields included information of authors, publication year, country, study aims, design, participants, themes, and study findings. Findings were sorted and grouped under themes describing domains of access to healthcare in developing countries ( 20 )[Fig. 1 ]. The third author (P.B) checked the results and discussed any changes and revisions until consensus was reached. Results Results of the study selection process are reported according to the PRISMA statement updated guidelines ( 21 ). Excluding duplicates, database searches produced 1154 records (Fig. 2 ). Following title and abstract screening 61 articles remained and were downloaded for full-text screening, out of which 10 articles met final inclusion criteria and were analysed. Three of these articles ( 18 , 25 , 26 ) emanated from one large study with each article reporting on participant groups investigated with different experimental designs. Study characteristics and findings are summarized in Table 2 . Table 2 Summary of study design, aims and objectives, participants, themes and findings Author, Year, Country Aims Design Participants Themes Findings Bates et al. (4), 2021, Malawi Investigate whether total household cancer-related health care costs over 6 months after a diagnosis of advanced cancer are associated with a patient receiving palliative care, and the experience of catastrophic costs in the household Prospective cross-sectional study 150 households with 150 patients with advanced cancer, and 121 family caregivers. At 6 months 89 households with 89 patients and 64 caregivers were evaluable, out of which 60 patients (67%) had cervical cancer Socially active people with responsibility People live in rural areas Limited facilities for cancer care countrywide Access available but limited Limited support. Patients depend on own resources for some needs People in urban areas within 50 km radius more likely to access services Majority of households living in extreme poverty Most patients/households experienced financial hardship More non-PC recipient households used a larger proportion of annual income on healthcare Fewer households receiving PC experienced catastrophic costs Some households chose to forgo treatment rather than have catastrophic costs More rural households associated with catastrophic costs Non-PC recipient households associated with dissaving Median patient age was 50 years (IQR 40–57); 47 (73%) of caregivers were female 48 households were rural Cancer care and PC facilities only available in the 4 tertiary hospitals Free treatment offered supported by Government and charitable groups Limited additional needs supported by charities 9 households received PC while 70 did not 89 households lived in extreme poverty (≤ $ 1.89 per day) Median annual household income before illness: • Overall - $ 204 (IQR 84–660) • PC recipients - $ 537 (07-821) • Non-PC recipients- $ 179(82–537) Household healthcare costs after 6 months: • PC patients - $ 50 (11–101) Direct costs $ 6 (4–26) Indirect costs $ 36 (5–56) • Non-PC patients - $ 55 (28–91) Direct costs $ 12 (0–21) Indirect costs $ 33 (13–56) Total healthcare cost as a proportion of total income • PC patients − 0.086 (0.037–0.579) • Non PC-patients − 0.278 (0.085–0.692), p = 0.126 Households experiencing catastrophic costs • PC – 9 of 19 (47%) Non-PC − 48 of 70 (69%), p = 0.109 • Rural – 37 of 48 (77%) Urban – 20 of 41 (49%), p = 0.008 Median dissaving at 6 months per household • PC - $ 11 (0–36) Non-PC - $ 34 (14–75), p = 0.005 Tapera et al. (25), 2021 Zimbabwe To investigate some key and contextual strategies which could be implemented to improve access and uptake of cervical cancer treatment and palliative care by women Qualitative inquiry as part of a sequential explanatory mixed method study 84 purposively enrolled participants: 16 in-depth interviews with cervical cancer patients/caregivers and 20 key informants (health workers, policy makers and spiritual leaders 6 focus group discussions of cervical cancer patients, caregivers and male partners Poor affordability Out-of-pocket expenditure on healthcare costs Poor access to definitive care Treatment unavailable to people in rural areas High costs of transport Accommodation costs Loss of income for patients and family members Limited knowledge and awareness by healthcare workers (HCW) Alternative care due to financial hardship Limited information on disease Limited resources Equipment unavailable Skills deficiency; no team approach to patient care Treatment guidelines and guidance unavailable Unmet needs Treatment associated with high cost which most patients could not afford Most patients relied on out of pocket funding for their treatment Most patients could not afford cost of histopathology tests to confirm cancer before treatment decision is made Servicers are centralized in major cities out of reach of most rural people Cost of transport to reach centralized services unaffordable Cost of accommodation while attending services in cities especially for out of town rural people Patients and accompanying family members unable to earn income Healthcare professionals not well informed about cervical cancer Seeking alternative medicine (traditional and spiritual healers) as people cannot afford conventional treatment for cervical cancer Patients and families are not given adequate information about their illness and treatment available to them Few cancer treatment and palliative care centres Frequent equipment breakdown at the few facilities Different disciplines required for PC such as social workers and psychologists are lacking Guidelines for patient referral and treatment to ensure uniformity of care not available Patient and family emotional, spiritual, information and communication needs not met due to deficiency of soft skills among HCW Tapera et al .(18), 2020 Zimbabwe To investigate palliative care knowledge and access among women with cervical cancer in Harare, Zimbabwe A sequential explanatory mixed method study with descriptive cross-sectional surveys as a major study and qualitative inquiry as a minor study 134 women with cervical cancer 78 HCW involved in cervical cancer screening, treatment and palliative care 16 in-depth interviews 48 participants in 6 FGD 20 key informant interviews Socially active people with responsibilities Advanced stage cancer Moderate level of education Unemployment rate is high No intimate partners Low palliative care Availability of PC skills among HCW Adequate training and guidance Poor PC referral Availability of medicine Limited PC knowledge among patients and HCW Limited access to PC Patient misconception about PC Misconception and/or limited knowledge of cervical cancer Misconception of PC Low affordability of medicines Poor implementation of PC policy Mean age of patients 52 years SD ± 12 Cancers stage FIGO ≥ 2b2 94% Secondary education − 61% No income - 51%; Unemployed - 67% Widowed, divorced or separated 60% Received palliative care − 13% Mean age of HCW 37 years SD ± 12 Trained to provide PC – 72% HCW accessing PC guidelines – 76%; HCW referring patient to PC specialty unit – 1.2% Stock-outs of pain medicine – 22% Knowledge of palliative care among HCW and patients are limited Few patients access palliative care even among women who received other forms of treatment Patient perceives cervical cancer as a death sentence Cervical cancer diagnosis and palliative care is stigmatized and linked to near death Palliative care only provided by hospice High cost of medicines for cancer patients Palliative care policy framework available but not fully implemented Kebede et al. (27), 2020- Ethiopia To explore communication in cancer care in Ethiopia from the perspective of physicians, patients, and family caregivers Ethnographic exploratory qualitative study using semi-structured interviews, and triangulating findings with direct observations and video-recordings of authentic interactions between physicians, patients, and family caregivers during hospital rounds Purposively sampled participants 54 cancer patients • 20 males 34 females • Age 22–53 years • Cervical cancer number not mentioned 22 family caregivers • 11 male 11 female 16 physicians • 3 senior 13 junior • 11 males 5 females • Ages 29–58 years Workload and time pressure Insufficient consultation time Insufficient information on disease Good HCW attitude Lack of privacy Language barrier No confidentiality No confidentiality Reluctance to reveal sensitive information Compromised autonomy Limited knowledge of cancer Long distances Influence from others Misconceptions about disease Culture/attitude Expectations Fear of stigmatization and isolation, Large number of patients; few physicians Difficulty in allocating sufficient time for patient and family caregiver consultation Patient and family caregiver but not provided with enough information Care recipients described communication with physician positively; nice and humble doctors Consultation done in small non-sound-proof cubicles; frequent interruptions by other patients and staff Physicians and patients/family caregivers speaking different languages; Use of interpreters Family caregivers tended to dominate interaction with physicians including discussion on diagnosis and prognosis Male family member often responsible for making decisions and taking responsibility for patient care and expenses Patient has problems understanding the disease and treatment process Patient comes from distant rural areas Some patients told that traditional medicine is better; seeks professional help late after going through religious treatment with holy water Some care-recipients believe cancer is a curse from God; while others believe it can be transmitted from one person to another Stigma and taboo related to genitals in some communities; some female patient found it difficult to discuss cervical cancer openly and withheld vital information Hope to receive help from the doctor Patients reluctant to share diagnosis with others, including family Tapera et al. (28), 2019 Zimbabwe To investigate the determinants of access to cervical cancer treatment and palliative care services in Harare, Zimbabwe Sequential explanatory mixed method Phase 1 –quantitative survey: 148 healthy women 134 cervical cancer patients or survivors 78 health workers involved in cervical cancer Phase 2- 6 FGD with 8 members per group 16 in-depth interviews 20 key informant interviews User’s location User’s attitude User’s resources User’s attitude or resources Self- efficacy/attitude Satisfaction with quality of care/Expectations Transportation / user’s resources /service location Demand for service / user’s resources / service location /user’s location Financial hardships Willingness to pay Cost and prices of service Over servicing/ characteristics of health services Financial hardship Misconceptions about disease and treatment Social factors / user’s attitude Acceptability Compared to those who did not receive any care, most patients receiving treatment: • Lived in urban high density population areas, (p = 0.025) • Were of protestant faith, (p = 0.028), • With household heads being a professional (p = 0.038). Most patients receiving no treatment had household heads with no formal education (p = 0.038) Locus of control was positively associated with uptake of treatment Perception of competency of HCW positively associated with treatment uptake Walking as a means of reaching nearest health facility was negatively associated with perceptions of access Mostly lack of transport or high transport cost for rural people who travel long distances to reach few cancer centres Accommodation often required for patient and family at these centre paid for by family Patient buys own drugs High cost of diagnostic tests, medications and other treatment unaffordable to most Same test ordered multiple times at every level of care Loss of employment for patient and accompanying family member Cervical cancer seen as death sentence and radiotherapy introduces foreign material into the body. Influence of traditional and some religious healers, family, attitudes play a major role in seeking treatment Prolonged waiting period Miranda et al . (29), 2016 Brazil To analyse the clinical and socio- demographic profile of cancer patients seen in a specialized emergency service, considering the availability of palliative care and home care Descriptive, cross-sectional study of medical records with an analytical component 191 medical reviews including those of 35 patients with cervical cancer Characteristics of health services Brazil has hierarchical and regionalized network that prevents 1 in 5 patients to be displaced from rural areas in the state for case review in a referral hospital Maree & Langley, (7), 2014 South Africa To elicit the experiences of underprivileged women being confronted with cervical cancer Qualitative exploratory and contextual with descriptive and interpretive elements 19 purposively selected newly diagnosed cervical cancer patients being prepared to receive radiotherapy Vulnerable population Anxiety and/or depression Misconceptions about cervical cancer Waiting for treatment / Characteristics of health services Dissatisfaction with health system Medical assistance available Financial hardship Out of pocket costs /Family support Unemployed / user’s resources HCW attitude Disclosing bad news Family support Cost of being away from work Alternative forms of treatment / attitudes Limited knowledge of disease Communication Limited knowledge of HCW Majority of patients has advanced stage cancer Mean age 47.2 years (29–70) Majority (16/19) were black South Africans. Most patients experience worrying symptoms such as excessive vaginal bleeding, offensive discharge, and pain Some patients experienced bleeding but did not have pain so they never though they had serious illness It took an average of 17 months from first symptoms to the start of specific treatment Patients felt the public health system failed them in terms of prompt diagnosis and start of treatment Patients do not pay for treatment in the public health system Private health system available and faster but patient could not afford the cost of treatment here unless paid for by relatives Most patients were unemployed The doctors were nice to the patients but had difficulty communicating bad news Some patients preferred to be alone when bad news was broken Found it difficult to disclose their diagnosis to the family to protect them from distress Patients who received their diagnosis in presence of family felt better after being consoled Accompanying family stayed away from work for consultations Seeking conventional medicine was delayed as some patients were advised by relatives to attend spiritual and traditional healing One patient did not know that cervical cancer is life threatening Most patients wanted to know more about the disease and treatment but the doctors could not explain to them Cancer stage 1b – 2a : 3 patients Cancer stage 2b to 4 : 15 Dutta et al . (30), 2013 India To find out he socio-demographic causes which lead to non-compliance to treatment even after registration for radiotherapy Retrospective analysis of medical records 144 patients with cancer of the cervix already registered to receive treatment They received initial treatment at a nearby centre but had to go for the second phase of treatment at a centre 567km away. Transport vouchers were provided but patients had to find and fund their own accommodation Family burden Dependency / resources Older age Low literacy level Transport difficulties and high cost Burden of family responsibility Social status Majority of patients were postmenopausal (56.94%), and had family burden of > 3 children Only 6.25% were self-employed The rest depended on family and husband for their livelihood Elderly patients > 50 were most unlikely to complete their course of treatment High number of illiterate women were unlikely to complete their treatment Most patient living more than 100km from the nearest treatment facility unlikely to complete their course of treatment Women with more children preferred to take care of their families rather than be away from home for prolonged period of time Women who completed their treatment in time were wealthier; middle-aged; with < 3 children Mwaka et al . (31), 2013 To explore the perceptions of operational level healthcare professionals who work directly with cervical cancer patients on challenges faced by women seeking cervical screening, cervical cancer