PAM50 breast cancer subtypes and survival of patients in rural Ethiopia without adjuvant treatment: a prospective observational study.

PURPOSE: Survival rates of breast cancer (BC) patients are particularly low in rural regions in sub-Saharan Africa (SSA) which is due to limited access to therapy. In recent years, gene expression profiling (GEP) of BC showed a strong prognostic value in patients with local tumour surgery and (neo)adjuvant treatment. The aim of this study was to evaluate the impact of intrinsic subtypes on survival of patients in rural Ethiopia without any (neo)adjuvant therapy. METHODS: In total, 113 female patients from Aira Hospital with histologically proven BC and treated only with surgery were included in this study. All samples were analysed by immunohistochemistry (IHC) for estrogen receptor, progesterone receptor, HER2 and Ki67, as well as RNA-expression analysis for PAM50 subtyping. RESULTS: A positive hormone receptor status was found in 69.0% of the tumours and intrinsic subtyping demonstrated Luminal B to be the most common subtype (34.5%). Follow-up data was available for 79 of 113 patients. Two-year overall survival (OS) was 57.3% and a considerably worse OS was observed in patients with Basal-like BC compared to Luminal A BC. Moreover, advanced tumours showed an increased risk of mortality. CONCLUSION: The OS was very low in the patient cohort that received no (neo)adjuvant treatment. Immunohistochemistry and GEP confirmed endocrine-sensitive tumours in more than half of the patients, with a large proportion of Luminal B, HER2-enriched and Basal-like tumours so that adjuvant chemotherapy should be recommended.

Perceived causes of cancer in a rural community of Ethiopia: a qualitative study.

BACKGROUND: Although cancer incidence and mortality are rising in Ethiopia, lay and health professional perceptions of the disease remain limited. OBJECTIVE: To explore perceptions of cancer, including its causes, signs and symptoms, and transmission within a rural community in Ethiopia. METHODS: We conducted a qualitative study in four rural neighbourhoods of Butajira in central Ethiopia. Seven Focus Group Discussions (FGDs) and six In-Depth Interviews (IDIs) were held with community members, women representatives, religious leaders and key informants using two interview guides (divided by method). Behaviour change theories and a community research framework were used to summarize the findings. RESULTS: Across respondent categories and data collection methods, respondents described cancer or nekersa, which translates as 'an illness that cannot be cured', as serious and fatal. Cancer was further viewed as becoming more common and as underpinning more deaths particularly among women. Causes of cancer largely focused on individual behaviours namely mitch (referring to exposure to sunlight), poor personal hygiene and urinating on the ground/dirty areas. Almost all participants strongly related cancer to a wound that does not heal and entails a foul-smelling discharge. Bleeding and weight loss were other commonly mentioned complaints of cancer. CONCLUSIONS: Although cancer is known among rural communities in this area, misconceptions about cancer aetiology and conflation of the signs and symptoms of cancer versus other diseases merit health messaging. Our study calls for design research to determine how to culturally tailor educational materials and deliver health campaigns regarding cancer causes, signs and symptoms within this context.

Main findings: Despite efforts to enhance cancer awareness and understanding among rural residents in Ethiopia, various misconceptions persist regarding its causes, transmission and prevention measures.Added knowledge: Unfavourable community perceptions, such as viewing cancer as a death sentence and believing in scientifically unfounded causes and modes of transmission, can significantly impede efforts for cancer prevention and control.Global health impact for policy and action: Effective global health action and policy must start from the local understanding of the terminologies and the perceived cause of the disease to design all-inclusive cancer prevention and control strategies.

Cancer Care Terminology in African Languages.

