Palliative care service utilization and associated factors among cancer patients at oncology units of public hospitals in Addis Ababa, Ethiopia

Nigus Afessa; Dagmawit Birhanu; Belete Negese; Mitiku Tefera

doi:10.1371/journal.pone.0294230

. 2024 Mar 14;19(3):e0294230. doi: 10.1371/journal.pone.0294230

Palliative care service utilization and associated factors among cancer patients at oncology units of public hospitals in Addis Ababa, Ethiopia

Nigus Afessa ¹, Dagmawit Birhanu ¹, Belete Negese ¹, Mitiku Tefera ^2,^*

Editor: Tariku Shimels³

PMCID: PMC10939243 PMID: 38483983

Abstract

Background

Palliative care helps patients and their families deal with the hardships that come with a life-threatening illness. However, patients were not fully utilizing the palliative care services provided by healthcare facilities for a number of reasons. In Ethiopia, there hasn’t been any research done on the variables that influence the utilization of palliative care services.

Objective

To assess palliative care service utilization & associated factors affecting cancer patients at public hospitals oncology units in Addis Ababa, Ethiopia.

Methods

An institution-based cross-sectional study design was carried out. A structured and pre-tested questionnaire was administered to 404 participants at Tikur Anbesa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College from July 4 to August 2, 2022. A systematic random sampling technique was used to select the study participants. The data was collected by ODK-Collect version 3.5 software and exported to excel and then to SPSS version 25 for recoding, cleaning, and analysis. Logistic regression model was employed. P-values <0.05 were regarded as statistically significant.

Result

About 404 participants’ responded questionnaire giving a 97.6% response rate. The extent of Palliative care service utilization was 35.4% [95% CI: 31.4, 40.3%]. College or university education were 2.3 times more likely and living in a distance of <23 km from PC service centers were 1.8 times more likely to use palliative care services. Factors hindering palliative care service utilization were inability to read & write, treatment side effects, long distance to a health institution, and low satisfaction with the health care service.

Conclusion and recommendation

The extent of palliative care service utilization which was low. Factors to palliative care service utilization were clients’ education level, treatment side effects, distance to a health institution, and patients’ satisfaction. Interventions to enhance health education and counseling of cancer patients, early detection and management of treatment side effects and accessibility of palliative care services for cancer patients should be emphasized and implemented by all concerned stakeholders.

Introduction

Palliative care (PC) refers to the active comprehensive care of a patient’s body, mind, and spirit, and so is a powerful complement to the psychosocial care of the entire patient [1,2]. Throughout a serious illness, palliative care emphasizes symptom management and quality of life [3]. A good understanding of the fundamentals of successful communication, symptom management, and end-of-life care is critical regardless of whether the care is inpatient or outpatient [4]. PC includes symptom control and end-of-life management, as well as communication with families and the establishment of care goals that ensure dignity in death and decision-making power [5].

Over 29 million people died worldwide as a result of conditions that needed palliative care. Of these, 9.6 million deaths are new cancer-diagnosed cases. A total of 20.4 million people were predicted to require palliative care at the end of their lives. Adults make up 94% of those who require palliative care, with 69% being over 60 years old and 25% being between 15 and 59 years old. But 78% of those in need of palliative care live in low- and middle-income countries [6,7].

Cancer is a leading cause of morbidity and mortality worldwide, especially in developed nations. In the United Kingdom, one in every two people will be diagnosed with cancer at some point in their lives, with one in every four dying from it.

The global burden of cancer is expected to keep increasing, especially in developing nations. To prevent long referral processes and delays in the delivery of care, effective cancer treatment necessitates the availability of surgery, radiation, and therapy in the same location. Chemotherapy for cancer is not currently included on the Ethiopian Essential Medicines List. In the majority of public hospitals, even basic painkillers are difficult to obtain [8].

Palliative care services are unavailable in 42% of the world’s countries. The critical shortage of palliative care services in low-resource settings results in significant personal, family, and societal expenses [9]. Most people view palliative care as a way to stop receiving life-saving treatments or to let them pass away. Moving consultation earlier in the hospitalization of "dying" patients is a bigger concern than encouraging more people to use palliative services earlier in the course of their disease [10].

Palliative care was provided to 50% of patients getting palliative radiation therapy (RT) for metastatic cancer, but it was underutilized in all patients receiving RT, particularly those with lung cancer and those treated in an outpatient environment [11].

Patients with cancer use palliative care at varying rates due to different factors [12]. According to a study done in Switzerland, patients’ and families’ misconceptions regarding palliative care serve as cognitive barriers to their use [13]. A research conducted in the United States found that among cancer patients treated as inpatients, PC services were used by 8.5% of patients throughout their stay [14].

There are different reasons that contribute to low palliative care service utilization among cancer patients in underdeveloped nations are multi-faceted, complicated, and little understood [15]. A study conducted in Ethiopia found that many cancer patients did not take advantage of palliative care services, and that patients with greater monthly incomes and families with more than two members were more likely to use these services [16]. Study’s in Africa, especially in Ethiopia variables of hindering factors like treatment side effects and distance to cancer treatment centers during palliative care services did not incorporated. Therefore, the objective of this study was to assess palliative care service utilization status and factors affecting it among patients diagnosed with cancer at public hospitals oncology unit in Addis Ababa, Ethiopia (see Fig 1).

Methods

Study design, setting and period

An institutional-based cross-sectional study was conducted. The study was conducted at Tikur Anbesa Specialized Hospital (TASH) and Saint Paul’s Hospital Millennium Medical College (SPHMMC) which are located at the capital city of Ethiopia, Addis Ababa from July 4 to August 2, 2022.

Population

Source population

All adult patients diagnosed with cancer at Tikur Anbesa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia, 2022.

Study population

Selected adult patients diagnosed with cancer at Tikur Anbesa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College oncology unit, Addis Ababa, Ethiopia, 2022

Eligibility criteria

Inclusion criteria

All adult cancer patients (aged ≥ 18 years) who had been diagnosed with any type of cancer and on treatment follow-up before the data collection period were included in the study.