diagnosis and management, and challenges faced by health professionals in providing cervical cancer care Qualitative inquiry using key informant interviews 10 female nurse/midwives, 2 gynaecologists, 2 medical officers and 1 surgeon working in a public regional and a mission hospital in northern Uganda Patients and community related factors Healthcare professionals deficiencies Health facility related factors Facilities Health policy factors Lack of awareness on cervical cancer and available services Discomfort with exposure of women’s genitals Perceived pain during pelvic examinations Men’s lack of emotional support to women Inadequate knowledge and skills about cervical cancer management Long distance to care centres Few gynaecologists and lack of pathologists Delayed histology results Lack of morphine for pain control Lack of specialized cancer treatment facilities Lack of vaccination policy for HPV Large number of women presenting with late stage cervical cancer Van Schalkwyk et al . (32), 2008 South Africa To gain an understanding of the routes that women presenting with advanced cervical cancer followed, from experiencing the first signs and symptoms of disease until they received radiotherapy Exploratory qualitative phenomenological study of the subjective experiences of women with cervical cancer 15 consecutive women with advanced (stage 2b and worse) cancer of cervix Limited knowledge Anxiety, fear of the unknown Stigmatization Self-efficacy Long waiting period for treatment, even longer for rural women Limited knowledge and awareness of HCW (Low index of suspicion) Culture of secrecy, taboo regarding reproductive organs Influence of significant others Misconceptions and limited knowledge of the disease Positive support from family Negative attitude of family and misinformation Dissatisfaction At first symptoms (bleeding, pains, discharge) most women knew something was wrong but lacked the knowledge of what was required to manage the problem Most experienced concern, sadness, embarrassment, sadness and isolation People avoided them in public spaces due to the bad smell Were able to seek treatment once they knew what the problem was Average time from diagnosis to treatment was 17.3 months (11.8 for urban vs 28.4 for rural women) First contact with HCW did not result in correct diagnosis at any level of care Some women did not report their symptoms due to embarrassment but instead only complained of minor problems Traditional healers were consulted as a result of advice or insistence of support persons Some believed that their problem was caused by demons and attended traditional healers first, going to hospital only when they did not get relief Some family members, intimate partners, workplaces, and the church were very understanding and supportive Others accused the patient of immorality, and did not allow them in church because of being unclean Most patients were not happy with the way they were treated in the healthcare facilities Of the 10 studies there were 2 retrospective cross-sectional ( 29 , 30 ), 1 prospective cross-sectional ( 4 ), 5 qualitative ( 7 , 25 , 27 , 31 , 32 ), and 2 mixed-method designs ( 18 , 26 ). There were no randomised control trials. Eight studies were conducted in Africa ( 4 , 7 , 18 , 25 – 27 , 31 , 32 ) and one each from Brazil ( 29 ) and India ( 30 ). Within the 10 studies, 505 unique women with cervical cancer, 148 healthy women, 64 family members, 78 healthcare workers involved with cervical cancer, and 20 informal caregivers were included. Findings from all the studies were collated under 10 sub-constructs alongside four main constructs of access to healthcare ( 20 ) [Table 3 ]. Table 3 Access domains and sub-domains Domains Geographic accessibility Availability Financial accessibility Acceptability Subdomains Articles Service location User’s location Health workers Drugs Equipment Demand for services Cost & prices of service User’s resources User’s willingness to pay User’s attitude User’s expectations Characteristics of health services Bates et al ., (4) • • • • • • Dutta et al ., (30) • • • Kebede et al .,(27) • • • • • • • Maree et al ., (7) • • • • • • Miranda et al ., (29) • • • • Mwaka et al.,(31) • • • • • • • • • • Tapera et al ., (25) • • • • • • • • Tapera et al. , (18) • • • • • • • Tapera et al ., (28) • • • • • • • • Van Schalkwyk et al ., (32) • • • • • • • Below, we present the findings of thematic analysis of the review under the following domains: geographic accessibility, availability, financial accessibility, and acceptability. Geographic accessibility Health facilities were found in central referral hospitals located in urban centres far from the rural areas where a majority of patients lived ( 4 , 18 , 27 – 32 ). Most patients travelled long distances, usually by public transport, or by walking to the nearest facility to access cancer treatment or primary care for pain and symptom relief ( 26 ). Availability The demand for palliative care services and unmet needs featured prominently in all studies except one ( 30 ). Three studies ( 18 , 26 , 31 ) reported lack or shortage of essential medicines used in palliative care such as morphine for pain control. One study ( 31 ) reported shortage of blood for transfusion of cervical cancer patients presenting in shock after excessive bleeding. Unavailability of radiotherapy equipment is reported in 2 studies ( 25 , 31 ) with each of the countries of origin possessing only one old-type radiotherapy equipment (cobalt-60) for the entire population. Six studies reported on the availability of healthcare workers. Shortage of specialists in oncology, gynaecology, pathology, and PC was reported in 2 studies ( 25 , 31 ) while limited knowledge of cervical cancer management and PC skills among healthcare workers was reported in 6 studies ( 7 , 18 , 26 , 27 , 31 , 32 ). Financial accessibility High cost of radiotherapy and pathology services, unaffordable by a majority of patients and families was reported in three studies ( 18 , 26 , 31 ). Only 1 study from South Africa found that radiological, radiotherapy, laboratory and consultation services were covered by the state in the public sector, but was still expensive in the private sector ( 7 ). In most studies, patients and their family were poor with limited financial resources ( 4 , 7 , 18 , 26 , 30 , 31 ). Financial hardship was reported in nearly all studies. In Malawi, most households, especially those from the rural areas lived in extreme poverty at ≤ $ 1.89 per day ( 4 ). Families were willing to pay for healthcare, mainly through out-of-pocket expenditure ( 18 , 27 , 31 , 32 ). Some households experienced catastrophic cost as a result, to the extent of dissaving or selling property to cover healthcare costs ( 4 ). In a few studies, basic healthcare costs were covered or subsidised by government ( 4 , 7 , 27 , 32 ), while in some family members shared costs with the government while non-governmental organizations provided support for subsistence needs ( 4 , 31 ). Substantial component of costs incurred by patients and families went towards covering the costs for travel, subsistence and accommodation while seeking or attending treatment in distant centres ( 18 , 27 , 31 ) Acceptability Characteristics of health services were preeminent in all the studies analysed of which most of them revealed scarcity of service points with significant physical distance away from users and associated difficulties accessing the needed services. In addition, the existing facilities were ill equipped with frequent radiotherapy interruptions due to breakdown and stock-outs of essential pain medicine such as morphine ( 18 , 31 ). Overcrowding in the consultation rooms with lack of privacy ( 27 ), healthcare staff with insufficient knowledge and skills to provide disease information that meets the need of the patient and family ( 7 , 18 , 27 , 31 , 32 ), and in some instance over-servicing with multiple radiological and other tests ordered at numerous service delivery points ( 18 ) were some of the challenges reported. Communicating unfavourable information to patients about their illness and addressing emotional needs was also poorly handled by staff in some studies ( 7 , 25 , 27 ). Misconceptions about the nature of cervical cancer, its treatment, and embarrassment on exposure of their body together with the culture of privacy associated with female genitals also prevented the patients from receiving prompt care ( 26 , 27 ). Patient satisfaction with healthcare providers and available services was highlighted in a few studies ( 7 , 27 ). However, other studies revealed dissatisfaction mainly due to long waiting period before treatment ( 26 , 32 ) and high cost of services ( 26 , 31 ). User’s attitudes reported in the studies included cultural beliefs and attitude towards healthcare services visited. Some patients preferred traditional medicine or religious healing to biomedical care due to pressure from significant people in their lives ( 26 , 27 , 31 ) or misconceptions about the cause of their illness ( 27 ). Other patients stayed away from conventional services due to stigma their communities associated with cancer or its symptoms such as offensive vaginal discharge and bleeding, including misconceptions that cancer can be transmitted directly on contact with a patient ( 27 , 32 ). Family responsibilities were also reported to affect access to health care. In one study, widowed, divorced, or separated cervical cancer patients who were the only income earners for their family through formal or informal self-employment could not afford prolonged absence from their jobs while seeking or receiving treatment ( 18 ). Family burden was also a factor in women with more than 3 children who preferred to stay at home to care for their families even though travel vouchers to treatment centres were provided ( 30 ). Another study reports that women’s responsibility of cultivating their farms preceded their need for healthcare and besides they first had to get permission from their husbands to be able to seek treatment ( 31 ). In some households, patients chose to forgo treatment rather than cause financial difficulties to their families ( 4 ). Yet other patients requested health care staff not to reveal their diagnosis for fear of causing anxiety to their family members ( 7 , 27 ). Discussion This systematic review reveals numerous palliative care access challenges, perceived and experienced, by women with advanced cancer of the uterine cervix and/or their caregivers in the LMICs. The challenges are both personal and system-based, emanating from all the four domains of access to quality healthcare such as lack of physical accessibility, unavailability of quality services, poverty and poor affordability, and barriers to acceptance and use of available services by those in need. Despite significant progress made in the development of palliative care in Africa ( 33 , 34 ), services are still not universally integrated into the healthcare system of many countries and remain inconsistent, occurring in isolated centres with limited geographical access by a majority of the population in need ( 35 ). However, limited access as a consequence of geographic location is not unique to the developing world as found in this systematic review. In developed countries such as the United States of America many patients still lack access to PC because of unfavourable geographic location or distance from appropriate treatment facilities ( 36 ). Geographic accessibility involves the physical distance or travel time from the user’s location to the service delivery location. Previous studies support the significant role of the geographic accessibility by demonstrating an inverse relationship between distance and travel time to service delivery points and the use of healthcare services ( 37 , 38 ). Good roads and adequate communication enhances geographic accessibility ( 20 ). The demand for PC services and unmet needs featured prominently in all studies analysed in this review. Accessing the right type of care that meets the demand of those who need it is central to availability ( 20 ). Availability concerns the opportunity to access the right type of healthcare promptly whenever needed. It involves the availability of knowledgeable and skilled healthcare providers, medicines, equipment, acceptable opening hours, and acceptable waiting times ( 20 ). Report from literature reiterate the findings of this study that most cervical cancer patients and their families live in the LMICs where availability of quality palliative care is minimal despite the high demand ( 39 ). Internationally, the American Society of Clinical Oncology (ASCO) recommends that a coordinated system to assess and meet PC needs of patients and family should be made available at all levels of a healthcare system ( 40 ). Available evidence from diverse resource settings suggest that women with cancer of the cervix frequently suffer from severe complex refractory symptoms not readily relieved by basic PC ( 41 ). Addressing these symptoms require more advanced procedures such as palliative external beam radiotherapy to control vaginal bleeding and discharge, advanced medical therapies, nerve block for intractable neuropathic pelvic pain, surgical procedures for bowel obstruction, and psycho-oncology to manage severe or refractory anxiety and depression ( 41 ). Identifying needs of patients and their families, communication, assessment and treatment of pain and other symptoms, and referral for management of complex distressing symptoms is recognised as a basic requirement even at lower levels of care ( 40 , 42 ). Many African countries still lack the ability to provide quality PC due to inadequate infrastructure, staff shortages, low doctor-patient ratio and paucity of trained PC specialists ( 43 ) compounded by insufficient supply of morphine, an opioid considered by World Health Organisation as an essential medicine in treatment of pain, including cancer pain ( 44 ). Poverty, loss of income and inability to afford basic subsistence and healthcare-related costs was a recurring observation in the review. Financial accessibility includes cost and prices of services, cost of time, users’ resources, and users’ willingness to pay for the services ( 20 ). Distance to health facilities has a significant bearing on the affordability especially for rural dwelling population incurring travelling, food and accommodation costs in addition to the direct cost of treatment. Unlike in the developed countries where medical insurance covers healthcare expenses ( 45 – 47 ), there is low medical insurance coverage in most LMICS and cost of treatment for people with serious illness is borne by patients and family mainly as out-of-pocket expenses ( 38 , 44 , 48 ). For instance, in South Africa only 16.4% of the population is covered by a medical aid ( 49 ). In an instance of extreme poverty, a proposal has been made for accessible social support for any patient in need of PC and for their main caregiver to include transportation vouchers, cash payments, food packages, and other types of in-kind support ( 48 ). Acceptability of heath care services involves factors such as characteristics of health services, and user’s attitudes and expectations ( 20 ). It encompasses how satisfied users are with the services provided. It also depends on care receiver’s attitude and cultural beliefs. Factors such as opening hours, geographic distance, availability of medicines, staff complement, attitude and knowledge, and costs, are some of the factors that determine acceptability of an available PC service for patients and their family. In this review, patients and family were not satisfied with the services as s a result of difficulties they encountered. The difficulties varied from long distance of travel to perception of poor communication with the staff. However, other factors were related to socio-cultural beliefs and influence from significant others. Lack of knowledge and awareness of available services, distrust of the healthcare system, traditional gender roles and language barriers have been reported elsewhere as factors that limit utilization of health services ( 50 ). Lack of knowledge has been reported to hinder the use of PC services in developed countries also ( 51 ). Community belief in the superiority and effectiveness of traditional medicine in treatment of cervical cancer and beliefs in spiritual healing also hinder