Importance: Effective communication between patients and health care teams is essential in the health care setting for delivering optimal cancer care and increasing cancer awareness. While the significance of communication in health care is widely acknowledged, the topic is largely understudied within African settings. Objective: To assess how the medical language of cancer and oncology translates into African languages and what these translations mean within their cultural context. Design, Setting, and Participants: In this multinational survey study in Africa, health professionals, community health workers, researchers, and scientists involved in cancer care and research and traditional healers were invited to participate in an online survey on a voluntary basis through online platforms. The survey provided 16 cancer and oncologic terms used in cancer diagnosis and treatment (eg, cancer, radiotherapy) to participants, mostly health care workers, who were asked to provide these terms in their local languages (if the terms existed) followed by a direct or close translation of the meaning in English. The survey was open from February to April 2023. Main Outcomes and Measures: Patterns of meaning that recurred across languages were identified using thematic analysis of 16 English-translated terms categorized into 5 themes (neutral, negative, positive, phonetic or borrowed, and unknown). Results: A total of 107 responses (response rate was unavailable given the open and widespread distribution strategy) were collected from 32 countries spanning 44 African languages, with most participants (63 [59%]) aged 18 to 40 years; 54 (50%) were female. Translations for cancer were classified as phonetic or borrowed (34 [32%]), unknown (30 [28%]), neutral (24 [22%]), and negative (19 [18%]), with the latter category including universal connotations of fear, tragedy, incurability, and fatality. Similar elements connoting fear or tragedy were found in translations of terms such as malignant, chronic, and radiotherapy. The term radiotherapy yielded a high percentage of negative connotations (24 [22%]), with a prevailing theme of describing the treatment as being burned or burning with fire, heat, or electricity, which may potentially hinder treatment. Conclusions and Relevance: In this survey study of cancer communication and the translation of oncology terminology in African languages, the findings suggest that the terminology may contribute to fear, health disparities, and barriers to care and pose communication difficulties for health professionals. The results reinforce the need for culturally sensitive cancer terminology for improving cancer awareness and communication.

Family-centered care for child cancer treatment in Ethiopia-A qualitative descriptive study.

BACKGROUND: Families are the primary source of support and strength in the care process of children with cancer. Family-centered care (FCC) is a healthcare delivery approach that considers parents as both partners and care recipients, characterized by providing care based on dignity and respect, information sharing, participation, and collaboration or partnership. AIM: This study aimed to describe the delivery of care based on the family-centered care approach at the Tikur Anbessa Specialized Hospital pediatric cancer unit. METHOD: An exploratory, descriptive qualitative study was conducted from March 2023 to August 2023. Eighteen participants (thirteen parents and five health care providers) were interviewed using a semi-structured interview guide. All interviews were audio-recorded, transcribed verbatim, and translated into English. The translated transcripts were used for inductive, data-driven thematic analysis. ATLAS.ti 9 software was used to assist the analysis process. RESULT: Two themes have emerged during the analysis. These are (1) Information sharing, and (2) Enabling and partnership. Under the information sharing theme, we described parents' understanding of child cancer, parents' information-related expectations, the process of obtaining information, adequacy of information received, and factors inhibiting information sharing. Under the enabling and partnership theme, we presented family participation in childcare, discussion among parents, parents' communication with healthcare providers and psychosocial support. CONCLUSION: Suboptimal implementation of family-centered care practice was identified at the pediatric oncology unit. PRACTICE IMPLICATIONS: The findings from this study indicate the need to strengthen the provision of child cancer-related information, improve communication, and strengthen family participation in childcare.

Correction: Beyond eves and cracks: An interdisciplinary study of socio-spatial variation in urban malaria transmission in Ethiopia.

[This corrects the article DOI: 10.1371/journal.pgph.0000173.].

Determinants of tuberculosis disease development in children in central Ethiopia: A matched case-control study.

BACKGROUND: The risk factors for tuberculosis (TB) disease development in children remained understudied, particularly in low-income countries like Ethiopia. The objective of this study was to identify determinants of TB disease development in general and in relation to BCG vaccination in children in central Ethiopia. METHODS: We employed a 1:1 age-matched case-control design to compare the characteristics of children who developed TB (cases) with those who did not (controls). Data were collected in healthcare facilities in Addis Ababa city, Adama, and Bishoftu towns between September 25, 2021, and June 24, 2022. Two hundred and fifty-six cases were drawn at random from a list of childhood TB patients entered into SPSS software, and 256 controls were selected sequentially at triage from the same healthcare facilities where the cases were treated. A bivariate conditional logistic regression analysis was performed first to select candidate variables with p-values less than or equal to 0.20 for the multivariable model. Finally, variables with a p-value less than 0.05 for a matched adjusted odds ratio (mORadj) were reported as independent determinants of TB disease development. RESULTS: The mean age of the cases was nine years, while that of the controls was 10 years. Males comprised 126 cases (49.2%) and 119 controls (46.5%), with the remainder being females. Ninety-nine (38.7%) of the cases were not BCG-vaccinated, compared to 58 (22.7%) of the controls. Household TB contact was experienced by 43 (16.8%) of the cases and 10 (3.9%) of the controls. Twenty-two (8.6%) of the cases and six (2.3%) of the controls were exposed to a cigarette smoker in their household. Twenty-two (8.6%) of the cases and three (1.2%) of the controls were positive for HIV. Children who were not vaccinated with BCG at birth or within two weeks of birth had more than twice the odds (mORadj = 2.11, 95% CI = 1.28-3.48) of developing TB compared to those who were. Children who ever lived with a TB-sick family member (mORadj = 4.28, 95% CI = 1.95-9.39), smoking family members (mORadj = 3.15, 95% CI = 1.07-9.27), and HIV-infected children (mORadj = 8.71, 95% CI = 1.96-38.66) also had higher odds of developing TB disease than their counterparts. CONCLUSIONS: Being BCG-unvaccinated, having household TB contact, having a smoker in the household, and being HIV-infected were found to be independent determinants of TB disease development among children.