Exclusion criteria

Those critically ill patients diagnosed with cancer who were non cooperative during the data collection period were excluded.

Sample size determination and Sampling procedure

The sample size for this study was generated using a formula for a single population proportion based on the assumptions listed below. A 95% confidence level, the margin of error (0.05), a previous related study of proportion 0.572 [17] and by taking 10% non-response rate, then the total sample size required to this study was 414 cancer patients.

Both TASH and SPHMMC oncology center public hospitals were selected and done proportional allocation to each hospital based on their monthly number of patients on treatment follow-up. A systematic random sampling technique was used to select the study participants, and the registration log book of adult patients diagnosed with cancer was used as a sampling frame. The first participant was selected by lottery method, while the remaining individuals were selected by every two k intervals across both hospitals (see Fig 2).

Data collection methods

Two nurses and one supervisor were trained for the data collection. A standardized interviewer-administered questionnaire adapted from different literature [17–19] and modified in the current context was used to collect data. ODK-Collect software version 3.5 was used to collect data. The questionnaire was written in English following a thorough assessment of previously verified published research. Then, the questionnaire was translated to the Amharic language and the data collector used the Amharic version of the questionnaire to collect data from the study participants. Again, it was translated back into English for analysis.

Study variables

Dependent variable

➢ Palliative Care Service Utilization

Independent variables

Predisposing factors

Socio- demographic characteristics: age, sex, educational status, marital status, Religion and residence Health beliefs factors: knowledge and attitude

Health Need factors–perceived severity of illness, treatment side effects

Enabling factors–family income, occupational status, satisfaction, distance to health facility & transportation fee

Health system factors–health service fee, availability of medications and procedures, bureaucracy services, time and attention from health care provider

Data quality management

Data collectors and supervisors were trained in data gathering processes using ODK-Collect software to ensure that the data was of high quality. The questionnaire was properly designed and written in English first, then translated into Amharic by language experts, and finally back to English to ensure consistency. Before the questionnaire was used to collect data, it was pretested on 5% (21) of cancer patients at Dessie referral hospital and any necessary adjustments or modifications were made like language translation errors and coherence. On a daily basis, the main investigators have been evaluated and checked the obtained data for completeness and consistency. Finally, data was gathered using an Amharic version.

Data processing and analysis

Before data collection, each questionnaire was double-checked for accuracy and kobo Toolbox templet for ODK application data collection was coded and then collected data was exported to excel and from excel to SPSS version 25 for recoding, cleaning, and analysis. Bivariate logistic regression was utilized to look at parameters related to palliative care usage. To choose potential variables for multivariable logistic regression analysis, first a bivariate logistic regression analysis was employed. Bi-variable logistic regression variables with p-values <0.25 were incorporated into a multivariable logistic regression model to discover their independent correlation with the dependent variable. P-values <0.05 were regarded as statistically significant. The multivariable analysis results were presented as an adjusted odds ratio with a 95% confidence interval. Descriptive statistics were used to present socio-demographic and other palliative care data. The Hosmer-Lemshow goodness test for the regression model’s fitness was checked and the multi-collinearity test result with a VIF ranged from 1.042 to 1.619.

Operational definitions

Palliative care service utilization: Respondents who scored above median level for 8 outcome measuring variables were considered as adequate utilization, while those who scored equals and or below median level were considered to inadequate utilization [20,21].

Knowledge about Palliative care

Based on 13 PaCKS questions; if a respondent answers ≥ 50% questions correctly, considered as adequate knowledge and if a respondent answers <50% questions correctly, considered as inadequate knowledge [18].

Attitude to Palliative care

based on the patients response to the 5 attitude questions; if a respondent answers above median level, considered as good attitude and if a respondent answers equals and or below median level, considered as poor attitude [17].

Satisfaction

based on the patient’s response to the 8 satisfaction questions; if patients’ response above median level were considered to satisfied, and if patients’ response equals and or below median level considered to be unsatisfied.

Severity of pain

based on WHO pain scale classification [22];

No Pain–pain Free
Mild Pain–Nagging, annoying, but doesn’t really interfere with daily living activities.
Moderate Pain–Interferes significantly with daily living activities.
Severe Pain–Disabling & unable to perform daily living activities.

Ethical consideration

The proposal was presented to Debre Berhan University Asrat Weldeyes Health Science Campus. A supportive letter and an ethical clearance paper from the Deber-Berehan University Aserat Woldeyese Health Science campus prior to the data gathering period were granted and submitted to the cancer center hospital’s administrative offices. Then those institutions gave me permission to collect data. The responders’ dignity and rights were respected as well. Each respondent’s verbal consent was obtained prior to any data collection, and because medical histories are sensitive personal matters, the importance of maintaining confidentiality was explained.

Result

Predisposing factors

Sociodemographic characteristics

A total of 404 cancer patients agreed to take part in the survey and completed the questionnaires, with a response rate of 97.56%. 63.4% of the participants in the study were between the ages of 18 and 47. The major portion of participants was married (73.8%), females (56.7%) & had a college or university degree (44.8%), while 12% of them were Unable to read & write. Most of participants 63.4% resided in urban (Table 1).

Table 1. Socio-demographic characteristics of adult cancer patients receiving palliative care services in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Characteristics		Frequency	Percentage
Age	18–47 48–63 ≥64	256 103 45	63.4 25.5 11.1
Gender	Female Male	229 175	56.7 43.3
Residence	Rural Urban	148 256	36.6 63.4
Marital status	Single Married Divorced Widowed	60 298 21 25	14.8 73.8 5.2 6.2
Family size	1–2 3–4 ≥ 5	57 201 146	14.1 49.8 36.1
Education Level	Unable to read & write Primary school Secondary school College/university	49 75 99 181	12.1 18.6 24.5 44.8
Religion	Orthodox Protestant Muslim Other	181 85 118 20	44.8 21.0 29.2 5.0

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Health belief factors (knowledge, attitude)

Knowledge

Less than half (48.5%) of participants believed that the goal of palliative care was to address psychological issues caused by an incurable disease. Only 21.3% of patients thought that palliative care was gave exclusively for people who were six months or closer to passing away. While 83.2% thought that the hospital was the only place where palliative care could be accessed (Table 2).