utilization of biomedical health services in some LMICs ( 27 , 52 , 53 ). STRENGTHS To the researchers’ knowledge this is the first systematic review that has looked into access to PC in women with advanced cervical cancer and their families in the LMICs. The use of thematic synthesis has the potential to draw conclusion based on common elements from studies of diverse designs ( 24 ). This may allow for generating future hypothesis that may form a structure for future research in this field to investigate culturally sensitive and acceptable PC provision. LIMITATIONS As only studies published in English were considered in the inclusion criteria, it is possible that there are studies published in other languages that could have been included also. Other limitations could be that the included studies used different study designs (qualitative, quantitative, mixed methods) and different outcomes or no validated outcome measures as such could not allow for meta-analysis. Additionally the relatively small number of studies included in the review may have limited the reliability of conclusions that could be drawn. IMPLICATION FOR PRACTICE Understanding the lived experiences and factors that primarily concern cervical cancer patients and their caregivers with respect to accessing PC services creates a better understanding of barriers, facilitators, and measurable factors that can act as basis of remedial actions to improve access and enable the development and implementation of PC models that specifically address needs of those affected. Establishing adequately staffed and equipped facilities within reach of the majority of the population served will help bring services close to the people. Conclusion Findings of this systematic review suggests that palliative care for cervical cancer patients is still not universally available especially in the LMICs. Cervical cancer patients often suffer significant distressing symptoms which could be alleviated by the provision of effective palliative care. As the development of the practice of palliative care gradually improves in the developing countries, concerted effort must be made to enhance access to cervical cancer patients and their families so as to improve their quality of life and disease experience. Declarations Data availability statement The authors confirm that the data supporting the findings of this study are available within the article and/or its related files. Any other information that support the findings of this study are available from the corresponding author, [F.O], upon reasonable request. Ethics approval and consent to participate: Not applicable Consent for publication: Not applicable Availability of data and materials: The data supporting the findings of this study are available within the article and/or its related files. Any other materials are available from the corresponding author, [F.O], upon request Competing interest: All authors declare no competing interest Funding: None Authors’ contributions: F.O., T.M., P.B. and J.W conceived the research. F.O., P.B. and J.W contributed to the design of the study and developed the search terms. F.O. and P.B completed database searches. F.O., P.B. and J.W. reviewed all titles, abstracts and full-text studies. F.O. extracted data from all studies and synthesized the data. P.B. and J.W. reviewed data synthesis and discussed with F.O. to reach a consensus on final data. F.O. drafted the manuscript. All authors read, revised and approved the final manuscript. Acknowledgements : None References Arbyn M, Weiderpass E, Bruni L, de Sanjosé S, Saraiya M, Ferlay J, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. The Lancet Global Health. 2020;8(2):e191-e203. Krakauer EL, Kwete X, Kane K, Afshan G, Bazzett-Matabele L, Bien-Aimé DDR, et al. Cervical cancer-associated suffering: Estimating the palliative care needs of a highly vulnerable population. JCO Global Oncology. 2021;7:862-72. Paul R, Musa G, Chungu H. Prevalence of depression among cervical cancer patients seeking treatment at the cancer diseases hospital. IOSR J Dent Med Sci Ver XI. 2016;15(6):2279-861. Bates MJ, Gordon MR, Gordon SB, Tomeny EM, Muula AS, Davies H, et al. Palliative care and catastrophic costs in Malawi after a diagnosis of advanced cancer: a prospective cohort study. The Lancet Global Health. 2021;9(12):e1750-e7. Krakauer EL, Kane K, Kwete X, Afshan G, Bazzett-Matabele L, Ruthnie Bien-Aimé DD, et al. Essential Package of Palliative Care for Women With Cervical Cancer: Responding to the Suffering of a Highly Vulnerable Population. JCO Glob Oncol. 2021;7:873-85. Miller BE, Pittman B, Strong C. Gynecologic cancer patients' psychosocial needs and their views on the physician's role in meeting those needs. International Journal of Gynecological Cancer. 2003;13(2):111-9. Maree JE, Langley G, Nqubezelo L. "Not a nice experience, not at all": Underprivileged women's experiences of being confronted with cervical cancer. Palliat Support Care. 2015;13(2):239-47. Allende-Perez S, Dominguez-Ocadio G, Velez-Salas V, Isla-Ortiz D, Peña-Nieves A, Verastegui E. Snapshot of symptoms of advanced cervical cancer patients referred to the palliative care service in a cancer center in Mexico. Int J Gynaecol Obstet. 2021;153(2):335-9. Radbruch L, De Lima L, Knaul F, Wenk R, Ali Z, Bhatnaghar S, et al. Redefining palliative care—A new consensus-based definition. Journal of pain and symptom management. 2020;60(4):754-64. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. New England Journal of Medicine. 2010;363(8):733-42. Temel JS, Greer JA, Admane S, Gallagher ER, Jackson VA, Lynch TJ, et al. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non–small-cell lung cancer: Results of a randomized study of early palliative care. Journal of clinical oncology. 2011;29(17):2319-26. El-Jawahri A, Greer JA, Temel JS. Does palliative care improve outcomes for patients with incurable illness? A review of the evidence. Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. 2011. Teno JM, Casarett D, Spence C, Connor S. It is “too late” or is it? Bereaved family member perceptions of hospice referral when their family member was on hospice for seven days or less. Journal of pain and symptom management. 2012;43(4):732-8. Hui D, Kim S-H, Kwon JH, Tanco KC, Zhang T, Kang JH, et al. Access to palliative care among patients treated at a comprehensive cancer center. The oncologist. 2012;17(12):1574. Abel J, Kellehear A, Mills J, Patel M. Access to palliative care reimagined. Future Healthcare Journal. 2021;8(3):e699. Alkhudairi HM. General public awareness, knowledge, and beliefs toward palliative care in a Saudi population. Journal of Nature and Science of Medicine. 2019;2(1):48. Pinto E, Gonçalves F, Sacarlal J, Castro L, Rego G. Pain management in cancer patients in the main hospitals in Mozambique. Ann Palliat Med. 2021;10(4):4069-79. Tapera O, Nyakabau AM. Limited knowledge and access to palliative care among women with cervical cancer: an opportunity for integrating oncology and palliative care in Zimbabwe. BMC Palliative Care. 2020;19(1):1-9. Islam JY, Deveaux A, Previs RA, Akinyemiju T. Racial and ethnic disparities in palliative care utilization among gynecological cancer patients. Gynecol Oncol. 2021;160(2):469-76. Peters DH, Garg A, Bloom G, Walker DG, Brieger WR, Hafizur Rahman M. Poverty and access to health care in developing countries. Annals of the new York Academy of Sciences. 2008;1136(1):161-71. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Systematic reviews. 2021;10(1):1-11. Erdis E. A rare metastatic region of cervix cancer; the brain. J Pak Med Assoc. 2014;64(1):89-90. O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Academic medicine. 2014;89(9):1245-51. Lucas PJ, Baird J, Arai L, Law C, Roberts HM. Worked examples of alternative methods for the synthesis of qualitative and quantitative research in systematic reviews. BMC medical research methodology. 2007;7(1):1-7. Tapera O, Dreyer G, Nyakabau AM, Kadzatsa W, Stray-Pedersen B, Hendricks SJH. Model strategies to address barriers to cervical cancer treatment and palliative care among women in Zimbabwe: a public health approach. BMC women's health. 2021;21(1):1-11. Tapera O, Dreyer G, Kadzatsa W, Nyakabau AM, Stray-Pedersen B, Hendricks SJH. Determinants of access and utilization of cervical cancer treatment and palliative care services in Harare, Zimbabwe. BMC Public Health. 2019;19(1):N.PAG-N.PAG. Kebede BG, Abraha A, Andersson R, Munthe C, Linderholm M, Linderholm B, et al. Communicative challenges among physicians, patients, and family caregivers in cancer care: An exploratory qualitative study in Ethiopia. PLoS ONE. 2020;15(3). Tapera O, Kadzatsa W, Nyakabau AM, Mavhu W, Dreyer G, Stray-Pedersen B, et al. Sociodemographic inequities in cervical cancer screening, treatment and care amongst women aged at least 25 years: evidence from surveys in Harare, Zimbabwe. BMC Public Health. 2019;19(1):428. Miranda B, Vidal SA, Mello MJ, Lima JT, Rêgo JC, Pantaleão MC, et al. Cancer patients, emergencies service and provision of palliative care. Rev Assoc Med Bras (1992). 2016;62(3):207-11. Dutta S, Biswas N, Muhkherjee G. Evaluation of Socio-demographic Factors for Non-compliance to Treatment in Locally Advanced Cases of Cancer Cervix in a Rural Medical College Hospital in India. Indian Journal of Palliative Care. 2013;19(3):158-65. Mwaka AD, Wabinga HR, Mayanja-Kizza H. Mind the gaps: a qualitative study of perceptions of healthcare professionals on challenges and proposed remedies for cervical cancer help-seeking in post conflict northern Uganda. BMC Family Practice. 2013;14:193. van Schalkwyk SL, Maree JE, Wright SC. Cervical cancer: the route from signs and symptoms to treatment in South Africa. Reprod Health Matters. 2008;16(32):9-17. Rhee JY, Garralda E, Torrado C, Blanco S, Ayala I, Namisango E, et al. Palliative care in Africa: a scoping review from 2005–16. The Lancet Oncology. 2017;18(9):e522-e31. Lynch T, Connor S, Clark D. Mapping levels of palliative care development: a global update. Journal of pain and symptom management. 2013;45(6):1094-106. Powell RA, Harding R, Namisango E, Katabira E, Gwyther L, Radbruch L, et al. Palliative care research in Africa: An overview. European Journal of Palliative Care. 2013;20(4):162-7. Ferrell BR, Temel JS, Temin S, Alesi ER, Balboni TA, Basch EM, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline update. Journal of Clinical Oncology. 2017;35(1):96-112. Hjortsberg C. Why do the sick not utilise health care? The case of Zambia. Health economics. 2003;12(9):755-70. Hjortsberg C, Mwikisa C. Cost of access to health services in Zambia. Health policy and planning. 2002;17(1):71-7. Organization WH. Global Atlas of Palliative Care 2nd Edition. London: Worldwide Palliative Care Alliance; 2020. Osman H, Shrestha S, Temin S, Ali ZV, Corvera RA, Ddungu HD, et al. Palliative care in the global setting: ASCO resource-stratified practice guideline. Journal of global oncology. 2018;4:1-24. Krakauer EL, Kane K, Kwete X, Afshan G, Bazzett-Matabele L, Ruthnie Bien-Aimé DD, et al. Augmented Package of Palliative Care for Women With Cervical Cancer: Responding to Refractory Suffering. JCO Global Oncology. 2021;7:886-95. Downing J, Grant L, Leng M, Namukwaya E. Understanding models of palliative care delivery in sub-Saharan Africa: learning from programs in Kenya and Malawi. Journal of Pain and Symptom Management. 2015;50(3):362-70. Mwangi-Powell F. APCA's role in the development of palliative care in Africa. Progress in Palliative Care. 2012;20(4):230-3. Stefan DC. Cancer care in Africa: an overview of resources. Journal of Global Oncology. 2015;1(1):30-6. Brown CM, Richards KM, Vohra Y, Kanu C, Stevens L, Sasane R, et al. Evaluation of access to care issues in patients with breast cancer. Journal of Medical Economics. 2021;24(1):38-45. Brown CM, Kanu C, Richards KM, Stevens L, Sasane R, McAneny B. Exploring access to care from the perspective of patients with breast cancer: A qualitative study. Cancer Medicine. 2022. Stevenson DG. Growing pains for the Medicare hospice benefit. N Engl J Med. 2012;367(18):1683-5. Krakauer EL, Kwete X, Verguet S, Arreola-Ornelas H, Bhadelia A, Mendez O, et al. Palliative care and pain control. Disease Control Priorities: Improving Health and Reducing Poverty 3rd edition. 2017. Stats S. Statistical release P0318: General Household Survey 2018. Pretoria: ISIbalo House. 2020. Thummapol O, Park T, Barton S. Exploring health services accessibility by indigenous women in Asia and identifying actions to improve it: a scoping review. Ethnicity & health. 2020;25(7):940-59. Kumar P, Casarett D, Corcoran A, Desai K, Li Q, Chen J, et al. Utilization of supportive and palliative care services among oncology outpatients at one academic cancer center: determinants of use and barriers to access. Journal of palliative medicine. 2012;15(8):923-30. Mwaka AD, Okello ES, Orach CG. Barriers to biomedical care and use of traditional medicines for treatment of cervical cancer: An exploratory qualitative study in northern Uganda. European Journal of Cancer Care. 2015;24(4):503-13. Mwaka AD, Mangi SP, Okuku FM. Use of traditional and complementary medicines by cancer patients at a national cancer referral facility in a low-income country. European Journal of Cancer Care. 2019;28(6). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 Sep, 2023 Read the published version in BMC Palliative Care → Version 1 posted Editorial decision: Major revision 03 Apr, 2023 Reviews received at journal 26 Mar, 2023 Reviewers agreed at journal 15 Mar, 2023 Reviewers invited by journal 15 Mar, 2023 Editor invited by journal 24 Jan, 2023 Editor assigned by journal 30 Dec, 2022 Submission checks completed at journal 29 Dec, 2022 First submitted to journal 24 Dec, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2412007","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":163562304,"identity":"9b206457-eaa2-4985-b253-a840cfacff2c","order_by":0,"name":"Francis Ooko","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIie3QvQrCMBSG4a8U7HLQNVKpt5Ag+AOKt6IIOglOjkUQ6tIL8EqcKwFdxLmjIDg56CIdHDxFEKfY0SHvcMjycJIANtsf5i3yKfNRAm5o/yaUfBFnDVGU4E1cKkR8fTllsxAVLxqee5FAZZW4t8xEyuOWiqVGNd7pxpSJOAygYgPpE5o+ZAKZTiI/J0iBAZm2kPdgEr5Jh0mdyfZpJJRvcZmMd77DRKZwluYtNK/yW4jfMlLxUZA6DJduzXyxjcieYcA/pk7ZvBsEe63vVwP50K+DsygAbDabzWbqBQnEPRh6ix5lAAAAAElFTkSuQmCC","orcid":"","institution":"University of Limpopo","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Francis","middleName":"","lastName":"Ooko","suffix":""},{"id":163562305,"identity":"daa1cba8-662f-4dea-a07d-818a49af8f76","order_by":1,"name":"Tebogo Mothiba","email":"","orcid":"","institution":"University of Limpopo","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tebogo","middleName":"","lastName":"Mothiba","suffix":""},{"id":163562306,"identity":"40ce9455-520a-4168-8478-6155064106d1","order_by":2,"name":"Peter Van Bogaert","email":"","orcid":"","institution":"University of Antwerp","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Peter","middleName":"Van","lastName":"Bogaert","suffix":""},{"id":163562307,"identity":"af8be8b2-4c8b-4bc9-ac15-7e2940750714","order_by":3,"name":"Johan Wens","email":"","orcid":"","institution":"University of Antwerp","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Johan","middleName":"","lastName":"Wens","suffix":""}],"badges":[],"createdAt":"2022-12-24 16:29:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2412007/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2412007/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12904-023-01263-9","type":"published","date":"2023-09-20T15:01:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":31107959,"identity":"8d92a1b1-cf70-4df2-9e90-42279d8e9cc4","added_by":"auto","created_at":"2023-01-04 17:40:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":64497,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual model for access to quality healthcare services in developing countries. Adapted with permission from Peters \u003cem\u003eet al\u003c/em\u003e. (20)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-2412007/v1/318b121026d5dec54fff622f.png"},{"id":31109567,"identity":"b33da832-c42a-484a-88cd-106008aae615","added_by":"auto","created_at":"2023-01-04 17:48:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":238437,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Flow diagram. Adapted from Page \u003cem\u003eet al\u003c/em\u003e (21)\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-2412007/v1/8850d3702208752460298e30.png"},{"id":43640763,"identity":"8cd452d6-946e-4837-b3fc-ae3fd52fc599","added_by":"auto","created_at":"2023-09-25 15:09:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":794472,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2412007/v1/df45885b-211d-4a68-9c37-96f99d9afac6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAccess to Palliative Care in Patients with Advanced Cancer of the Uterine Cervix in the Low- and Middle-Income Countries: A Systematic Review\u003c/p\u003e","fulltext":[{"header":"Introduction And Background","content":"\u003cp\u003eCervical cancer is the second most prevalent cancer in women in South Africa. Recent data reveal that 6945 cases of cervical cancer were diagnosed in 2019 being 15.85% of all histologically diagnosed cancers (Cancer Statistics NICD, 2022: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nicd.ac.za\u003c/span\u003e\u003cspan address=\"https://www.nicd.ac.za\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), with an estimated mortality of 19.6 per 100000 population (Global Cancer Observatory, 2022: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://gco.iarc.fr\u003c/span\u003e\u003cspan address=\"https://gco.iarc.fr\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). Therefore, cervical cancer is a public health problem in South Africa.