Spatiotemporal Distribution, Time to Treatment Outcome Clustering and Determinants of Esophageal Cancer in Ethiopia, a Scoping Study.

INTRODUCTION: Esophageal cancer was the eighth and sixth leading cause of morbidity of all cancers in the world, and the 15th and 12th in Ethiopia, respectively. There is a lack of comprehensive data regarding Ethiopia's esophageal cancer hotspot, treatment outcome clustering, and other factors. OBJECTIVE: This scoping review was designed to understand the extent and type of existing evidence regarding spatiotemporal distribution, time to treatment outcome clustering, and determinants of esophageal cancer in Ethiopia up to March 28, 2023. METHODS: Three-step search strategies were employed for the scoping review from March 15 to 28, 2023. Targeted databases included PubMed/Medline, PubMed Central (PMC), Google Scholar, Hinari, and Cochrane for published studies and different websites for unpublished studies for evidence synthesis. Data were extracted using the Joanna Briggs Institute (JBI) manual format. RESULTS: Our final analysis comprised 17 (16 quantitative and 1 qualitative) studies. Three studies attempted to depict the country's temporal distribution, whereas 12 studies showed the spatial distribution of esophageal cancer by proportion. The regional state of Oromia recorded a high percentage of cases. Numerous risk factors linked to the tumor have been identified in 8 investigations. Similarly, 5 studies went into detail regarding the likelihood of survival and the factors that contribute to malignancy, while 2 studies covered the results of disease-related treatments. CONCLUSIONS: The substantial body of data that underpins this finding supports the fact that esophageal cancer has several risk factors and that its prevalence varies greatly across the country and among regions. Surgery, radiotherapy, or chemotherapy helped the patient live longer. However, no research has investigated which treatment is best for boosting patient survival and survival clustering. Therefore, research with robust models for regional distribution, clustering of time to treatment outcomes, and drivers of esophageal cancer will be needed.

The review was based on 17 studies searched from five electronic databases, and six additional sources. Esophageal cancer incidence varies across the nation (from region to region). The median survival time of esophageal cancer cases were four months, and six months. No study investigated the better treatment that improved the survival of patients with esophageal cancer. A contradicting report were found about the link b/n khat chewing and esophageal cancer. The temporal distribution of the tumor was controversial.

Understanding referral of patients with cancer in rural Ethiopia: a qualitative study.

BACKGROUND: Cancer incidence is increasing in Ethiopia mainly due to increased life expectancy, while oncological capacities remain limited. Strong referral linkages between different levels of the healthcare system are key to provide timely access to cancer care. In this qualitative study, we assessed limitations and potential of cancer patient referral in the rural Southwest of Ethiopia. METHODS: We held four focus group discussions (FGD) with health professionals at one primary and three secondary hospitals and conducted eight in-depth interviews (IDI) with the hospitals´ medical executives and local health bureau representatives. Data was analysed inductively using thematic analysis and emerging themes were categorized within the revised concept of access by Penchansky and Saurman. RESULTS: The inevitable referral of patients with cancer in the rural Southwest of Ethiopia is characterized by the absence of clear communication protocols and the lack of formal referral linkages. The newly implemented hub-system has improved emergency referrals and could be expanded to non-emergency referrals, sensitive to the needs of advanced oncological care. Liaison officers can pave the way but need to be trained and equipped adequately. Referred patients struggle with inadequate transportation systems, the lack of accommodation close to specialized facilities as well as the inability to navigate at those sites due to language barriers, illiteracy, and stigmatization. Few Non-Governmental Organizations (NGOs) help but cannot compensate the limited governmental support. The shortage of medications at public hospitals leads to patients being directed to costly private pharmacies. In the light of those challenges, cancer remains to be perceived as a "death sentence" within the rural communities. CONCLUSIONS: Standardized referral linkages and a multi-faceted support network throughout the cancer care continuum are necessary to make oncology care accessible to Ethiopia´s large rural population.