Table 2. Knowledge status of adult Cancer patients towards palliative care service utilization in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Characteristics		Frequency	Percentage
A goal of Palliative Care is to address any psychological issues brought up by serious illness.	Yes No	196 208	48.5 51.5
Stress from serious illness can be addressed by palliative care	Yes No	189 215	46.8 53.2
Palliative Care can help people manage the side effects of their medical treatment	Yes No	349 55	86.4 13.6
When people receive Palliative Care, they must give up their other doctor	Yes No	169 235	41.8 58.2
Palliative Care is exclusively for people who are in the last six months of life	Yes No	86 318	21.3 78.7
Palliative care is specifically for people with cancer	Yes No	241 163	59.7 40.3
People must be in the hospital to receive palliative care	Yes No	336 68	83.2 16.8
Palliative care is designed specifically for older adults	Yes No	202 202	50.0 50.0
Palliative care is a team-based approach to care	Yes No	316 88	78.2 21.8
A goal of Palliative Care is to help people better understand their treatment options	Yes No	394 10	97.5 2.5
Palliative care encourages people to stop treatments aimed at curing their illness	Yes No	5 399	1.2 98.8
A goal of palliative care is to improve a person’s ability to participate in daily activities	Yes No	379 25	93.8 6.2
Palliative care helps the whole family cope with a serious illness	Yes No	191 213	47.3 52.7

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Attitude

Participants who have good attitude towards palliative care service utilization were 35.1%. 36.9% were not frightened to consider using palliative care, and 89.4% of them wish to use palliative care services. From the study participants, 52.5% were not believed to give PC in conjunction with curative cancer treatments (Table 3).

Table 3. Attitude status of adult Cancer patients towards palliative care service utilization in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Characteristics	Frequency	Percentage
Cancer patients afraid even to think about Palliative care utilization Good Poor	149 255	36.9 63.1
The thought of Palliative care utilization scares. Good Poor	237 167	58.7 41.3
Cancer patients want to use Palliative care services. Good Poor	361 43	89.4 10.6
Cancer patients have a close relationship with their Palliative care health service providers Good Poor	264 140	65.3 34.7
PC cannot be delivered concurrently with curative cancer treatments Good Poor	212 192	52.5 47.5
Attitude towards Palliative Care Service Utilization Good Poor	142 262	35.1 64.9

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Health need factors

Cancer site

The most common type of cancer among the participants was breast cancer, affecting 30.9% of them (see Fig 3).

Severity of pain and treatment side effects

The majority of them reported mild to moderate pain. A 70.8% of cancer patients had side effects from their treatments. Among the treatment side effects, gastro intestinal disturbance (anorexia, nausea, vomiting, and diarrhea) account for 21% (Table 4).

Table 4. Severity of pain & treatment side effects of adult cancer patients receiving palliative care services in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Characteristics		Frequency	Percent
Rate of pain scale	No pain Mild pain Moderate pain Severe pain	60 124 146 74	14.9 30.7 36.1 18.3
Treatment side effects	Gastrointestinal disturbance Skin problems Central nevus system manifestation Loss of hair Muscle & joint stiffness Total patients treatment side effect experienced	86 63 63 46 28 286	21.3 15.6 15.6 11.4 6.9 70.8

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GI disturbance = anorexia, nausea, vomiting, and diarrhea, Skin problems = Bruising/ Itching/ Sore mouth, CNS manifestation = Tiredness, Headache.

Enabling factors

Occupation, monthly income & satisfaction

The participants’ average monthly income was <3001 Ethiopian Birr, and 22.5% of them worked for the government. Most cancer patients (68.6%) have had satisfaction. The majority of them (91.6%) were satisfied with the counseling services, although the majorities were not with the service brochure (97%), reception conditions & recreation room (80.4%), telephone help, and cancer advisory (89.4%). Access to information satisfied 69.6% of participants, but home nursing care and charitable support left 100% respectively. About 97.3% of cancer patients said they were satisfied with their family’s support (Tables 5 and 6).

Table 5. Jobs held by adult cancer patients and their monthly wages in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Variables	Frequency	Percentage
Occupation Governmental employee Farmer Merchant Other	91 97 63 153	22.5 24.0 15.6 37.9
Monthly income <3001 3001–6000 >6000	187 105 112	46.3 26.0 27.7

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Table 6. Satisfaction of adult Cancer patient with institutional services and family support in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Variables	Frequency	Percentage
Counseling services Satisfied Unsatisfied	370 34	91.6 8.4
Service brochure & benefit Satisfied Unsatisfied	12 392	3.0 97.0
Reception conditions & recreation room Satisfied Unsatisfied	79 325	19.6 80.4
Telephone support and cancer advisory Satisfied Unsatisfied	43 361	10.6 89.4
Access to information Satisfied Unsatisfied	281 123	69.6 30.4
Home nursing service Satisfied Unsatisfied	0 404	0 100.0
Charity support Satisfied Unsatisfied	54 350	13.4 86.6
Family support Satisfied Unsatisfied	393 11	97.3 2.7
Over all patients satisfaction High satisfaction Low satisfaction	277 127	68.6 31.4

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Health system factors

According to the responses from the participants, 72.5% of them revealed that hospitals had bureaucratic procedures for accessing palliative care, and just 13.6% said that all medications and procedures were readily available. Ninety-nine percent of patients were required to purchase their prescribed medicines outside of hospitals, and the majority of patients (79.7%) had trouble paying their hospital bills. But 81.2% of the patients received enough time and attention from the service providers (Table 7).

Table 7. Responses of adult cancer patients to health system factor questions in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Variables	N	%
The hospital has bureaucratic procedures for receiving palliative care Yes No	293 111	72.5 27.5
All medications and procedures available Yes No	55 349	13.6 86.4
Patients are facing financial shortage for hospitalization fee Yes No	322 82	79.7 20.3
Patients are forced to buy prescribed medications outside due to stock-outs Yes No	400 4	99.0 1.0
The service providers give enough time and attention to their patients Yes No	328 76	81.2 18.8

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Prevalence of Palliative care service utilization (PCSU)

The prevalence of palliative care utilization is 35.4% [95% CI: 59.7, 68.6%] (see Fig 4).