\u003c/p\u003e \u003cp\u003eAlthough cervical cancer is a preventable disease, it still causes significant morbidity and mortality in women, particularly in the low- and middle-income countries (LMICs) where up to 88% of all global cervical cancer related deaths occur (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). High prevalence of symptoms such as vaginal discharge, vaginal bleeding, and spiritual distress are found in women living with or who die from cervical cancer (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Clinically evident anxiety, depressed mood, sexual dysfunction, and abandonment are common among these patients (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) in addition to financial distress particularly among patients and their families living in less developed countries (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Globally, approximately 2.6\u0026nbsp;million patients living with and 250 000 who died from cervical cancer in 2017 reported a combination of moderate to severe physical, psychological, social, and spiritual distress of whom 85% were in the LMICs (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Nevertheless, many other studies worldwide report significant unmet physical, psychosocial, and spiritual needs among cervical patients and their families (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Such report exemplify the need to provide palliative care (PC) alongside specific cancer therapy in patients with advanced cancer of the uterine cervix to alleviate distress and achieve for them good quality of life (QoL). Therefore, access to PC according to an individual\u0026rsquo;s need is critical in patients with cervical cancer and their families throughout the disease trajectory.\u003c/p\u003e \u003cp\u003ePalliative care is \u0026ldquo;the active holistic care of individuals across all ages with serious health-related suffering due to severe illness and especially of those near the end of life. It aims to improve the quality of life of patients, their families, and their caregivers\u0026rdquo;(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Earlier studies provide evidence that provision of PC alongside usual oncologic care significantly improves QoL of patients and their families (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). However, access to PC is not universally guaranteed for all in need due to complex factors such as poor referral system, lack of physical facilities, poor general public awareness, negative beliefs, and other sociocultural factors (\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Furthermore, lack of PC knowledge and skills have been reported among a large number of healthcare professionals in many LMICs (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Other factors known to affect access include geographic distance from health facilities, lack of medicine, poor affordability of services, lack of information on the specific disease, and poor healthcare professionals\u0026rsquo; attitude, knowledge and skills (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDisparities in access to PC by women with cervical cancer from different resource settings have been studied (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). We conducted this systematic review to gain a better understanding of barriers, facilitators, and measurable factors that can act as basis of remedial actions for improving access to PC by cervical cancer patients and their families living in the LMICs. In particular, this review aims to identify the physical availability of PC facilities and the enablers and barriers to utilization of these services guided by the conceptual model of access to quality healthcare in developing countries (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe review question, PICOTS, and inclusion/exclusion criteria are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudy eligibility criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReview question: What factors are important for access to palliative care by women with advanced cancer of the uterine cervix in the low- and middle-income countries?\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePopulation\u003c/b\u003e: Women diagnosed with advanced cancer of the uterine cervix (advanced cancer being defined as any of the following: FIGO stage IB to IV; or presence of distant metastasis; or cancer that is life limiting; or cancer with prognosis of 6 to 12 months); Age 19 years and older (this age group defines and adult); and/or family or caregiver of the patient\u003c/p\u003e \u003cp\u003e\u003cb\u003eIntervention(s), exposure (s\u003c/b\u003e):Any care given to relieve distressing symptoms, \u0026ndash; physical or otherwise, before, alongside, or after the disease specific treatment, such as pain management, vaginal bleeding, vaginal discharge, and psychosocial support\u003c/p\u003e \u003cp\u003e\u003cb\u003eComparator\u003c/b\u003e: Palliative care in any form is not provided\u003c/p\u003e \u003cp\u003e\u003cb\u003eOutcome\u003c/b\u003e: Specified or unspecified aspects of palliative care outcomes and/or associated outcomes such as problems or facilitators of access; physical or psychosocial needs; cultural factors; communication of needs \u0026ndash; with family, healthcare staff, or other patients; underserved/minority groups \u0026ndash; ethnic or socio-economic factors\u003c/p\u003e \u003cp\u003e\u003cb\u003eOutcome measures\u003c/b\u003e: Qualitative and/or quantitative with regard to availability, affordability, physical accessibility and acceptability of the care; primary palliative care use - access, provision, implementation, integration\u003c/p\u003e \u003cp\u003e\u003cb\u003eSetting\u003c/b\u003e: Home, hospice facility, outpatient oncology setting, outpatient non-oncology setting, in-patient oncology setting, and inpatient non-oncology setting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInclusion criteria\u003c/b\u003e :\u003c/p\u003e \u003cp\u003e\u0026bull; Original research involving data on adult women with advanced stage uterine cervical cancer, and/or their caregivers\u003c/p\u003e \u003cp\u003e\u0026bull; Studies of cancer patients, or gynecological cancer patients with an arm including patients with cervical cancer\u003c/p\u003e \u003cp\u003e\u0026bull; Any care intended to relieve distressing symptoms\u003c/p\u003e \u003cp\u003e\u0026bull; Outcome includes qualitative or quantitative measures\u003c/p\u003e \u003cp\u003e\u0026bull; Published anytime from inception of database\u003c/p\u003e \u003cp\u003e\u0026bull; Study design can include experimental studies (randomized controlled trials, other types of trials), observational studies (cohort studies, case-control studies, controlled and uncontrolled pre/post studies), retrospective studies, cross-sectional studies, qualitative, quantitative, mixed-method studies\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExclusion criteria\u003c/b\u003e :\u003c/p\u003e \u003cp\u003e\u0026bull; Trials of medications or medical procedures related to primary cancer therapy\u003c/p\u003e \u003cp\u003e\u0026bull; Case reports, editorials, letters to the editor, commentaries, historical perspectives, reviews, gray literature including guidelines and protocols, newspaper articles, social media\u003c/p\u003e \u003cp\u003e\u0026bull; Review articles (not systematic review)\u003c/p\u003e \u003cp\u003e\u0026bull; Diseases other than cancer of cervix\u003c/p\u003e \u003cp\u003e\u0026bull; Studies reporting factors not expressed by patients or caregivers\u003c/p\u003e \u003cp\u003e\u0026bull; Papers published in any language other than English\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe study proposal is registered in the International Prospective Register of Systematic Reviews (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022310163\u003c/span\u003e\u003cspan address=\"https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022310163\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e)\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSearch strategy\u003c/h2\u003e \u003cp\u003eThe updated Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) 2020 statement guideline for systematic reviews (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) was followed to standardize the search and reporting process. Literature search was conducted in six electronic databases (Cumulative Index of Nursing and Allied Literature [CINAHL], Cochrane Central Register of Controlled Trials [CENTRAL], MEDLINE, PubMed, PsychINFO and Scopus) in May 2022. Advanced Boolean search strategy with at least the following terms using controlled vocabulary and free text was used: (((woman OR women OR female*) AND (neoplasm* OR oncology OR cancer OR tumo?r or malignanc*)) AND (palliative care OR end of life care OR terminal care OR hospice care OR palliati*) AND (cervi*)). Second line of search among records after screening of titles and abstract done using search terms: access* OR availability OR available OR barriers OR utilization OR utilize*. Additional hand searches of the reference lists of the included studies was also done to identify relevant articles not initially picked up by electronic search. Overview of the search strategy is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy selection\u003c/h2\u003e \u003cp\u003eSearch results were uploaded onto EndNote\u0026trade;20 to identify and remove duplicates, and perform further screening. The remaining articles after deduplication were screened for eligibility based on the criteria in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Two authors (F.O. and P.B) screened the titles, abstracts, and full-text articles for eligibility, and reached a consensus on the included articles.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eQuality appraisal\u003c/h2\u003e \u003cp\u003eDue to heterogeneity of the selected articles, different methods were used to assess the methodological quality of the included studies. The Strengthening Reporting of Observational Studies in Epidemiology (STROBE) statement (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) was used for observational studies, whereas Standards for Reporting Qualitative Research (SRQR) checklist (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) was used for qualitative studies. Studies that scored at least 75% in the respective checklists were considered of good methodological quality and included in the final analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData extraction\u003c/h2\u003e \u003cp\u003eSelected articles were heterogeneous with both quantitative and qualitative designs thus not allowing either meta-analysis of the quantitative studies or meta-synthesis of the qualitative studies. A textual narrative approach was used to synthesize the different types of research evidence for qualitative, quantitative, and mixed-method studies (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). For each included article, the first author (F.O) extracted data into a preformatted table. Data fields included information of authors, publication year, country, study aims, design, participants, themes, and study findings. Findings were sorted and grouped under themes describing domains of access to healthcare in developing countries (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)[Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]. The third author (P.B) checked the results and discussed any changes and revisions until consensus was reached.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eResults of the study selection process are reported according to the PRISMA statement updated guidelines (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Excluding duplicates, database searches produced 1154 records (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Following title and abstract screening 61 articles remained and were downloaded for full-text screening, out of which 10 articles met final inclusion criteria and were analysed. Three of these articles (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) emanated from one large study with each article reporting on participant groups investigated with different experimental designs. Study characteristics and findings are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of study design, aims and objectives, participants, themes and findings\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor, Year, Country\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAims\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFindings\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBates \u003cem\u003eet al.\u003c/em\u003e(4), 2021, Malawi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvestigate whether total household cancer-related health care costs over 6 months after a diagnosis of advanced cancer are associated with a patient receiving palliative care, and the experience of catastrophic costs in the household\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProspective cross-sectional study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e150 households with 150 patients with advanced cancer, and 121 family caregivers.