One-year outcomes of traumatic injuries among survivors in Ethiopia: a cross-sectional study on the employment outcomes and functioning state.

Background: Traumatic injury is one of the top public health challenges globally. Injury survivors often experience poor health and functioning and restricted participation in employment. In Ethiopia, there is a paucity of evidence about the long-term consequences of injuries, particularly about their employment outcomes and disability status. This study characterizes injury survivors by their preinjury status, injury characteristics, postinjury employment outcomes and disability status 1 year post injury. Methods: An institution-based cross-sectional study was conducted on injury survivors who received services from a large public hospital in Addis Ababa. Medical records of all emergency room patients who visited the hospital within a 3-month period were reviewed to identify those who were eligible. A structured questionnaire was completed using a telephone interview. Descriptive statistics were used to characterize the outcomes. Results: Of the 254 participants, 78% were men, 48% were young adults (age 25-39 years), 41% were injured by road traffic collision, 52% were admitted to the hospital for up to a week and only 16% received compensation for the injury. Before the injury, 87% were working in manual labor. One-year after the injury, the total return to work (RTW) rate was 59%; 61% of participants experienced some level of disability, 33% had at least one type of chronic illness and 56% reported challenges of physical stressors when attempting to RTW. Among the 150 who returned to work, 46% returned within 12 weeks, 78% to the same employer and most received support from multiple sources, including community-level institutions (88%) and families/friends (67%). Conclusion: Traumatic injury substantially impacted the employment outcomes of survivors and contributed to increased disability in Ethiopia. This study lays a foundation for future research and contributes crucial evidence for advocacy to improve injury prevention and trauma rehabilitation in low and middle-income contexts. Level of evidence: II.

The magnitude of unfavorable tuberculosis treatment outcomes and their relation with baseline undernutrition and sustained undernutrition among children receiving tuberculosis treatment in central Ethiopia.

Background: One of the global key indicators for monitoring the implementation of the World Health Organization's End Tuberculosis (TB) Strategy is the treatment outcome rate. Objective: This study aims to assess the magnitude of unfavorable treatment outcomes and estimate their relationship with baseline undernutrition and sustained undernutrition among children receiving TB treatment in central Ethiopia. Methods: This retrospective cohort study included children treated for drug-susceptible TB between June 2014 and February 2022. The study comprised children aged 16 and younger who were treated in 32 randomly selected healthcare facilities. A log-binomial model was used to compute adjusted risk ratios (aRR) with 95% confidence intervals (CIs). Results: Of 640 children, 42 (6.6%; 95% CI = 4.8-8.8%) had an unfavorable TB treatment outcomes, with 31 (73.8%; 95% CI = 58.0-86.1%) occurring during the continuation phase of TB treatment. We confirmed that baseline undernutrition (aRR = 2.68; 95% CI = 1.53-4.71), age less than 10 years (aRR = 2.69; 95% CI = 1.56-4.61), HIV infection (aRR = 2.62; 95% CI = 1.50-4.59), and relapsed TB (aRR = 3.19; 95% CI = 1.79-4.71) were independent predictors of unfavorable TB treatment outcomes. When we looked separately at children who had been on TB treatment for two months or more, we found that sustained undernutrition (aRR = 3.76; 95% CI = 1.90-7.43), age below ten years (aRR = 2.60; 95% CI = 1.31-5.15), and HIV infection (aRR = 2.26; 95% CI = 1.11-4.59) remained predictors of unfavorable outcomes, just as they had in the first two months. However, the effect of relapsed TB became insignificant (aRR = 2.81; 95% CI = 0.96-8.22) after the first two months TB treatment. Conclusions: The magnitude of unfavorable TB treatment outcomes among children in central Ethiopia met the World Health Organization's 2025 milestone. Nearly three-quarters of unfavorable TB treatment outcomes occurred during the continuation phase of TB treatment. Baseline undernutrition, sustained undernutrition, younger age, HIV infection, and relapsed TB were found to be independent predictors of unfavorable TB treatment outcomes among children receiving TB treatment in central Ethiopia.