Most cancer patients used chemotherapy (75%) and physical/pain relievers (77.2%). Those participants who used radiotherapy, surgery, psychological support, spiritual support, and financial support were 30%, 20.5%, 17.8%, 17.6%, and 0.7%, respectively. None of them were used for home nursing care (Table 8).

Table 8. Responses of adult cancer patients to outcome measuring variables of palliative care service utilization in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Variables	Frequency	Percentage
Have you received chemotherapy? Yes No	303 101	75 25
Have you received radiotherapy? Yes No	121 283	30 70
Have you received surgical treatment? Yes No	83 321	20.5 79.5
Have you received psychological/emotional support? Yes No	72 332	17.8 82.2
Have you received physical/pain relievers? Yes No	312 92	77.2 22.8
Have you received spiritual support? Yes No	71 333	17.6 82.4
Have you received financial support? Yes No	3 401	0.7 99.3

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Factors associated with palliative care service utilization

From eight variables; client education level, occupation, treatment side effects, loss of appetite, distance, availability of all medications & procedures, facing financial shortage and satisfaction found to have p value < 0.25 in the bivariate analysis, only four variables (client education level, treatment side effects, distance, and satisfaction) were found statistically significant (p value < 0.05) via the multivariable logistic regression model and strongly linked to respondents’ palliative care service utilization.

Cancer diagnosed patients who have college or university level of education were 2.3 times more likely to use palliative care services than Cancer diagnosed patients with unable to read and write (AOR = 2.3, 95% CI: 1.01, 5.16).

Cancer diagnosed patients who did not experienced a side effect from their treatment were 3.5 times more likely to use palliative care services than those who experienced treatment side effects (AOR = 3.5, 95% CI: 2.01, 6.21). Cancer diagnosed patients who traveled less than 23 km (within the area of Addis Ababa) were 1.8 times more likely than those who traveled long distance to use PC services (AOR = 1.8, 95% CI: 1.08, 3.15). Cancer diagnosed patients who satisfied by health care services were 2.1 times more likely to use palliative care services than less-satisfied cancer diagnosed patients (AOR = 2.1, 95% CI: 1.28, 3.59). On the other hand, unavailability of medications and procedures, patients’ financial shortage for hospitalization fee, and loss of appetite had an association with PCSU in binary regression but not significantly associated by adjusted odds ratio (Table 9).

Table 9. Factors associated with Palliative Care Service Utilization at Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia (n = 404).

Variables	Palliative Care Service Utilization		COR (95% CI)	AOR (95% CI)	P-value
Variables	Inadequate N (%)	Adequate N (%)	COR (95% CI)	AOR (95% CI)	P-value
Education
Unable to read & write	38 (69)	17(31)	1
Primary school	49 (65)	26(35)	1.2 (0.56, 2.50)	1.5 (0.69, 3.48)	0.295
Secondary school	63 (72)	25(28)	0.9 (0.43, 1.85)	1.8 (0.79, 4.24)	0.152
Secondary school	111(60)	75(40)	1.5 (0.79, 2.87)^**	2.3 (1.01, 5.16)	0.046^*
Occupation
Other^***	99(62)	60(38)	1
Farmer	63(69)	28(31)	0.7 (0.42, 1.27)	1.9 (0.92, 4.29)	0.079
Merchant	47(75)	16(25)	0.6 (0.29, 1.08)^**	0.7 (0.34, 1.42)	0.318
Governmental employee	52(57)	39(43)	1.2 (0.73, 2.09)	1.3 (0.69, 2.46)	0.419
Treatment side effect
Yes	210(73)	93(31)	1
No	51(43)	67(57)	3.6 (2.32, 5.68)^**	3.5 (2.01, 6.21)	<0.001^*
Loss of Appetite
Yes	208(69)	93(31)	1
No	53(51)	50(49)	2.1 (1.34, 3.33)^**	1.2 (0.62, 2.16)	0.641
Distance
>23.0 km	130(73)	48(27)	1
<23.1 km	131(58)	95(42)	1.9 (1.28, 3.00)^**	1.8 (1.08, 3.15)	0.024^*
All medications & procedures available
Poor(Not available)	209(69)	93(31)	1
Good(Available)	52(51)	50(49)	2.2 (1.37, 3.42)^**	1.4 (0.72, 2.60)	0.334
Patients are facing financial shortage for hospitalization fee
Poor(Yes)	188(69)	83(31)	1
Good(No)	73(55)	60(45)	1.8 (1.21, 2.86)^**	1.1 (0.61, 2.04)	0.726
Satisfaction
Low satisfaction	94(74)	33(26)	1
High satisfaction	167(60)	110(40)	1.8 (1.18, 2.98)^**	2.1 (1.28, 3.59)	0.004^*

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Other*** = (daily labor, private employee, unable to work because of age and/illness)

** indicates at bi-variables p = < 0.25

*indicates the variables were significant at P<0.05, COR = Crude odds ratio, AOR = Adjusted odds ratio, CI = confidence interval, 1 = reference group (those less to utilize palliative care service were considered as a reference group).

Discussion

The results of this study are in accordance with new and current national, international, and sub-Saharan African (SSA) literature on the variables influencing PC service use among patients diagnosed with cancer. The extent of palliative care service utilization in this study was 35.4% (95% CI: 31.4, 40.3%). This study was a little bit more than previous studies conducted in Asia (35.0%) and less than other studies conducted in the United States (41.9%) and in Ethiopia (TASH) (57.2%) [23–25].

The higher results in the study area might be due to a difference in study population, area, and setup. The study in Asia employed a wide area (i.e., Bangladesh, Philippines, Sri Lanka, and Vietnam) and the rate used was among those with PC awareness (n = 234). The lower results in the study area also might be due to a difference in study population, area, setup, and design. In the United States, the study design was retrospective and National Inpatient Sample data (2005–2014) was used. In the previous TASH, the source of the population was only from one cancer oncology centre, and a smaller sample size was used.