\u003c/p\u003e \u003cp\u003eAt 6 months 89 households with 89 patients and 64 caregivers were evaluable, out of which 60 patients (67%) had cervical cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSocially active people with responsibility\u003c/p\u003e \u003cp\u003ePeople live in rural areas\u003c/p\u003e \u003cp\u003eLimited facilities for cancer care countrywide\u003c/p\u003e \u003cp\u003eAccess available but limited\u003c/p\u003e \u003cp\u003eLimited support. Patients depend on own resources for some needs\u003c/p\u003e \u003cp\u003ePeople in urban areas within 50 km radius more likely to access services\u003c/p\u003e \u003cp\u003eMajority of households living in extreme poverty\u003c/p\u003e \u003cp\u003eMost patients/households experienced financial hardship\u003c/p\u003e \u003cp\u003eMore non-PC recipient households used a larger proportion of annual income on healthcare\u003c/p\u003e \u003cp\u003eFewer households receiving PC experienced catastrophic costs\u003c/p\u003e \u003cp\u003eSome households chose to forgo treatment rather than have catastrophic costs\u003c/p\u003e \u003cp\u003eMore rural households associated with catastrophic costs\u003c/p\u003e \u003cp\u003eNon-PC recipient households associated with dissaving\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMedian patient age was 50 years (IQR 40\u0026ndash;57); 47 (73%) of caregivers were female\u003c/p\u003e \u003cp\u003e48 households were rural\u003c/p\u003e \u003cp\u003eCancer care and PC facilities only available in the 4 tertiary hospitals\u003c/p\u003e \u003cp\u003eFree treatment offered supported by Government and charitable groups\u003c/p\u003e \u003cp\u003eLimited additional needs supported by charities\u003c/p\u003e \u003cp\u003e9 households received PC while 70 did not\u003c/p\u003e \u003cp\u003e89 households lived in extreme poverty (\u0026le; \u003cspan\u003e$\u003c/span\u003e1.89 per day)\u003c/p\u003e \u003cp\u003eMedian annual household income before illness:\u003c/p\u003e \u003cp\u003e\u0026bull; Overall - \u003cspan\u003e$\u003c/span\u003e204 (IQR 84\u0026ndash;660)\u003c/p\u003e \u003cp\u003e\u0026bull; PC recipients - \u003cspan\u003e$\u003c/span\u003e537 (07-821)\u003c/p\u003e \u003cp\u003e\u0026bull; Non-PC recipients- \u003cspan\u003e$\u003c/span\u003e179(82\u0026ndash;537)\u003c/p\u003e \u003cp\u003eHousehold healthcare costs after 6 months:\u003c/p\u003e \u003cp\u003e\u0026bull; PC patients - \u003cspan\u003e$\u003c/span\u003e50 (11\u0026ndash;101)\u003c/p\u003e \u003cp\u003eDirect costs \u003cspan\u003e$\u003c/span\u003e6 (4\u0026ndash;26)\u003c/p\u003e \u003cp\u003eIndirect costs \u003cspan\u003e$\u003c/span\u003e36 (5\u0026ndash;56)\u003c/p\u003e \u003cp\u003e\u0026bull; Non-PC patients - \u003cspan\u003e$\u003c/span\u003e55 (28\u0026ndash;91)\u003c/p\u003e \u003cp\u003eDirect costs \u003cspan\u003e$\u003c/span\u003e12 (0\u0026ndash;21)\u003c/p\u003e \u003cp\u003eIndirect costs \u003cspan\u003e$\u003c/span\u003e33 (13\u0026ndash;56)\u003c/p\u003e \u003cp\u003eTotal healthcare cost as a proportion of total income\u003c/p\u003e \u003cp\u003e\u0026bull; PC patients \u0026minus;\u0026thinsp;0.086 (0.037\u0026ndash;0.579)\u003c/p\u003e \u003cp\u003e\u0026bull; Non PC-patients \u0026minus;\u0026thinsp;0.278 (0.085\u0026ndash;0.692), p\u0026thinsp;=\u0026thinsp;0.126\u003c/p\u003e \u003cp\u003eHouseholds experiencing catastrophic costs\u003c/p\u003e \u003cp\u003e\u0026bull; PC \u0026ndash; 9 of 19 (47%)\u003c/p\u003e \u003cp\u003eNon-PC \u0026minus;\u0026thinsp;48 of 70 (69%), p\u0026thinsp;=\u0026thinsp;0.109\u003c/p\u003e \u003cp\u003e\u0026bull; Rural \u0026ndash; 37 of 48 (77%)\u003c/p\u003e \u003cp\u003eUrban \u0026ndash; 20 of 41 (49%), p\u0026thinsp;=\u0026thinsp;0.008\u003c/p\u003e \u003cp\u003eMedian dissaving at 6 months per household\u003c/p\u003e \u003cp\u003e\u0026bull; PC - \u003cspan\u003e$\u003c/span\u003e11 (0\u0026ndash;36)\u003c/p\u003e \u003cp\u003eNon-PC - \u003cspan\u003e$\u003c/span\u003e34 (14\u0026ndash;75), p\u0026thinsp;=\u0026thinsp;0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTapera \u003cem\u003eet al.\u003c/em\u003e (25), 2021\u003c/p\u003e \u003cp\u003eZimbabwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo investigate some key and contextual strategies which could be implemented to improve access and uptake of cervical cancer treatment and palliative care by women\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQualitative inquiry as part of a sequential explanatory mixed method study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84 purposively enrolled participants:\u003c/p\u003e \u003cp\u003e16 in-depth interviews with cervical cancer patients/caregivers and 20 key informants (health workers, policy makers and spiritual leaders\u003c/p\u003e \u003cp\u003e6 focus group discussions of cervical cancer patients, caregivers and male partners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePoor affordability\u003c/p\u003e \u003cp\u003eOut-of-pocket expenditure on healthcare costs\u003c/p\u003e \u003cp\u003ePoor access to definitive care\u003c/p\u003e \u003cp\u003eTreatment unavailable to people in rural areas\u003c/p\u003e \u003cp\u003eHigh costs of transport\u003c/p\u003e \u003cp\u003eAccommodation costs\u003c/p\u003e \u003cp\u003eLoss of income for patients and family members\u003c/p\u003e \u003cp\u003eLimited knowledge and awareness by healthcare workers (HCW)\u003c/p\u003e \u003cp\u003eAlternative care due to financial hardship\u003c/p\u003e \u003cp\u003eLimited information on disease\u003c/p\u003e \u003cp\u003eLimited resources\u003c/p\u003e \u003cp\u003eEquipment unavailable\u003c/p\u003e \u003cp\u003eSkills deficiency; no team approach to patient care\u003c/p\u003e \u003cp\u003eTreatment guidelines and guidance unavailable\u003c/p\u003e \u003cp\u003eUnmet needs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTreatment associated with high cost which most patients could not afford\u003c/p\u003e \u003cp\u003eMost patients relied on out of pocket funding for their treatment\u003c/p\u003e \u003cp\u003eMost patients could not afford cost of histopathology tests to confirm cancer before treatment decision is made\u003c/p\u003e \u003cp\u003eServicers are centralized in major cities out of reach of most rural people\u003c/p\u003e \u003cp\u003eCost of transport to reach centralized services unaffordable Cost of accommodation while attending services in cities especially for out of town rural people\u003c/p\u003e \u003cp\u003ePatients and accompanying family members unable to earn income\u003c/p\u003e \u003cp\u003eHealthcare professionals not well informed about cervical cancer\u003c/p\u003e \u003cp\u003eSeeking alternative medicine (traditional and spiritual healers) as people cannot afford conventional treatment for cervical cancer\u003c/p\u003e \u003cp\u003ePatients and families are not given adequate information about their illness and treatment available to them\u003c/p\u003e \u003cp\u003eFew cancer treatment and palliative care centres\u003c/p\u003e \u003cp\u003eFrequent equipment breakdown at the few facilities\u003c/p\u003e \u003cp\u003eDifferent disciplines required for PC such as social workers and psychologists are lacking\u003c/p\u003e \u003cp\u003eGuidelines for patient referral and treatment to ensure uniformity of care not available\u003c/p\u003e \u003cp\u003ePatient and family emotional, spiritual, information and communication needs not met due to deficiency of soft skills among HCW\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTapera \u003cem\u003eet al\u003c/em\u003e.(18), 2020 Zimbabwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo investigate palliative care knowledge and access among women with cervical cancer in Harare, Zimbabwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA sequential explanatory mixed method study with descriptive cross-sectional surveys as a major study and qualitative inquiry as a minor study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e134 women with cervical cancer\u003c/p\u003e \u003cp\u003e78 HCW involved in cervical cancer screening, treatment and palliative care\u003c/p\u003e \u003cp\u003e16 in-depth interviews\u003c/p\u003e \u003cp\u003e48 participants in 6 FGD\u003c/p\u003e \u003cp\u003e20 key informant interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSocially active people with responsibilities\u003c/p\u003e \u003cp\u003eAdvanced stage cancer\u003c/p\u003e \u003cp\u003eModerate level of education\u003c/p\u003e \u003cp\u003eUnemployment rate is high\u003c/p\u003e \u003cp\u003eNo intimate partners\u003c/p\u003e \u003cp\u003eLow palliative care\u003c/p\u003e \u003cp\u003eAvailability of PC skills among HCW\u003c/p\u003e \u003cp\u003eAdequate training and guidance\u003c/p\u003e \u003cp\u003ePoor PC referral\u003c/p\u003e \u003cp\u003eAvailability of medicine\u003c/p\u003e \u003cp\u003eLimited PC knowledge among patients and HCW\u003c/p\u003e \u003cp\u003eLimited access to PC\u003c/p\u003e \u003cp\u003ePatient misconception about PC\u003c/p\u003e \u003cp\u003eMisconception and/or limited knowledge of cervical cancer\u003c/p\u003e \u003cp\u003eMisconception of PC\u003c/p\u003e \u003cp\u003eLow affordability of medicines\u003c/p\u003e \u003cp\u003ePoor implementation of PC policy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean age of patients 52 years SD\u0026thinsp;\u0026plusmn;\u0026thinsp;12\u003c/p\u003e \u003cp\u003eCancers stage FIGO\u0026thinsp;\u0026ge;\u0026thinsp;2b2 94%\u003c/p\u003e \u003cp\u003eSecondary education \u0026minus;\u0026thinsp;61%\u003c/p\u003e \u003cp\u003eNo income - 51%; Unemployed - 67%\u003c/p\u003e \u003cp\u003eWidowed, divorced or separated 60%\u003c/p\u003e \u003cp\u003eReceived palliative care \u0026minus;\u0026thinsp;13%\u003c/p\u003e \u003cp\u003eMean age of HCW 37 years SD\u0026thinsp;\u0026plusmn;\u0026thinsp;12\u003c/p\u003e \u003cp\u003eTrained to provide PC \u0026ndash; 72%\u003c/p\u003e \u003cp\u003eHCW accessing PC guidelines \u0026ndash; 76%;\u003c/p\u003e \u003cp\u003eHCW referring patient to PC specialty unit \u0026ndash; 1.2%\u003c/p\u003e \u003cp\u003eStock-outs of pain medicine \u0026ndash; 22%\u003c/p\u003e \u003cp\u003eKnowledge of palliative care among HCW and patients are limited\u003c/p\u003e \u003cp\u003eFew patients access palliative care even among women who received other forms of treatment\u003c/p\u003e \u003cp\u003ePatient perceives cervical cancer as a death sentence\u003c/p\u003e \u003cp\u003eCervical cancer diagnosis and palliative care is stigmatized and linked to near death\u003c/p\u003e \u003cp\u003ePalliative care only provided by hospice\u003c/p\u003e \u003cp\u003eHigh cost of medicines for cancer patients\u003c/p\u003e \u003cp\u003ePalliative care policy framework available but not fully implemented\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKebede \u003cem\u003eet al.\u003c/em\u003e (27), 2020- Ethiopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo explore communication in cancer care in Ethiopia from the perspective of physicians, patients, and family caregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEthnographic exploratory qualitative study using semi-structured interviews, and triangulating findings with direct observations and video-recordings of authentic interactions between physicians, patients, and family caregivers during hospital rounds\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePurposively sampled participants\u003c/p\u003e \u003cp\u003e54 cancer patients\u003c/p\u003e \u003cp\u003e\u0026bull; 20 males\u003c/p\u003e \u003cp\u003e34 females\u003c/p\u003e \u003cp\u003e\u0026bull; Age 22\u0026ndash;53 years\u003c/p\u003e \u003cp\u003e\u0026bull; Cervical cancer number not mentioned\u003c/p\u003e \u003cp\u003e22 family caregivers\u003c/p\u003e \u003cp\u003e\u0026bull; 11 male\u003c/p\u003e \u003cp\u003e11 female\u003c/p\u003e \u003cp\u003e16 physicians\u003c/p\u003e \u003cp\u003e\u0026bull; 3 senior\u003c/p\u003e \u003cp\u003e13 junior\u003c/p\u003e \u003cp\u003e\u0026bull; 11 males\u003c/p\u003e \u003cp\u003e5 females\u003c/p\u003e \u003cp\u003e\u0026bull; Ages 29\u0026ndash;58 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWorkload and time pressure\u003c/p\u003e \u003cp\u003eInsufficient consultation time\u003c/p\u003e \u003cp\u003eInsufficient information on disease\u003c/p\u003e \u003cp\u003eGood HCW attitude\u003c/p\u003e \u003cp\u003eLack of privacy\u003c/p\u003e \u003cp\u003eLanguage barrier\u003c/p\u003e \u003cp\u003eNo confidentiality\u003c/p\u003e \u003cp\u003eNo confidentiality\u003c/p\u003e \u003cp\u003eReluctance to reveal sensitive information\u003c/p\u003e \u003cp\u003eCompromised autonomy\u003c/p\u003e \u003cp\u003eLimited knowledge of cancer\u003c/p\u003e \u003cp\u003eLong distances\u003c/p\u003e \u003cp\u003eInfluence from others\u003c/p\u003e \u003cp\u003eMisconceptions about disease\u003c/p\u003e \u003cp\u003eCulture/attitude\u003c/p\u003e \u003cp\u003eExpectations\u003c/p\u003e \u003cp\u003eFear of stigmatization and isolation,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLarge number of patients; few physicians\u003c/p\u003e \u003cp\u003eDifficulty in allocating sufficient time for patient and family caregiver consultation Patient and family caregiver but not provided with enough information\u003c/p\u003e \u003cp\u003eCare recipients described communication with physician positively; nice and humble doctors\u003c/p\u003e \u003cp\u003eConsultation done in small non-sound-proof cubicles; frequent interruptions by other patients and staff\u003c/p\u003e \u003cp\u003ePhysicians and patients/family caregivers speaking different languages;\u003c/p\u003e \u003cp\u003eUse of interpreters\u003c/p\u003e \u003cp\u003eFamily caregivers tended to dominate interaction with physicians including discussion on diagnosis and prognosis\u003c/p\u003e \u003cp\u003eMale family member often responsible for making decisions and taking responsibility for patient care and expenses\u003c/p\u003e \u003cp\u003ePatient has problems understanding the disease and treatment process\u003c/p\u003e \u003cp\u003ePatient comes from distant rural areas\u003c/p\u003e \u003cp\u003eSome patients told that traditional medicine is better; seeks professional help late after going through religious treatment with holy water\u003c/p\u003e \u003cp\u003eSome care-recipients believe cancer is a curse from God; while others believe it can be transmitted from one person to another\u003c/p\u003e \u003cp\u003eStigma and taboo related to genitals in some communities; some female patient found it difficult to discuss cervical cancer openly and withheld vital information\u003c/p\u003e \u003cp\u003eHope to receive help from the doctor\u003c/p\u003e \u003cp\u003ePatients reluctant to share diagnosis with others, including family\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTapera \u003cem\u003eet al.\u003c/em\u003e (28), 2019 Zimbabwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo investigate the determinants of access to cervical cancer treatment and palliative care services in Harare, Zimbabwe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSequential explanatory mixed method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhase 1 \u0026ndash;quantitative survey:\u003c/p\u003e \u003cp\u003e148 healthy women\u003c/p\u003e \u003cp\u003e134 cervical cancer patients or survivors\u003c/p\u003e \u003cp\u003e78 health workers involved in cervical cancer\u003c/p\u003e \u003cp\u003ePhase 2-\u003c/p\u003e \u003cp\u003e6 FGD with 8 members per group\u003c/p\u003e \u003cp\u003e16 in-depth interviews\u003c/p\u003e \u003cp\u003e20 key informant interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUser\u0026rsquo;s location\u003c/p\u003e \u003cp\u003eUser\u0026rsquo;s attitude\u003c/p\u003e \u003cp\u003eUser\u0026rsquo;s resources\u003c/p\u003e \u003cp\u003eUser\u0026rsquo;s attitude or resources\u003c/p\u003e \u003cp\u003eSelf- efficacy/attitude\u003c/p\u003e \u003cp\u003eSatisfaction with quality of care/Expectations\u003c/p\u003e \u003cp\u003eTransportation / user\u0026rsquo;s resources /service location\u003c/p\u003e \u003cp\u003eDemand for service / user\u0026rsquo;s resources / service location /user\u0026rsquo;s location\u003c/p\u003e \u003cp\u003eFinancial hardships\u003c/p\u003e \u003cp\u003eWillingness to pay\u003c/p\u003e \u003cp\u003eCost and prices of service\u003c/p\u003e \u003cp\u003eOver servicing/ characteristics of health services\u003c/p\u003e \u003cp\u003eFinancial hardship\u003c/p\u003e \u003cp\u003eMisconceptions about disease and\u003c/p\u003e \u003cp\u003etreatment\u003c/p\u003e \u003cp\u003eSocial factors / user\u0026rsquo;s attitude\u003c/p\u003e \u003cp\u003eAcceptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCompared to those who did not receive any care, most patients receiving treatment:\u003c/p\u003e \u003cp\u003e\u0026bull; Lived in urban high density population areas, (p\u0026thinsp;=\u0026thinsp;0.025)\u003c/p\u003e \u003cp\u003e\u0026bull; Were of protestant faith, (p\u0026thinsp;=\u0026thinsp;0.028),\u003c/p\u003e \u003cp\u003e\u0026bull; With household heads being a professional (p\u0026thinsp;=\u0026thinsp;0.038).\u003c/p\u003e \u003cp\u003eMost patients receiving no treatment had household heads with no formal education (p\u0026thinsp;=\u0026thinsp;0.038)\u003c/p\u003e \u003cp\u003eLocus of control was positively associated with uptake of treatment\u003c/p\u003e \u003cp\u003ePerception of competency of HCW positively associated with treatment uptake\u003c/p\u003e \u003cp\u003eWalking as a means of reaching nearest health facility was negatively associated with perceptions of access\u003c/p\u003e \u003cp\u003eMostly lack of transport or high transport cost for rural people who travel long distances to reach few cancer centres\u003c/p\u003e \u003cp\u003eAccommodation often required for patient and family at these centre paid for by family\u003c/p\u003e \u003cp\u003ePatient buys own drugs\u003c/p\u003e \u003cp\u003eHigh cost of diagnostic tests, medications and other treatment\u003c/p\u003e \u003cp\u003eunaffordable to most\u003c/p\u003e \u003cp\u003eSame test ordered multiple times at every level of care\u003c/p\u003e \u003cp\u003eLoss of employment for patient and accompanying family member\u003c/p\u003e \u003cp\u003eCervical cancer seen as death sentence and radiotherapy introduces foreign material into the body.