Willingness and ability to pay for breast cancer treatment among patients from Addis Ababa, Ethiopia: A cross-sectional study.

INTRODUCTION: Breast cancer (BC) is the most common malignant neoplasm among women in Addis Ababa, Ethiopia. The willingness and ability to pay (WATP) for treatment is a contributing factor in the utilization of health care services. The World Health Organization Breast Cancer Initiative calls for 80% of patients to complete multimodality treatment and indicates payment as central factor to improve BC outcome. The objectives of this study are to identify how much female BC patients paid in Addis Ababa for BC treatment, their WATP for BC treatment, and the factors that affect WATP. METHODS: The researchers collected data from 204 randomly selected BC patients who were treated in one of four different health facilities (one public and three private) between September 2018 and May 2019. A structured questionnaire was used to assess their WATP for BC treatment and multivariable regression to investigate factors associated with patients' WATP. RESULTS: Of interviewed patients, 146 (72%) were at reproductive age. Patients' median expenditure for all BC treatment services was 336 US dollars (USD) in a public cancer center and 926 USD in privately owned health facilities. These amounts are in contrast with a reported WATP of 50 USD and 149 USD. WATP increased with increasing expenditure (OR 1.43; 95% CI 1.09 to 1.89 per 100 US), educational level (OR 1.37; 95% CI 1.02 to 1.85) and service quality (OR 1.34; 95% CI 1.04 to 1.72). In contrast, a monthly income increase by 100 USD corresponds to a 17% decrease of WATP (OR 0.83; 95% CI 0.70 to 0.99). CONCLUSIONS: We demonstrated that BC treatment was very expensive for patients, and the cost was much higher than their WATP. Thus, we suggest that BC should be included in both social and community-based health insurance plans and treatment fees should consider patients' WATP.

Health-related quality of life assessment among patients with oesophageal cancer at Tikur Anbessa Specialised Tertiary Hospital in Ethiopia: a cross sectional study.

Background: In low-income countries, oesophageal cancer often presents at an advanced stage, leaving patients with limited curative treatment options. Furthermore, palliative treatments such as oesophageal stents or brachytherapy are lacking. This has a detrimental effect on their quality of life. In this study, we investigated the health-related quality of life of patients with oesophageal cancer at a tertiary hospital in Ethiopia. Methods: This cross-sectional study was conducted at Tikur Anbessa Specialised Tertiary Hospital in Ethiopia. The validated Amharic version of the questionnaire of the European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire Cancer 30 (EORTC QLQ C-30) and the oesophageal cancer disease-specific questionnaire QLQ-OES18 were used to assess the quality of life of each patient. Results: The overall mean score for the EORTC QLQ C-30 was 35.43 (SD 18.04). The mean scores for the functional scales revealed that cognitive function was the highest, whereas role function was the lowest. The symptom scale results showed the highest score for pain and the lowest for diarrhoea. Dysphagia, choking, role functioning and financial difficulty correlated with the quality of life of patients with oesophageal cancer. Conclusion: Dysphagia, choking, role functioning and financial difficulty are important factors that affect the quality of life of patients with oesophageal cancer patients. Increasing the availability of palliative treatments for dysphagia to improve the quality of life in patients with oesophageal cancer is recommended.

Catastrophic Health Expenditure and Associated Factors Among Hospitalized Cancer Patients in Addis Ababa, Ethiopia.