In this study, patients who were college or university education were significantly associated with the presence and use of PC service. Patients diagnosed with cancer who have college or university education were 2.3 times more likely to use palliative care services than those who unable to read and write (AOR = 2.3, 95% CI: 1.01, 5.16). This may be explained by the fact that people with higher level of education easily understand the written and oral instructions given by health care professionals, following instructions like prescriptions or appointment schedules, and understanding the health care system well enough to obtain needed services [26]. Patients with higher educational levels thus frequently receive sufficient health care services. Public education was also mentioned in the Korean study as a social need to counteract misconceptions and cultural attitudes concerning PCSU [27]. Therefore, cancer patients who are college or university education may regularly engage appointments, and follow their prescribed treatment plans, all of which might have an influence to use PC services. This factor was different from earlier findings of TASH in Ethiopia, which showed that formal education was associated with a 49% less likely to utilized palliative care services (AOR = 0.51, 95% CI: 0.23, 0.94) [25]. The reason for this discrepancy may be related to the different sample sizes and numbers of cancer centers included.

The second factor linked to the utilization of PC services was side effects from cancer therapy. Cancer patients who had no side effects from their therapy were 3.5 times more likely to utilize PC services than those who experienced treatment side effects (AOR = 3.5, 95% CI: 2.01, 6.21). No other studies were found on the relationship in this regard. This might be because unfavorable side effects such as bleeding, loss of appetite, diarrhea, exhaustion, hair loss, infections, anemia, sore mouth, and the serious side effect of neutropenia, which may be related to drugs and radiation relatively low in those participants [28,29]. On the other hand, patients from near palliative care center areas with high educational levels are more likely to engage appointments because they understand the side effects that are addressed by PC services. Because of this, those cancer patients did not experiencing side effects from their treatment receive adequate PC services.

Respondents who came from a distance of <23 km were 1.8 times more likely to use palliative care service compared to those who came from a distance of >23.1 km away from PC service centers (AOR = 1.8, 95% CI: 1.08, 3.15). This study was in agreement with the Italian study and Zimbabwe. In Italy, patients were more likely to use palliative care services if they lived less than 20 km from a facility that provided specialist palliative care [30]. Patients in Zimbabwe, who lived in closed distance from radiotherapy facilities had a higher likelihood of receiving palliative radiotherapy [31]. According to a qualitative study conducted at the Parirenyatwa Hospital in Harare, the majority of cancer patients travel great distances to receive care, which results in high transportation costs [32]. So living closest to palliative care centers could be attributed to minimize financial shortage for transportation and hospital service fees, have an access of transportation, and may have good awareness about palliative care services.

This study also showed that respondents who had high satisfaction were 2.1 times more likely to use palliative care services compared to those who had low satisfaction(AOR = 2.1, 95% CI: 1.28, 3.59). Similarly the study in South Carolina shows that patients were highly satisfied with the care they received in the multidisciplinary breast clinic (MDBC) program more likely utilize palliative care service (AOR = 3.77, 95% CI: 3.65, 3.89) [33]. On the other hand; the PC department’s appointments and the admission office’s waiting time, both of which were considered to be particularly low, were factors in the high satisfaction which increase PCSU [34]. Due to the limits of cross-sectional studies, it may not be possible to define specific qualitative criteria that are associated with PCSU from this finding. This study also did not specify which kind of medication the participants received had any particular side effects. Private cancer palliative care facilities were not also included.

Conclusion

The extent of palliative care service utilization were lower than previous studies in Ethiopia. Clients’ higher educational level, treatment side effects, distance to a medical facility, and high patient satisfaction were all significantly associated with palliative care service utilization. Health care providers working in palliative care centers should improve health education and counseling about PCSU as well as early detection and management of treatment side effects to enhance the patients’ quality of life until the end of their life. The Ministry of health should plan for the accessibility of cancer palliative care service centers outside of Addis Ababa, as well as to enhance social support. Researchers should investigate all cancer centers in Ethiopia at a national level through a variety of methods from various parties involved in the delivery of palliative care services in order to identify the factors linked to the use of such services.

Consent for data collection

During as per international standard or university standard, patient’s written consent has been collected and preserved by the data collectors.

Supporting information

S1 File. English version questioners.

(DOCX)

pone.0294230.s001.docx^{(32.6KB, docx)}

Acknowledgments

First, we want to express our heartfelt gratitude to Debre Birhan University Asrat Woldeyes Health Science Campus School of Nursing & Midwifery for giving valuable support. Secondly, the deepest gratitude to all Pre-Publication Support Service (PRESS) of PLOS ONE, the staff member of both Saint Paul’s Hospital Millennium Medical College and Tikur Anbesa Specialized hospitals, study participants and the data collectors their cooperation in this study.

Data Availability

All relevant data are within the manuscript and its Supporting Information files as well as we attached our SPSS data. But if you request at any time we will send any other data.

Funding Statement

The authors received no specific funding for this work.

References

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PLoS One. doi: 10.1371/journal.pone.0294230.r001

Decision Letter 0

Tariku Shimels

17 Apr 2023

PONE-D-23-02089

Factors affecting palliative care service utilization among cancer patients at public hospitals oncology unit Addis Ababa, Ethiopia, 2022