\u003c/p\u003e \u003cp\u003eInfluence of traditional and some religious healers, family, attitudes play a major role in seeking treatment\u003c/p\u003e \u003cp\u003eProlonged waiting period\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiranda \u003cem\u003eet al\u003c/em\u003e. (29), 2016 Brazil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo analyse the clinical and socio- demographic profile of cancer patients seen in a specialized emergency service, considering the availability of palliative care and home care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDescriptive, cross-sectional study of medical records with an analytical component\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e191 medical reviews including those of 35 patients with cervical cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCharacteristics of health services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBrazil has hierarchical and regionalized network that prevents 1 in 5 patients to be displaced from rural areas in the state for case review in a referral hospital\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaree \u0026amp; Langley, (7), 2014 South Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo elicit the experiences of underprivileged women being confronted with cervical cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQualitative exploratory and contextual with descriptive and interpretive elements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 purposively selected newly diagnosed cervical cancer patients being prepared to receive radiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVulnerable population\u003c/p\u003e \u003cp\u003eAnxiety and/or depression\u003c/p\u003e \u003cp\u003eMisconceptions about cervical cancer\u003c/p\u003e \u003cp\u003eWaiting for treatment / Characteristics of health services\u003c/p\u003e \u003cp\u003eDissatisfaction with health system\u003c/p\u003e \u003cp\u003eMedical assistance available\u003c/p\u003e \u003cp\u003eFinancial hardship\u003c/p\u003e \u003cp\u003eOut of pocket costs /Family support\u003c/p\u003e \u003cp\u003eUnemployed / user\u0026rsquo;s resources\u003c/p\u003e \u003cp\u003eHCW attitude\u003c/p\u003e \u003cp\u003eDisclosing bad news\u003c/p\u003e \u003cp\u003eFamily support\u003c/p\u003e \u003cp\u003eCost of being away from work\u003c/p\u003e \u003cp\u003eAlternative forms of treatment / attitudes\u003c/p\u003e \u003cp\u003eLimited knowledge of disease\u003c/p\u003e \u003cp\u003eCommunication\u003c/p\u003e \u003cp\u003eLimited knowledge of HCW\u003c/p\u003e \u003cp\u003eMajority of patients has advanced stage cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean age 47.2 years (29\u0026ndash;70)\u003c/p\u003e \u003cp\u003eMajority (16/19) were black South Africans.\u003c/p\u003e \u003cp\u003eMost patients experience worrying symptoms such as excessive vaginal bleeding, offensive discharge, and pain\u003c/p\u003e \u003cp\u003eSome patients experienced bleeding but did not have pain so they never though they had serious illness\u003c/p\u003e \u003cp\u003eIt took an average of 17 months from first symptoms to the start of specific treatment\u003c/p\u003e \u003cp\u003ePatients felt the public health system failed them in terms of prompt diagnosis and start of treatment\u003c/p\u003e \u003cp\u003ePatients do not pay for treatment in the public health system\u003c/p\u003e \u003cp\u003ePrivate health system available and faster but patient could not afford the cost of treatment here unless paid for by relatives\u003c/p\u003e \u003cp\u003eMost patients were unemployed\u003c/p\u003e \u003cp\u003eThe doctors were nice to the patients but had difficulty communicating bad news\u003c/p\u003e \u003cp\u003eSome patients preferred to be alone when bad news was broken\u003c/p\u003e \u003cp\u003eFound it difficult to disclose their diagnosis to the family to protect them from distress\u003c/p\u003e \u003cp\u003ePatients who received their diagnosis in presence of family felt better after being consoled\u003c/p\u003e \u003cp\u003eAccompanying family stayed away from work for consultations\u003c/p\u003e \u003cp\u003eSeeking conventional medicine was delayed as some patients were advised by relatives to attend spiritual and traditional healing\u003c/p\u003e \u003cp\u003eOne patient did not know that cervical cancer is life threatening\u003c/p\u003e \u003cp\u003eMost patients wanted to know more about the disease and treatment but the doctors could not explain to them\u003c/p\u003e \u003cp\u003eCancer stage 1b \u0026ndash; 2a : 3 patients\u003c/p\u003e \u003cp\u003eCancer stage 2b to 4 : 15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDutta \u003cem\u003eet al\u003c/em\u003e. (30), 2013 India\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo find out he socio-demographic causes which lead to non-compliance to treatment even after registration for radiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective analysis of medical records\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e144 patients with cancer of the cervix already registered to receive treatment\u003c/p\u003e \u003cp\u003eThey received initial treatment at a nearby centre but had to go for the second phase of treatment at a centre 567km away. Transport vouchers were provided but patients had to find and fund their own accommodation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFamily burden\u003c/p\u003e \u003cp\u003eDependency / resources\u003c/p\u003e \u003cp\u003eOlder age\u003c/p\u003e \u003cp\u003eLow literacy level\u003c/p\u003e \u003cp\u003eTransport difficulties and high cost\u003c/p\u003e \u003cp\u003eBurden of family responsibility\u003c/p\u003e \u003cp\u003eSocial status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMajority of patients were postmenopausal (56.94%), and had family burden of \u0026gt;\u0026thinsp;3 children\u003c/p\u003e \u003cp\u003eOnly 6.25% were self-employed\u003c/p\u003e \u003cp\u003eThe rest depended on family and husband for their livelihood\u003c/p\u003e \u003cp\u003eElderly patients\u0026thinsp;\u0026gt;\u0026thinsp;50 were most unlikely to complete their course of treatment\u003c/p\u003e \u003cp\u003eHigh number of illiterate women were unlikely to complete their treatment\u003c/p\u003e \u003cp\u003eMost patient living more than 100km from the nearest treatment facility unlikely to complete their course of treatment\u003c/p\u003e \u003cp\u003eWomen with more children preferred to take care of their families rather than be away from home for prolonged period of time\u003c/p\u003e \u003cp\u003eWomen who completed their treatment in time were wealthier; middle-aged; with \u0026lt;\u0026thinsp;3 children\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMwaka \u003cem\u003eet al\u003c/em\u003e. (31), 2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo explore the perceptions of operational level healthcare professionals who work directly with cervical cancer patients on challenges faced by women seeking cervical screening, cervical cancer diagnosis and management, and challenges faced by health professionals in providing cervical cancer care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQualitative inquiry using key informant interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 female nurse/midwives, 2 gynaecologists, 2 medical officers and 1 surgeon working in a public regional and a mission hospital in northern Uganda\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePatients and community related factors\u003c/p\u003e \u003cp\u003eHealthcare professionals deficiencies\u003c/p\u003e \u003cp\u003eHealth facility related factors\u003c/p\u003e \u003cp\u003eFacilities\u003c/p\u003e \u003cp\u003eHealth policy factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLack of awareness on cervical cancer and available services\u003c/p\u003e \u003cp\u003eDiscomfort with exposure of women\u0026rsquo;s genitals\u003c/p\u003e \u003cp\u003ePerceived pain during pelvic examinations\u003c/p\u003e \u003cp\u003eMen\u0026rsquo;s lack of emotional support to women\u003c/p\u003e \u003cp\u003eInadequate knowledge and skills about cervical cancer management\u003c/p\u003e \u003cp\u003eLong distance to care centres\u003c/p\u003e \u003cp\u003eFew gynaecologists and lack of pathologists\u003c/p\u003e \u003cp\u003eDelayed histology results\u003c/p\u003e \u003cp\u003eLack of morphine for pain control\u003c/p\u003e \u003cp\u003eLack of specialized cancer treatment facilities\u003c/p\u003e \u003cp\u003eLack of vaccination policy for HPV\u003c/p\u003e \u003cp\u003eLarge number of women presenting with late stage cervical cancer\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVan Schalkwyk \u003cem\u003eet al\u003c/em\u003e. (32), 2008\u003c/p\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo gain an understanding of the routes that women presenting with advanced cervical cancer followed, from experiencing the first signs and symptoms of disease until they received radiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExploratory qualitative phenomenological study of the subjective experiences of women with cervical cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 consecutive women with advanced (stage 2b and worse) cancer of cervix\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLimited knowledge\u003c/p\u003e \u003cp\u003eAnxiety, fear of the unknown\u003c/p\u003e \u003cp\u003eStigmatization\u003c/p\u003e \u003cp\u003eSelf-efficacy\u003c/p\u003e \u003cp\u003eLong waiting period for treatment, even longer for rural women\u003c/p\u003e \u003cp\u003eLimited knowledge and awareness of HCW (Low index of suspicion)\u003c/p\u003e \u003cp\u003eCulture of secrecy, taboo regarding reproductive organs\u003c/p\u003e \u003cp\u003eInfluence of significant others\u003c/p\u003e \u003cp\u003eMisconceptions and limited knowledge of the disease\u003c/p\u003e \u003cp\u003ePositive support from family\u003c/p\u003e \u003cp\u003eNegative attitude of family and misinformation\u003c/p\u003e \u003cp\u003eDissatisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAt first symptoms (bleeding, pains, discharge) most women knew something was wrong but lacked the knowledge of what was required to manage the problem\u003c/p\u003e \u003cp\u003eMost experienced concern, sadness, embarrassment, sadness and isolation\u003c/p\u003e \u003cp\u003ePeople avoided them in public spaces due to the bad smell\u003c/p\u003e \u003cp\u003eWere able to seek treatment once they knew what the problem was\u003c/p\u003e \u003cp\u003eAverage time from diagnosis to treatment was 17.3 months (11.8 for urban vs 28.4 for rural women)\u003c/p\u003e \u003cp\u003eFirst contact with HCW did not result in correct diagnosis at any level of care\u003c/p\u003e \u003cp\u003eSome women did not report their symptoms due to embarrassment but instead only complained of minor problems\u003c/p\u003e \u003cp\u003eTraditional healers were consulted as a result of advice or insistence of support persons\u003c/p\u003e \u003cp\u003eSome believed that their problem was caused by demons and attended traditional healers first, going to hospital only when they did not get relief\u003c/p\u003e \u003cp\u003eSome family members, intimate partners, workplaces, and the church were very understanding and supportive\u003c/p\u003e \u003cp\u003eOthers accused the patient of immorality, and did not allow them in church because of being unclean\u003c/p\u003e \u003cp\u003eMost patients were not happy with the way they were treated in the healthcare facilities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOf the 10 studies there were 2 retrospective cross-sectional (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), 1 prospective cross-sectional (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), 5 qualitative (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), and 2 mixed-method designs (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). There were no randomised control trials. Eight studies were conducted in Africa (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) and one each from Brazil (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) and India (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Within the 10 studies, 505 unique women with cervical cancer, 148 healthy women, 64 family members, 78 healthcare workers involved with cervical cancer, and 20 informal caregivers were included. Findings from all the studies were collated under 10 sub-constructs alongside four main constructs of access to healthcare (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) [Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAccess domains and sub-domains\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGeographic accessibility\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003eAvailability\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003eFinancial accessibility\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003eAcceptability\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubdomains\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eArticles\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eService location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUser\u0026rsquo;s location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHealth workers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDrugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEquipment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDemand for services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCost \u0026amp; prices of service\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUser\u0026rsquo;s resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUser\u0026rsquo;s willingness to pay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eUser\u0026rsquo;s attitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eUser\u0026rsquo;s expectations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eCharacteristics of health services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBates \u003cem\u003eet al\u003c/em\u003e., (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDutta \u003cem\u003eet al\u003c/em\u003e., (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKebede \u003cem\u003eet al\u003c/em\u003e.,(27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaree \u003cem\u003eet al\u003c/em\u003e., (7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiranda \u003cem\u003eet al\u003c/em\u003e., (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMwaka et al.,(31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTapera \u003cem\u003eet al\u003c/em\u003e., (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTapera \u003cem\u003eet al.\u003c/em\u003e, (18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTapera \u003cem\u003eet al\u003c/em\u003e., (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVan Schalkwyk \u003cem\u003eet al\u003c/em\u003e., (32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBelow, we present the findings of thematic analysis of the review under the following domains: geographic accessibility, availability, financial accessibility, and acceptability.