Background: Out-of-pocket (OOP) health expenditures for cancer care expose households to unanticipated economic consequences. When the available health services are mainly dependent on OOP expenditure, the household faces catastrophic health expenditure (CHE). This study aimed to estimate the incidence and intensity of CHE in hospitalized cancer patients and identify coping strategies and associated factors. Method and Material: Hospital-based cross-sectional study design was conducted on 305 cancer inpatients in Addis Ababa between November 2021 and February 2022. All patients with cancer who were hospitalized during the data collection period were included in the study. The incidence of CHE was estimated at the 40% threshold of households' non-food expenditure and the intensity of CHE was captured based on the amount by which household expenditure exceeded the threshold and mean positive overshoot, the mean level by which CHE exceeds the threshold used. Multivariate logistic regression was used to assess the relationship between CHE levels and the independent variables. Results: The incidence of CHE at the 40% threshold of households' non-food expenditure was 77.7%, while the O and MPO were 36.2% and 46.6%, respectively. CHE for cancer care was significantly associated with patient residence, increased number of chemotherapy cycles, increased duration of hospital admission, lack of insurance enrolment, and lower-income quintiles. Saving and selling assets were identified as the primary coping mechanisms. Conclusion: The incidence and intensity of CHE among inpatients with cancer were high and which could lead to impoverishment of households. Improved quality and coverage of health insurance and decentralizing cancer care to regions standards similar to Addis Ababa will save households from incurring CHE.

Level of Family centered care and associated factors among parents of children with cancer at tertiary level hospital, Ethiopia.

OBJECTIVE: To determining level and factors affecting Family Centered Care (FCC) in pediatric oncology unit of Tikur Anbessa Specialized hospital (TASH), Ethiopia. METHOD: A cross sectional study was conducted from June to December 2022. Three hundred ninety-three parents of children with cancer were consecutively interviewed using Measure of Processes of Care (MPOC-20). Multivariable linear regression was used to identify independent predictors of FCC. RESULT: The total MPOC 20 means was 3.71(SD = 1.04). The mean score for respectful and supportive care, coordinated and comprehensive care, enabling and partnership, providing specific information and providing general information were found to be 4.8, 4.6, 3.7, 2.3 and 2.6, respectively. Family employment (-0.33(95% CI = -0.63, -0.03; P = .029)), low family education (-0.40 (95% CI = -0.70, -0.11; P = .008)), referral cases (-0.37(95% CI = -0.59, -0.14; P = .001)), shorter time spent in hospital (-0.49(95% CI = -0.85, -0.12; P = .010)) and psychological distress (-0.01(95% CI = -0.026, -0.001; P = .028)) were associated with lower mean score of FCC. CONCLUSION: The total FCC mean score was found to be low. From the five FCC components providing general and specific information scored the lowest mean level. PRACTICE IMPLICATIONS: Mechanism to improve information delivery that address parents from different background and referred from other health facility should be in place in order to improve FCC level. In addition, the FCC should be designed to address parents of children with different lengths of stay.

Adherence to Treatment and Follow-Up of Precancerous Cervical Lesions in Ethiopia.

BACKGROUND: In Ethiopia, both incidence and mortality of cervical cancer are relatively high. Screening services, which were implemented during the past few years, are currently being expanded. The World Health Organization recommends patients with a positive VIA (visual inspection with acetic acid) result should immediately receive treatment followed by rescreening after 1 year as precancerous lesions can reoccur or become residential despite treatment. MATERIALS AND METHODS: Screening logbooks dating between 2017 and 2020 were retrospectively reviewed in 14 health facilities of Addis Ababa and Oromia region. Data for 741 women with a VIA-positive result were extracted and those women were asked to participate in a questionnaire-based phone interview to gain insights about adherence to treatment and follow-up. Data were analyzed using descriptive methods and then fitted into 2 generalized linear models to test variables for an influence on adherence to follow up. RESULTS: Around 13 800 women had received a VIA screening, of which approximately 820 (5.9%) were VIA positive. While over 90% of women with a positive screen received treatment, only about half of the treated patients returned for a follow-up examination. After treatment, 31 women had a VIA-positive re-screen. We found that educational status, age over 40, no/incorrect follow-up appointment, health facility-related barriers, and use of reminders are important drivers of adherence to follow up. CONCLUSION: Our results revealed that adherence to treatment after VIA positive screening is relatively high whereas adherence to follow up recommendations still needs improvement. Reminders like appointment cards and phone calls can effectively reduce the loss of follow-up.

"How can a woman live without having a breast?": challenges related to mastectomy in Ethiopia.