PLOS ONE

Dear Dr. Afessa,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Generally, the introduction is not aligned to the topic presented. Mainly, the authors are expected to cover the status of palliative care utilization, what should have been done, the gap noted and why the current study has been intended in the specified context. The extended literature on the prevalence of cancer shown in the middle of this section should be limited.
The objectives of the study should be integrated in the last section of the introduction.
The source and study population is not clearly stated. Please revise. The term ‘cancer patient/s’ is not sounding and appropriate. Please use proper terms, such as ‘patients diagnosed with cancer’.
The study appears to assume that every patient diagnosed with cancer should utilize palliative care service. How can this be possible, especially, at the early stages of the disease, or do you have any justification for this?
Line 103 ‘’ Those critically ill patients who can’t response during the data collection period were excluded’’. Please check statement for correctness and punctuation. These are patients who actually require PC, but excluded. How can this bias be accounted for?
Lines 114 and 116: ‘every 2’ and ‘3rd’ please revise.
How was the systematic random sampling methods performed in two different hospitals?
Please make tables consistent
Line 314 the statement ‘Eight variables were found to have p value < 0.025 in the bivariate analysis. Four variables were found statistically significant via the multivariable logistic regression model’ is not clear or requires revision.
Line 319: ‘….were 2.3 times AOR = 2.3, 95% CI (1.01, 5.16)…’ please check and fix rephrase statement appropriately.
Lines 321 to 324; ‘’ AOR = 1.8, 95% CI (1.08, 3.15) indicates that respondents who traveled less than 23 km (within the area of Addis Ababa) were 1.8 times more likely than those who traveled long distance to use PC services. High satisfied respondents were 2.1 times (AOR = 2.1, 95% CI (1.28, 3.59)’’ require revision. Please rephrase text of the first statement and appropriate use of the parentheses in the second statement.
Line 417: ‘’heath healthcare’’ please check and fix. Also check uniformity of writing /punctuation under this subsection.
Discussion section: flow of ideas seems confusing. The authors started a deductive approach with influencing factors followed by the prevalence, which also has been repeated latter. Please avoid the intermingled narration and follow the logical order.
The term ‘prevalence of utilization’ should be replaced by appropriate words/phrases, such as ‘level or extent of utilization’’ as it often connotes negative outcomes.

Please submit your revised manuscript by Jun 01 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Tariku Shimels, B. Pharm., B.A, M.Sc.

Academic Editor

PLOS ONE

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[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: No

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Reviewer Comment

Comment 1 (Abstract): Revise and re-write the Background makes it complete paragraph which can introduce the novice and scientific readers about palliative care service utilization.

Comment 2: In general the paper reads better. However, I comment you on the hard work. You have shown the prevalence of the palliative care service utilization as worldwide, at the continent level and the country level. That sounds good, but you didn’t show your research gap well.

Comment 3: The introduction build clearly into the research question. Nevertheless, the research

question is only expressed in the abstract, and should ideally be the last sentence of the

last paragraph.

Comment 4: Some grammatical and language errors exist throughout the article. Please have a

language expert or editor review the article as a whole.

Comment 5: "The checklist was pretested on 5% of cancer patients at Dessie referral hospital for validity and reliability "- please indicate the findings of the pilot mentioned here.

Comment 6 (Data quality management): “The questionnaire was properly designed and written in English first, then translated into Amharic by language experts”- what about other patients who were unable to hear Amharic language?

- The rest of the methodology appears clear

Comment 7 (Ethical Considerations): The study was conducted at TASH and SPHMMC oncology unit, Addis Ababa Ethiopia, but Ethical Review was obtained from Debre-Berhan University! Why? How?

Comment 8 (Results): I am not clear with indicators and parameters the author/s used to measure palliative care service utilization! This the most critical and confusing. It will be difficult to get sound scientific answers for basic research questions in the current forms of result descriptions! What is the importance of identifying factors associated with palliative care service utilization?

Comment 9: The discussion brings the results out and clearly seeks to explain the factors associated with the results found in this study. But a large portion of this discussion is then spent on comparing the results with other studies from Africa and abroad, and commenting that the difference might be due to study population, area, and setup.

� Please review this as it makes the discussion elaborate and the reader loses his/her train of thought comparing statistics with all the various countries mentioned.

Conclusion: Well written and concise summary of the article.

� Please, would the author/s consider the following questions:

• “What findings from this study are unique?"

• "Why is the clinically relevant?"

• "Would this change practice?"

• "What are next steps?"

Reviewer #2: I suggest authors that this paper could have outcome measurement bias. most interview questions were asked as general questions, as Ethiopian patient do not understand it. This could make the conclusion highly biased as outcome measurement bias.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

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Attachment

Submitted filename: Reviewer PLOS.docx

pone.0294230.s002.docx^{(15.3KB, docx)}

PLoS One. 2024 Mar 14;19(3):e0294230. doi: 10.1371/journal.pone.0294230.r002

Author response to Decision Letter 0

7 Jul 2023

We try to respond your comments at all and we ready for your next suggestion.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0294230.s003.docx^{(25.6KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0294230.r003

Decision Letter 1

Tariku Shimels

25 Aug 2023

PONE-D-23-02089R1Factors affecting palliative care service utilization among cancer patients at public hospitals oncology unit Addis Ababa, Ethiopia, 2022PLOS ONE

Dear Dr. Tefera,

==============================

ACADEMIC EDITOR:Please find the below comments and make sure to address both reviewers' concerns in your revision. Alternatively, attachment of both reviews results has been appended with this decision. Please ensure that your decision is justified on PLOS ONE’s publication criteria and not, for example, on novelty or perceived impact.

==============================

Please submit your revised manuscript by Oct 09 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Tariku Shimels, B. Pharm., B.A, M.Sc.

Academic Editor

PLOS ONE

Additional Editor Comments:

i) There is mix of using uppercase and lower case words in the abstract and the document. for example, ‘’Occupation, treatment side effects, Loss of Appetite, distance, availability of all medications & procedures, …’ Please revise appropriately.

ii) There is inconsistency in using punctuation for statements presented in the tables (2 and 3). Ideally, you do not need to put a period for such statements.

iii) There is inconsistent use of punctuation, and improper parentheses under the variables subsection. Please revise.

iv) Table 9 needs revision for variables occupation status.

v) The references should be checked against PLOS ONE’s guideline, and styles applied consistently.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

**********

6. Review Comments to the Author

Reviewer #1: Thank for the rigorous change made to your manuscript. Other comments you need to correct were uploaded.