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eGeographic accessibility\u003c/h2\u003e \u003cp\u003eHealth facilities were found in central referral hospitals located in urban centres far from the rural areas where a majority of patients lived (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28 CR29 CR30 CR31\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Most patients travelled long distances, usually by public transport, or by walking to the nearest facility to access cancer treatment or primary care for pain and symptom relief (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eAvailability\u003c/h2\u003e \u003cp\u003eThe demand for palliative care services and unmet needs featured prominently in all studies except one (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Three studies (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) reported lack or shortage of essential medicines used in palliative care such as morphine for pain control. One study (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) reported shortage of blood for transfusion of cervical cancer patients presenting in shock after excessive bleeding. Unavailability of radiotherapy equipment is reported in 2 studies (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) with each of the countries of origin possessing only one old-type radiotherapy equipment (cobalt-60) for the entire population. Six studies reported on the availability of healthcare workers. Shortage of specialists in oncology, gynaecology, pathology, and PC was reported in 2 studies (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) while limited knowledge of cervical cancer management and PC skills among healthcare workers was reported in 6 studies (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eFinancial accessibility\u003c/h2\u003e \u003cp\u003eHigh cost of radiotherapy and pathology services, unaffordable by a majority of patients and families was reported in three studies (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Only 1 study from South Africa found that radiological, radiotherapy, laboratory and consultation services were covered by the state in the public sector, but was still expensive in the private sector (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In most studies, patients and their family were poor with limited financial resources (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Financial hardship was reported in nearly all studies. In Malawi, most households, especially those from the rural areas lived in extreme poverty at \u0026le;\u003cspan\u003e$\u003c/span\u003e1.89 per day (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Families were willing to pay for healthcare, mainly through out-of-pocket expenditure (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Some households experienced catastrophic cost as a result, to the extent of dissaving or selling property to cover healthcare costs (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In a few studies, basic healthcare costs were covered or subsidised by government (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), while in some family members shared costs with the government while non-governmental organizations provided support for subsistence needs (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Substantial component of costs incurred by patients and families went towards covering the costs for travel, subsistence and accommodation while seeking or attending treatment in distant centres (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAcceptability\u003c/h2\u003e \u003cp\u003eCharacteristics of health services were preeminent in all the studies analysed of which most of them revealed scarcity of service points with significant physical distance away from users and associated difficulties accessing the needed services. In addition, the existing facilities were ill equipped with frequent radiotherapy interruptions due to breakdown and stock-outs of essential pain medicine such as morphine (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Overcrowding in the consultation rooms with lack of privacy (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), healthcare staff with insufficient knowledge and skills to provide disease information that meets the need of the patient and family (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), and in some instance over-servicing with multiple radiological and other tests ordered at numerous service delivery points (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) were some of the challenges reported. Communicating unfavourable information to patients about their illness and addressing emotional needs was also poorly handled by staff in some studies (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMisconceptions about the nature of cervical cancer, its treatment, and embarrassment on exposure of their body together with the culture of privacy associated with female genitals also prevented the patients from receiving prompt care (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Patient satisfaction with healthcare providers and available services was highlighted in a few studies (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). However, other studies revealed dissatisfaction mainly due to long waiting period before treatment (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) and high cost of services (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUser\u0026rsquo;s attitudes reported in the studies included cultural beliefs and attitude towards healthcare services visited. Some patients preferred traditional medicine or religious healing to biomedical care due to pressure from significant people in their lives (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) or misconceptions about the cause of their illness (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Other patients stayed away from conventional services due to stigma their communities associated with cancer or its symptoms such as offensive vaginal discharge and bleeding, including misconceptions that cancer can be transmitted directly on contact with a patient (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFamily responsibilities were also reported to affect access to health care. In one study, widowed, divorced, or separated cervical cancer patients who were the only income earners for their family through formal or informal self-employment could not afford prolonged absence from their jobs while seeking or receiving treatment (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Family burden was also a factor in women with more than 3 children who preferred to stay at home to care for their families even though travel vouchers to treatment centres were provided (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Another study reports that women\u0026rsquo;s responsibility of cultivating their farms preceded their need for healthcare and besides they first had to get permission from their husbands to be able to seek treatment (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). In some households, patients chose to forgo treatment rather than cause financial difficulties to their families (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Yet other patients requested health care staff not to reveal their diagnosis for fear of causing anxiety to their family members (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis systematic review reveals numerous palliative care access challenges, perceived and experienced, by women with advanced cancer of the uterine cervix and/or their caregivers in the LMICs. The challenges are both personal and system-based, emanating from all the four domains of access to quality healthcare such as lack of physical accessibility, unavailability of quality services, poverty and poor affordability, and barriers to acceptance and use of available services by those in need.\u003c/p\u003e \u003cp\u003eDespite significant progress made in the development of palliative care in Africa (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), services are still not universally integrated into the healthcare system of many countries and remain inconsistent, occurring in isolated centres with limited geographical access by a majority of the population in need (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). However, limited access as a consequence of geographic location is not unique to the developing world as found in this systematic review. In developed countries such as the United States of America many patients still lack access to PC because of unfavourable geographic location or distance from appropriate treatment facilities (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Geographic accessibility involves the physical distance or travel time from the user\u0026rsquo;s location to the service delivery location. Previous studies support the significant role of the geographic accessibility by demonstrating an inverse relationship between distance and travel time to service delivery points and the use of healthcare services (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Good roads and adequate communication enhances geographic accessibility (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe demand for PC services and unmet needs featured prominently in all studies analysed in this review. Accessing the right type of care that meets the demand of those who need it is central to availability (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Availability concerns the opportunity to access the right type of healthcare promptly whenever needed. It involves the availability of knowledgeable and skilled healthcare providers, medicines, equipment, acceptable opening hours, and acceptable waiting times (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Report from literature reiterate the findings of this study that most cervical cancer patients and their families live in the LMICs where availability of quality palliative care is minimal despite the high demand (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Internationally, the American Society of Clinical Oncology (ASCO) recommends that a coordinated system to assess and meet PC needs of patients and family should be made available at all levels of a healthcare system (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAvailable evidence from diverse resource settings suggest that women with cancer of the cervix frequently suffer from severe complex refractory symptoms not readily relieved by basic PC (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Addressing these symptoms require more advanced procedures such as palliative external beam radiotherapy to control vaginal bleeding and discharge, advanced medical therapies, nerve block for intractable neuropathic pelvic pain, surgical procedures for bowel obstruction, and psycho-oncology to manage severe or refractory anxiety and depression (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Identifying needs of patients and their families, communication, assessment and treatment of pain and other symptoms, and referral for management of complex distressing symptoms is recognised as a basic requirement even at lower levels of care (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Many African countries still lack the ability to provide quality PC due to inadequate infrastructure, staff shortages, low doctor-patient ratio and paucity of trained PC specialists (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) compounded by insufficient supply of morphine, an opioid considered by World Health Organisation as an essential medicine in treatment of pain, including cancer pain (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePoverty, loss of income and inability to afford basic subsistence and healthcare-related costs was a recurring observation in the review. Financial accessibility includes cost and prices of services, cost of time, users\u0026rsquo; resources, and users\u0026rsquo; willingness to pay for the services (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Distance to health facilities has a significant bearing on the affordability especially for rural dwelling population incurring travelling, food and accommodation costs in addition to the direct cost of treatment. Unlike in the developed countries where medical insurance covers healthcare expenses (\u003cspan additionalcitationids=\"CR46\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e), there is low medical insurance coverage in most LMICS and cost of treatment for people with serious illness is borne by patients and family mainly as out-of-pocket expenses (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). For instance, in South Africa only 16.4% of the population is covered by a medical aid (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). In an instance of extreme poverty, a proposal has been made for accessible social support for any patient in need of PC and for their main caregiver to include transportation vouchers, cash payments, food packages, and other types of in-kind support (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAcceptability of heath care services involves factors such as characteristics of health services, and user\u0026rsquo;s attitudes and expectations (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). It encompasses how satisfied users are with the services provided. It also depends on care receiver\u0026rsquo;s attitude and cultural beliefs. Factors such as opening hours, geographic distance, availability of medicines, staff complement, attitude and knowledge, and costs, are some of the factors that determine acceptability of an available PC service for patients and their family. In this review, patients and family were not satisfied with the services as s a result of difficulties they encountered. The difficulties varied from long distance of travel to perception of poor communication with the staff. However, other factors were related to socio-cultural beliefs and influence from significant others.\u003c/p\u003e \u003cp\u003eLack of knowledge and awareness of available services, distrust of the healthcare system, traditional gender roles and language barriers have been reported elsewhere as factors that limit utilization of health services (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Lack of knowledge has been reported to hinder the use of PC services in developed countries also (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). Community belief in the superiority and effectiveness of traditional medicine in treatment of cervical cancer and beliefs in spiritual healing also hinder utilization of biomedical health services in some LMICs (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eSTRENGTHS \u003c/h3\u003e\n\u003cp\u003e To the researchers\u0026rsquo; knowledge this is the first systematic review that has looked into access to PC in women with advanced cervical cancer and their families in the LMICs. The use of thematic synthesis has the potential to draw conclusion based on common elements from studies of diverse designs (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). This may allow for generating future hypothesis that may form a structure for future research in this field to investigate culturally sensitive and acceptable PC provision.\u003c/p\u003e\n\u003ch3\u003eLIMITATIONS\u003c/h3\u003e\n\u003cp\u003eAs only studies published in English were considered in the inclusion criteria, it is possible that there are studies published in other languages that could have been included also. Other limitations could be that the included studies used different study designs (qualitative, quantitative, mixed methods) and different outcomes or no validated outcome measures as such could not allow for meta-analysis. Additionally the relatively small number of studies included in the review may have limited the reliability of conclusions that could be drawn.\u003c/p\u003e\n\u003ch3\u003eIMPLICATION FOR PRACTICE\u003c/h3\u003e\n\u003cp\u003eUnderstanding the lived experiences and factors that primarily concern cervical cancer patients and their caregivers with respect to accessing PC services creates a better understanding of barriers, facilitators, and measurable factors that can act as basis of remedial actions to improve access and enable the development and implementation of PC models that specifically address needs of those affected. Establishing adequately staffed and equipped facilities within reach of the majority of the population served will help bring services close to the people.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFindings of this systematic review suggests that palliative care for cervical cancer patients is still not universally available especially in the LMICs. Cervical cancer patients often suffer significant distressing symptoms which could be alleviated by the provision of effective palliative care. As the development of the practice of palliative care gradually improves in the developing countries, concerted effort must be made to enhance access to cervical cancer patients and their families so as to improve their quality of life and disease experience.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that the data supporting the findings of this study are available within the article and/or its related files. Any other information that support the findings of this study are available from the corresponding author, [F.O], upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The data supporting the findings of this study are available within the article and/or its related files. Any other materials are available from the corresponding author, [F.O], upon request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest:\u003c/strong\u003e All authors declare no competing interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eF.O., T.M., P.B. and J.W conceived the research.