BACKGROUND: Although mastectomy is the standard treatment modality for breast cancer patients in Ethiopia, our previous study revealed that one in five patients do not receive the recommended procedure, half due to patient refusal or lack of returning to the hospital. Therefore, this study aimed to explore reasons for refusing mastectomy and identify challenges among breast cancer patients in Ethiopia. METHODS: An explorative qualitative study was conducted in four hospitals located in the towns of Woliso, Butajira, Hossana, and Assela. A total of 14 in-depth interviews (IDIs) and eight focus group discussions (FGDs) were held with breast cancer patients, patient relatives, and health professionals. Four semi-structured interview guides were used to facilitate the IDIs and FDGs. All recorded IDIs and FGDs were transcribed and translated verbatim and entered in NVivo 12 software. Emerging ideas were categorised and explained using an inductive content analysis approach. RESULTS: Our participants reported that particularly elderly and very young women refuse to have mastectomy. The main reasons identified in this study were summarised into six themes: (i) fear of the surgical procedure, (ii) religious beliefs and practice, (iii) utilisation of traditional treatments, (iv) in relation to having a baby and breastfeeding their children (young patients often request to remove only the lump, leaving their breast tissue intact), (v) lack of awareness about the disease, and (vi) sociocultural factors and advice from the community that influence women, since breasts are considered an attribute of femininity, beauty, and motherhood. In addition, knowing someone who died after mastectomy emerged as a main reason for not having breast cancer surgery. CONCLUSIONS: High refusal rate for mastectomy has direct implication on increased breast cancer mortality. Hence, expansion of radiotherapy service is instrumental to initiate breast-conserving surgery as an alternative surgical procedure, especially for young women with early-stage breast cancer. Involving religious leaders, traditional healers, and breast cancer survivors could be an effective strategy to persuade newly diagnosed breast cancer patients. Addressing individual patient psychosocial needs and preferences may substantially improve retention of breast cancer patients in the health system.

A Qualitative Study on Psychosocial Challenges of Patients With Cancer in Ethiopia Using the Social-Ecological Model.

Cancer diagnosis and treatment can be physically arduous, disrupting patients' social and work lives. Understanding the extent of these problems is key to addressing patients' needs, but specific psychosocial challenges have not yet been well studied in resource-limited settings. A qualitative study was conducted in the capital and two regions of Ethiopia with the aim of exploring psychosocial challenges among cancer patients. A total of 14 in-depth interviews (IDIs) and 16 focus group discussions (FGDs) were done with cancer patients, health professionals, community representatives, and religious leaders. Four separate interview guides were used to facilitate the interviews and discussions. All transcribed documents, field notes, and reflexive memos were entered into NVivo 12 software, and deductive thematic analysis using the social-ecological model was applied to summarize the main findings. At an individual level, emotional distress, suicidal risk, denial, and refusal of treatment were identified immediately after diagnosis while hopelessness, feeling depressed, and fear of death were commonly reported psychosocial challenges during the course of treatment. Involvement of family members in major treatment decisions was recognized at an interpersonal level. Our result also revealed that cancer patients had strong social support from family members and close friends. In the community, traditional medicine and religious rituals were considered an alternative treatment for cancer. The findings indicate that counselling and psychoeducation are crucial for cancer patients, family members, and close friends. Awareness creation programmes should be delivered through collaboration with religious leaders and traditional healers.

Household air pollution and pneumococcal density related to nasopharyngeal inflammation in mothers and children in Ethiopia: A cross-sectional study.