Reviewer 2 comments

Minor

Iine 159 is not clear. “The Hosmer-Lemshow goodness test for the regression 160 model's fitness was 86.2 %”. What does Hosmer-lemeshow goodness test mean? It is a significance test, but not as mentioned in the text. See it again.
Sampling estimation not clear. No citations to former proportion.
Why all adults included? Does all cancer patients need palliative care? Why? There will also be easily cured patients…what does PC mean?
Why using mean or above for utilization of PC? No any standard in nursing palliative care?
Line 274, table 6, why not you present findings in a scale, so that your audience understands where the response has been concentrated.
Language editing is big issue??

Major

Line 301, table8, outcome measurement is not satisfactory. It could have been better to ask client speicifically to the services rather than asking for general questions, such as ‘Have you received psychological/emotional support?’, ‘Have you received spiritual support?’, ‘Have you received financial support?’, etc. so, my conclusion is I have no confidence to accept the output with this somewhat general measurements. Because our client doesn’t understand it. Please see it again.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

**********

Attachment

Submitted filename: Reviewer Comment 2.docx

pone.0294230.s004.docx^{(13.4KB, docx)}

PLoS One. 2024 Mar 14;19(3):e0294230. doi: 10.1371/journal.pone.0294230.r004

Author response to Decision Letter 1

29 Aug 2023

Dear editors and reviewers, We have tried to process, edit, and respond to your feedback without wasting any time. Therefore, we are still ready to receive and edit your feedback.

We Thank you very much!

Attachment

Submitted filename: Response to Reviewers.docx

pone.0294230.s005.docx^{(22.6KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0294230.r005

Decision Letter 2

Tariku Shimels

1 Sep 2023

PONE-D-23-02089R2Factors affecting palliative care service utilization among cancer patients at public hospitals oncology unit Addis Ababa, Ethiopia, 2022PLOS ONE

Dear Dr. Tefera,

==============================

ACADEMIC EDITOR:

Still more issues to address: please edit on the following and return.

The first statement of the abstract is complex. Please fragment it into simpler sentences.
The statement ‘’….404 of 414’’ in the abstract is confusing. Please state the number only to whom the questionnaires were administered.
Please check some terminologies used, for example what is ‘assistante in mentioning your rank’?
Please do not start a paragraph with a number, ex. 78% in the introduction. Also check all text all through the manuscript.
There is an unclear punctuation period in citations 11, 13 extra, please check and fix.
Last paragraph of the background section, [show fig 1] is not clear. Please either remove ‘show’ or replace by ‘see’. The same correction needs to be made in other legends (ex. figure 2 or figure 3.
In the label ‘schematic presentation….’of the conceptual framework, please add a comma after ‘Addis Ababa’. Make similar corrections in other sections including the methods. Also remove the period at the end of the caption, and add a period after ‘Figure 1’. Please check PLOS ONE’s criteria of labeling captions.
The phase ‘non cooperative ‘ in the methods should be replaced by ‘non-cooperative’
Please check the consistency of in text citation for tables and legends. For example, table 1 and other tables are cited differently (Table :1 vs. Table 2 or 3). Would you check such mistakes throughout?
Please avoid use of a period at the end of all table and figure legends.
Table 9 ‘’ Factors associated with Palliative Care Service Utilization shows that Bi-Variable & multivariable logistic regression with Crud & Adjusted Odd Ratio in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Ethiopia, 2022 (n = 404).’’There are many problems in this title. I suggest revising this as ‘Factors associated with Palliative Care Service Utilization at Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia, 2022 (n = 404)’’
Table 9. There was an earlier comment regarding the variable of ‘occupation status’. Probably, ‘government employee is in the upper row. Please check and fix.
Please include the ‘limitation’ section to the end of the discussion’ preceded by any possible strength.
Present the statements under the recommendation section to the end of the conclusion section.

==============================

Please submit your revised manuscript by Oct 16 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Tariku Shimels, B. Pharm., B.A, M.Sc.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Still more issues to address: please edit on the following and return.

i. The first statement of the abstract is complex. Please fragment it into simpler sentences.

ii. The statement ‘’….404 of 414’’ in the abstract is confusing. Please state the number only to whom the questionnaires were administered.

iii. Please check some terminologies used, for example what is ‘assistante in mentioning your rank’?

iv. Please do not start a paragraph with a number, ex. 78% in the introduction. Also check all text all through the manuscript.

v. There is an unclear punctuation period in citations 11, 13 extra, please check and fix.

vi. Last paragraph of the background section, [show fig 1] is not clear. Please either remove ‘show’ or replace by ‘see’. The same correction needs to be made in other legends (ex. figure 2 or figure 3.

vii. In the label ‘schematic presentation….’of the conceptual framework, please add a comma after ‘Addis Ababa’. Make similar corrections in other sections including the methods. Also remove the period at the end of the caption, and add a period after ‘Figure 1’. Please check PLOS ONE’s criteria of labeling captions.

viii. The phase ‘non cooperative ‘ in the methods should be replaced by ‘non-cooperative’

ix. Please check the consistency of in text citation for tables and legends. For example, table 1 and other tables are cited differently (Table :1 vs. Table 2 or 3). Would you check such mistakes throughout?

x. Please avoid use of a period at the end of all table and figure legends.

xi. Table 9 ‘’ Factors associated with Palliative Care Service Utilization shows that Bi-Variable & multivariable logistic regression with Crud & Adjusted Odd Ratio in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Ethiopia, 2022 (n = 404).’’There are many problems in this title. I suggest revising this as ‘Factors associated with Palliative Care Service Utilization at Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia, 2022 (n = 404)’’

xii. Table 9. There was an earlier comment regarding the variable of ‘occupation status’. Probably, ‘government employee is in the upper row. Please check and fix.

xiii. Please include the ‘limitation’ section to the end of the discussion’ preceded by any possible strength.

xiv. Present the statements under the recommendation section to the end of the conclusion section.

[Note: HTML markup is below. Please do not edit.]

PLoS One. 2024 Mar 14;19(3):e0294230. doi: 10.1371/journal.pone.0294230.r006

Author response to Decision Letter 2

2 Sep 2023

Dear Reviewers and Editors, We are very grateful for your additional relevant comments, questions and suggestions and we are suspenseing by your next decision and also comments.