\u003c/p\u003e\n\u003cp\u003eF.O., P.B. and J.W contributed to the design of the study and developed the search terms.\u003c/p\u003e\n\u003cp\u003eF.O. and P.B completed database searches.\u003c/p\u003e\n\u003cp\u003eF.O., P.B. and J.W. reviewed all titles, abstracts and full-text studies.\u003c/p\u003e\n\u003cp\u003eF.O. extracted data from all studies and synthesized the data.\u003c/p\u003e\n\u003cp\u003eP.B. and J.W. reviewed data synthesis and discussed with F.O. to reach a consensus on final data.\u003c/p\u003e\n\u003cp\u003eF.O. drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors read, revised and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: None\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eArbyn M, Weiderpass E, Bruni L, de Sanjos\u0026eacute; S, Saraiya M, Ferlay J, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. The Lancet Global Health. 2020;8(2):e191-e203.\u003c/li\u003e\n\u003cli\u003eKrakauer EL, Kwete X, Kane K, Afshan G, Bazzett-Matabele L, Bien-Aim\u0026eacute; DDR, et al. Cervical cancer-associated suffering: Estimating the palliative care needs of a highly vulnerable population. JCO Global Oncology. 2021;7:862-72.\u003c/li\u003e\n\u003cli\u003ePaul R, Musa G, Chungu H. Prevalence of depression among cervical cancer patients seeking treatment at the cancer diseases hospital. IOSR J Dent Med Sci Ver XI. 2016;15(6):2279-861.\u003c/li\u003e\n\u003cli\u003eBates MJ, Gordon MR, Gordon SB, Tomeny EM, Muula AS, Davies H, et al. Palliative care and catastrophic costs in Malawi after a diagnosis of advanced cancer: a prospective cohort study. The Lancet Global Health. 2021;9(12):e1750-e7.\u003c/li\u003e\n\u003cli\u003eKrakauer EL, Kane K, Kwete X, Afshan G, Bazzett-Matabele L, Ruthnie Bien-Aim\u0026eacute; DD, et al. Essential Package of Palliative Care for Women With Cervical Cancer: Responding to the Suffering of a Highly Vulnerable Population. JCO Glob Oncol. 2021;7:873-85.\u003c/li\u003e\n\u003cli\u003eMiller BE, Pittman B, Strong C. Gynecologic cancer patients\u0026apos; psychosocial needs and their views on the physician\u0026apos;s role in meeting those needs. International Journal of Gynecological Cancer. 2003;13(2):111-9.\u003c/li\u003e\n\u003cli\u003eMaree JE, Langley G, Nqubezelo L. \u0026quot;Not a nice experience, not at all\u0026quot;: Underprivileged women\u0026apos;s experiences of being confronted with cervical cancer. Palliat Support Care. 2015;13(2):239-47.\u003c/li\u003e\n\u003cli\u003eAllende-Perez S, Dominguez-Ocadio G, Velez-Salas V, Isla-Ortiz D, Pe\u0026ntilde;a-Nieves A, Verastegui E. Snapshot of symptoms of advanced cervical cancer patients referred to the palliative care service in a cancer center in Mexico. Int J Gynaecol Obstet. 2021;153(2):335-9.\u003c/li\u003e\n\u003cli\u003eRadbruch L, De Lima L, Knaul F, Wenk R, Ali Z, Bhatnaghar S, et al. Redefining palliative care\u0026mdash;A new consensus-based definition. Journal of pain and symptom management. 2020;60(4):754-64.\u003c/li\u003e\n\u003cli\u003eTemel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non\u0026ndash;small-cell lung cancer. New England Journal of Medicine. 2010;363(8):733-42.\u003c/li\u003e\n\u003cli\u003eTemel JS, Greer JA, Admane S, Gallagher ER, Jackson VA, Lynch TJ, et al. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non\u0026ndash;small-cell lung cancer: Results of a randomized study of early palliative care. Journal of clinical oncology. 2011;29(17):2319-26.\u003c/li\u003e\n\u003cli\u003eEl-Jawahri A, Greer JA, Temel JS. Does palliative care improve outcomes for patients with incurable illness? A review of the evidence. Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. 2011.\u003c/li\u003e\n\u003cli\u003eTeno JM, Casarett D, Spence C, Connor S. It is \u0026ldquo;too late\u0026rdquo; or is it? Bereaved family member perceptions of hospice referral when their family member was on hospice for seven days or less. Journal of pain and symptom management. 2012;43(4):732-8.\u003c/li\u003e\n\u003cli\u003eHui D, Kim S-H, Kwon JH, Tanco KC, Zhang T, Kang JH, et al. Access to palliative care among patients treated at a comprehensive cancer center. The oncologist. 2012;17(12):1574.\u003c/li\u003e\n\u003cli\u003eAbel J, Kellehear A, Mills J, Patel M. Access to palliative care reimagined. Future Healthcare Journal. 2021;8(3):e699.\u003c/li\u003e\n\u003cli\u003eAlkhudairi HM. General public awareness, knowledge, and beliefs toward palliative care in a Saudi population. Journal of Nature and Science of Medicine. 2019;2(1):48.\u003c/li\u003e\n\u003cli\u003ePinto E, Gon\u0026ccedil;alves F, Sacarlal J, Castro L, Rego G. Pain management in cancer patients in the main hospitals in Mozambique. Ann Palliat Med. 2021;10(4):4069-79.\u003c/li\u003e\n\u003cli\u003eTapera O, Nyakabau AM. Limited knowledge and access to palliative care among women with cervical cancer: an opportunity for integrating oncology and palliative care in Zimbabwe. BMC Palliative Care. 2020;19(1):1-9.\u003c/li\u003e\n\u003cli\u003eIslam JY, Deveaux A, Previs RA, Akinyemiju T. Racial and ethnic disparities in palliative care utilization among gynecological cancer patients. Gynecol Oncol. 2021;160(2):469-76.\u003c/li\u003e\n\u003cli\u003ePeters DH, Garg A, Bloom G, Walker DG, Brieger WR, Hafizur Rahman M. Poverty and access to health care in developing countries. Annals of the new York Academy of Sciences. 2008;1136(1):161-71.\u003c/li\u003e\n\u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Systematic reviews. 2021;10(1):1-11.\u003c/li\u003e\n\u003cli\u003eErdis E. A rare metastatic region of cervix cancer; the brain. J Pak Med Assoc. 2014;64(1):89-90.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Academic medicine. 2014;89(9):1245-51.\u003c/li\u003e\n\u003cli\u003eLucas PJ, Baird J, Arai L, Law C, Roberts HM. Worked examples of alternative methods for the synthesis of qualitative and quantitative research in systematic reviews. BMC medical research methodology. 2007;7(1):1-7.\u003c/li\u003e\n\u003cli\u003eTapera O, Dreyer G, Nyakabau AM, Kadzatsa W, Stray-Pedersen B, Hendricks SJH. Model strategies to address barriers to cervical cancer treatment and palliative care among women in Zimbabwe: a public health approach. BMC women\u0026apos;s health. 2021;21(1):1-11.\u003c/li\u003e\n\u003cli\u003eTapera O, Dreyer G, Kadzatsa W, Nyakabau AM, Stray-Pedersen B, Hendricks SJH. Determinants of access and utilization of cervical cancer treatment and palliative care services in Harare, Zimbabwe. BMC Public Health. 2019;19(1):N.PAG-N.PAG.\u003c/li\u003e\n\u003cli\u003eKebede BG, Abraha A, Andersson R, Munthe C, Linderholm M, Linderholm B, et al. Communicative challenges among physicians, patients, and family caregivers in cancer care: An exploratory qualitative study in Ethiopia. PLoS ONE. 2020;15(3).\u003c/li\u003e\n\u003cli\u003eTapera O, Kadzatsa W, Nyakabau AM, Mavhu W, Dreyer G, Stray-Pedersen B, et al. Sociodemographic inequities in cervical cancer screening, treatment and care amongst women aged at least 25 years: evidence from surveys in Harare, Zimbabwe. BMC Public Health. 2019;19(1):428.\u003c/li\u003e\n\u003cli\u003eMiranda B, Vidal SA, Mello MJ, Lima JT, R\u0026ecirc;go JC, Pantale\u0026atilde;o MC, et al. Cancer patients, emergencies service and provision of palliative care. Rev Assoc Med Bras (1992). 2016;62(3):207-11.\u003c/li\u003e\n\u003cli\u003eDutta S, Biswas N, Muhkherjee G. Evaluation of Socio-demographic Factors for Non-compliance to Treatment in Locally Advanced Cases of Cancer Cervix in a Rural Medical College Hospital in India. Indian Journal of Palliative Care. 2013;19(3):158-65.\u003c/li\u003e\n\u003cli\u003eMwaka AD, Wabinga HR, Mayanja-Kizza H. Mind the gaps: a qualitative study of perceptions of healthcare professionals on challenges and proposed remedies for cervical cancer help-seeking in post conflict northern Uganda. BMC Family Practice. 2013;14:193.\u003c/li\u003e\n\u003cli\u003evan Schalkwyk SL, Maree JE, Wright SC. Cervical cancer: the route from signs and symptoms to treatment in South Africa. Reprod Health Matters. 2008;16(32):9-17.\u003c/li\u003e\n\u003cli\u003eRhee JY, Garralda E, Torrado C, Blanco S, Ayala I, Namisango E, et al. Palliative care in Africa: a scoping review from 2005\u0026ndash;16. The Lancet Oncology. 2017;18(9):e522-e31.\u003c/li\u003e\n\u003cli\u003eLynch T, Connor S, Clark D. Mapping levels of palliative care development: a global update. Journal of pain and symptom management. 2013;45(6):1094-106.\u003c/li\u003e\n\u003cli\u003ePowell RA, Harding R, Namisango E, Katabira E, Gwyther L, Radbruch L, et al. Palliative care research in Africa: An overview. European Journal of Palliative Care. 2013;20(4):162-7.\u003c/li\u003e\n\u003cli\u003eFerrell BR, Temel JS, Temin S, Alesi ER, Balboni TA, Basch EM, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline update. Journal of Clinical Oncology. 2017;35(1):96-112.\u003c/li\u003e\n\u003cli\u003eHjortsberg C. Why do the sick not utilise health care? The case of Zambia. Health economics. 2003;12(9):755-70.\u003c/li\u003e\n\u003cli\u003eHjortsberg C, Mwikisa C. Cost of access to health services in Zambia. Health policy and planning. 2002;17(1):71-7.\u003c/li\u003e\n\u003cli\u003eOrganization WH. Global Atlas of Palliative Care 2nd Edition. London: Worldwide Palliative Care Alliance; 2020.\u003c/li\u003e\n\u003cli\u003eOsman H, Shrestha S, Temin S, Ali ZV, Corvera RA, Ddungu HD, et al. Palliative care in the global setting: ASCO resource-stratified practice guideline. Journal of global oncology. 2018;4:1-24.\u003c/li\u003e\n\u003cli\u003eKrakauer EL, Kane K, Kwete X, Afshan G, Bazzett-Matabele L, Ruthnie Bien-Aim\u0026eacute; DD, et al. Augmented Package of Palliative Care for Women With Cervical Cancer: Responding to Refractory Suffering. JCO Global Oncology. 2021;7:886-95.\u003c/li\u003e\n\u003cli\u003eDowning J, Grant L, Leng M, Namukwaya E. Understanding models of palliative care delivery in sub-Saharan Africa: learning from programs in Kenya and Malawi. Journal of Pain and Symptom Management. 2015;50(3):362-70.\u003c/li\u003e\n\u003cli\u003eMwangi-Powell F. APCA\u0026apos;s role in the development of palliative care in Africa. Progress in Palliative Care. 2012;20(4):230-3.\u003c/li\u003e\n\u003cli\u003eStefan DC. Cancer care in Africa: an overview of resources. Journal of Global Oncology. 2015;1(1):30-6.\u003c/li\u003e\n\u003cli\u003eBrown CM, Richards KM, Vohra Y, Kanu C, Stevens L, Sasane R, et al. Evaluation of access to care issues in patients with breast cancer. Journal of Medical Economics. 2021;24(1):38-45.\u003c/li\u003e\n\u003cli\u003eBrown CM, Kanu C, Richards KM, Stevens L, Sasane R, McAneny B. Exploring access to care from the perspective of patients with breast cancer: A qualitative study. Cancer Medicine. 2022.\u003c/li\u003e\n\u003cli\u003eStevenson DG. Growing pains for the Medicare hospice benefit. N Engl J Med. 2012;367(18):1683-5.\u003c/li\u003e\n\u003cli\u003eKrakauer EL, Kwete X, Verguet S, Arreola-Ornelas H, Bhadelia A, Mendez O, et al. Palliative care and pain control. Disease Control Priorities: Improving Health and Reducing Poverty 3rd edition. 2017.\u003c/li\u003e\n\u003cli\u003eStats S. Statistical release P0318: General Household Survey 2018. Pretoria: ISIbalo House. 2020.\u003c/li\u003e\n\u003cli\u003eThummapol O, Park T, Barton S. Exploring health services accessibility by indigenous women in Asia and identifying actions to improve it: a scoping review. Ethnicity \u0026amp; health. 2020;25(7):940-59.\u003c/li\u003e\n\u003cli\u003eKumar P, Casarett D, Corcoran A, Desai K, Li Q, Chen J, et al. Utilization of supportive and palliative care services among oncology outpatients at one academic cancer center: determinants of use and barriers to access. Journal of palliative medicine. 2012;15(8):923-30.\u003c/li\u003e\n\u003cli\u003eMwaka AD, Okello ES, Orach CG. Barriers to biomedical care and use of traditional medicines for treatment of cervical cancer: An exploratory qualitative study in northern Uganda. European Journal of Cancer Care. 2015;24(4):503-13.\u003c/li\u003e\n\u003cli\u003eMwaka AD, Mangi SP, Okuku FM. Use of traditional and complementary medicines by cancer patients at a national cancer referral facility in a low-income country. European Journal of Cancer Care. 2019;28(6).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cervical cancer, access, palliative care, low and middle-income countries","lastPublishedDoi":"10.21203/rs.3.rs-2412007/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2412007/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eWomen with advanced uterine cervical cancer suffer from a combination of moderate to severe physical, psychological, social, and spiritual distress due to their disease and are in need of palliative care to improve their quality of life. Approximately 85% of the women live in the low- and middle-income countries. Whether these women and their families access palliative care is not known.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eTo understand the geographic accessibility, availability, financial accessibility, and acceptability of palliative care by patients with advanced cervical cancer and their families.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e We conducted a Systematic review following PRISMA guidelines in CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE, PsychINFO, PubMed and Scopus for the core concepts: palliative care, access, advanced uterine cervical cancer. Eligible articles were published in English, contained original data on experiences of patients and/or caregivers including symptoms management, and discussed available resources, communication, satisfaction, and healthcare utilization.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOverall there was limited access to palliative care with insufficient facilities located in cities away from the rural areas where most women lived. Pervasive poverty was common with poor affordability of healthcare, travelling, accommodation, and subsistence expenses. Misconceptions and poor knowledge of the disease, cultural beliefs and attitudes, and other health system insufficiencies also presented challenges for access.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eConcerted effort should be made to improve availability of palliative care facilities. Health education to address misconceptions and other cognitive barriers that limit access among cervical cancer patients and their families should be urgently undertaken in the LMICs.\u003c/p\u003e","manuscriptTitle":"Access to Palliative Care in Patients with Advanced Cancer of the Uterine Cervix in the Low- and Middle-Income Countries: A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-01-04 17:40:21","doi":"10.21203/rs.3.rs-2412007/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-04-03T11:27:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-03-26T15:48:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"fe5e46ee-129c-4c82-a82e-f3a33ab4e863","date":"2023-03-15T13:15:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-03-15T12:27:13+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-01-24T16:18:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-12-30T14:14:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-12-29T06:24:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2022-12-24T16:16:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4b84598a-718a-41ba-9b3f-25b85819a831","owner":[],"postedDate":"January 4th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-09-25T15:07:17+00:00","versionOfRecord":{"articleIdentity":"rs-2412007","link":"https://doi.org/10.1186/s12904-023-01263-9","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2023-09-20 15:01:30","publishedOnDateReadable":"September 20th, 2023"},"versionCreatedAt":"2023-01-04 17:40:21","video":"","vorDoi":"10.1186/s12904-023-01263-9","vorDoiUrl":"https://doi.org/10.1186/s12904-023-01263-9","workflowStages":[]},"version":"v1","identity":"rs-2412007","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2412007","identity":"rs-2412007","version":["v1"]},"buildId":"pf3fE39SIOqb-0xH_OWvX","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}