BACKGROUND: Three billion people in low- and middle-income countries are exposed to household air pollution as they use biomass fuel for cooking. We investigated the associations between solid fuel use and nasopharyngeal (NP) inflammation, as well as the associations between high pneumococcal density and NP inflammation, in mothers and children in rural and urban Ethiopia. MATERIALS AND METHODS: Sixty pairs of mothers (median age, 30 years; range, 19-45 years) with a child (median age, 9 months; range, 1-24 months) were included from rural Butajira (n = 30) and urban Addis Ababa (n = 30) in Ethiopia. The cohort was randomly selected from a previous study of 545 mother/child pairs included 2016. Questionnaire-based data were collected which included fuel type used (solid: wood, charcoal, dung or crop waste; cleaner: electricity, liquefied petroleum gas). Nasopharyngeal (NP) samples were collected from all mothers and children and analyzed for the levels of 18 cytokines using a Luminex immunoassay. Pneumococcal DNA densities were measured by a real-time multiplex PCR and a high pneumococcal density was defined as a cyclic threshold (Ct) value ≤ 30. RESULTS: Mothers from rural areas had higher median CXCL8 levels in NP secretions than those from urban areas (8000 versus 1900 pg/mL; p < 0.01), while rural children had slightly higher IL-10 levels than those from the urban area (26 vs 13 pg/mL; p = 0.04). No associations between fuel type and cytokine levels were found. However, a high pneumococcal density was associated with higher levels of cytokines in both mothers (CCL4, CXCL8, IL-1ß, IL-6 and VEGF-A) and children (CCL4, CXCL8, IL-1ß, IL-6 and IL-18). CONCLUSIONS: No significant associations were found between solid fuel use and NP inflammation in Ethiopian mothers and children, but the inflammatory activity was higher in individuals living in the rural compared to the urban area. In addition, high cytokine levels were associated with high pneumococcal density in both mothers and children, indicating a significant impact of NP pathogens on inflammatory mediator levels in upper airways.

Intention to Undergo Clinical Breast Examination and Its Associated Factors among Women Attending Rural Primary Healthcare Facilities in South Central Ethiopia.

Background: Breast cancer is a global public health problem with higher mortality in developing countries. The Ethiopian National Cancer Control Plan recommends clinical breast examination (CBE) for all women aged >18 years. However, there is low breast examination practice in Ethiopia. Therefore, this study aimed to describe level of intention to undergo CBE and associated factors among women visited selected rural healthcare facilities in south central Ethiopia using Theory of Planned Behavior (TPB). Methods: This study used facility-based cross-sectional study design. A total of 420 women participated in this study. Interviewer-administered structured questionnaire was adopted from previously published research works and Ajzen's TPB manual. Statistical Package for Social Sciences (SPSS), version 27, was used for analysis. Binary logistic regression model was used to determine factors associated with intention to undergo CBE. Results: In this study, nine out of ten women had never had CBE. Mean score for intention to undergo CBE was 12.55 (SD ± 3.22; min 5, max 20). Intention to undergo CBE was negatively associated with being in the second and middle wealth quantiles compared to the highest wealth quantile, and with the spouse not being able to read or write compared to having attended formal education. Positive attitude and higher subjective norm had relevant association with intention to undergo CBE. Conclusion: The high score for intention to undergo CBE should encourage primary healthcare facilities to offer CBE. Behavioral change communication interventions could address women's attitude, subjective norm, and spouse's education associated with intention to undergo CBE.

Association of Delay in Breast Cancer Diagnosis With Survival in Addis Ababa, Ethiopia: A Prospective Cohort Study.

PURPOSE: There are limited data on the association between delay in breast cancer diagnosis after breast symptom recognition and survival, particularly in sub-Saharan Africa. The recently launched Global Breast Cancer Initiative by WHO includes measuring delay as the core indicator for quality of breast cancer care. Herein, we examined the association between delay in breast cancer diagnosis with overall survival among women in Addis Ababa, Ethiopia. MATERIALS AND METHODS: A total of 439 women diagnosed with breast cancer from January 1, 2017, to June 30, 2018, in Addis Ababa were followed for survival to the end of 2019. Survival rates were estimated using the Kaplan-Meier method. The association between delay in diagnosis (>3 months after symptom recognition) and overall survival was computed using the multivariable Cox regression model after adjusting for demographic and clinical factors. RESULTS: Nearly 70% (303/439) of women with breast cancer were delayed in diagnosis of their cancer. During a median follow-up period of 25.1 months, 2-year overall survival rate was 73.5% (95% CI, 68.0 to 78.2) in women with diagnosis delay compared with 79.1% (95% CI, 71.2 to 85.1) in those women without diagnosis delay. In the multivariable Cox regression model, the risk of death was 73% higher (hazard ratio, 1.73; 95% CI, 1.09 to 2.74) in women with diagnosis delay compared with those without diagnosis delay. CONCLUSION: Delay in diagnostic confirmation of breast cancer after recognition of breast symptoms was negatively associated with overall survival in Addis Ababa, Ethiopia, underscoring the need to increase awareness about the importance of prompt presentation for clinical evaluation and referral for diagnostic confirmation to mitigate the undue high burden of the disease.