Thanks to much for your quick response !

Attachment

Submitted filename: Response to Reviewers.docx

pone.0294230.s006.docx^{(24.1KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0294230.r007

Decision Letter 3

Tariku Shimels

6 Sep 2023

PONE-D-23-02089R3Factors affecting palliative care service utilization among cancer patients at public hospitals oncology unit Addis Ababa, Ethiopia, 2022PLOS ONE

Dear Dr. Tefera,

==============================

ACADEMIC EDITOR:Please check comments below.

==============================

Please submit your revised manuscript by Oct 21 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Tariku Shimels, B. Pharm., B.A, M.Sc.

Academic Editor

PLOS ONE

Journal Requirements:

1. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Dear author(s),

Thank you for your revised submission. The manuscript has, now, improved markedly. However, there are a few issues left unaddressed.

i) The limitation section should appear under the end of the discussion.

ii) The recommended statements should be linked to the end of the conclusion section.

More concerns to add:

i) The title has some issues to fix. Suggested title 'Palliative care service utilization and associated factors among cancer patients at oncology units of public hospitals in Addis Ababa, Ethiopia''

ii) Please also check the superscript placement of authors' information on the first page. If you use 1 as superscript in the authors' list, you should follow the same style in the information provided below the list.

[Note: HTML markup is below. Please do not edit.]

PLoS One. 2024 Mar 14;19(3):e0294230. doi: 10.1371/journal.pone.0294230.r008

Author response to Decision Letter 3

6 Sep 2023

We are happy by your comments and suggestion so we thanks too.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0294230.s007.docx^{(24.7KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0294230.r009

Decision Letter 4

Tariku Shimels

11 Sep 2023

PONE-D-23-02089R4Factors affecting palliative care service utilization among cancer patients at public hospitals oncology unit Addis Ababa, Ethiopia, 2022PLOS ONE

Dear Dr. Tefera,

==============================

ACADEMIC EDITOR: Please check a few more comments provided below once again. I would suggest that you go through a published PLOS paper and make all necessary changes before returning this revision.

==============================

Please submit your revised manuscript by Oct 26 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Tariku Shimels, B. Pharm., B.A, M.Sc.

Academic Editor

PLOS ONE

Journal Requirements:

Additional Editor Comments:

Dear Author(s),

Thank you for submitting your revision. Unfortunately, the manuscript still suffers from a lot of unaddressed and additional issues.

a)Title: please avoid putting a period at the end of the title. Good also if you avoid the date (2022) in the objective.

b) authors' information: please put as for example this: '' 1Department of Nursing, school of nursing and midwifery, Asrat woldeyes health science campus, Debre Berhan University, Ethiopia'' if all authors are from the same department. Please note that 1 is in superscript form with no dot after it, and that there is comma after 'midwifery'. In addition, please put 1 for all authors if they still belong to the same department. If not, assign them affiliation. Next, remove 2 and add the following instead:

*correspondence: put your email here

c) The discussion section requires revision considering the way the 95% C.Is were stated. Please follow a uniform and meaningful style of presenting it. For example the statement

i) ''Patients diagnosed with cancer who have college or university education were 2.3 times AOR = 2.3, 95% CI (1.01, 5.16) more likely to use palliative care services than those who unable to read and write.'' in the discussion OR

ii) ''Cancer diagnosed patients who traveled less than 23 km (within the area of Addis Ababa) were 1.8 times AOR = 1.8, 95% CI (1.08, 3.15) more likely than those who traveled long distance to use PC services.'' in the results are either meaningless or unclear.

Please revise the results and discussion for consistency and clarity. You could rewrite it, for example, as ''Patients diagnosed with cancer and who have college or university education were 2.3 times more likely to use palliative care services as compared with those who were unable to read and write (AOR = 2.3, 95% CI:1.01, 5.16) for i above. It should be uniform for all cases, however.

iii) The use of the 95% CI is inconsistent. In all sections, authors used square brackets mixed with open brackets. Please use uniform formatting, preferably the one that does not confuse with citations i.e ().

c) It would be advisable to remove the abbreviations section, but make sure to define full term, in brackets at first use.

d)The references are not adequately revised. Some lacked either of a journal name, a publisher, a doi, or a page number when appropriate. The URL name/site and access date should also be mentioned when full journal profile may not be available, for example for repository manuscripts not published. There is also a duplicate in year of publication. Please revise all thoroughly.

[Note: HTML markup is below. Please do not edit.]

PLoS One. 2024 Mar 14;19(3):e0294230. doi: 10.1371/journal.pone.0294230.r010

Author response to Decision Letter 4

16 Sep 2023

We are very grateful for your relevant comments, questions, and suggestions, and we are anticipating your next decision and also your comments.

We thanks too!

Attachment

Submitted filename: Response to Reviewers.docx

pone.0294230.s008.docx^{(26.1KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0294230.r011

Decision Letter 5

Tariku Shimels

30 Oct 2023

Palliative care service utilization and associated factors among cancer patients at oncology units of public hospitals in Addis Ababa, Ethiopia

PONE-D-23-02089R5

Dear Dr. Tefera,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Tariku Shimels, B. Pharm., B.A, M.Sc.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Please check and fix these issues:

a) Remove the dot (.) from the end of the title

b) Refer a Plos paper and fix the title page accordingly. For example, no address has been provided for superscript 2. Also put the numbers in the address details as were in the author lists (i.e. as superscript)

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0294230.r012

Acceptance letter

Tariku Shimels

17 Nov 2023

PONE-D-23-02089R5

Palliative care service utilization and associated factors among cancer patients at oncology units of public hospitals in Addis Ababa, Ethiopia.

Dear Dr. Tefera:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at customercare@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Mr. Tariku Shimels

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 File. English version questioners.

(DOCX)

pone.0294230.s001.docx^{(32.6KB, docx)}

Attachment

Submitted filename: Reviewer PLOS.docx

pone.0294230.s002.docx^{(15.3KB, docx)}

Attachment

Submitted filename: Response to Reviewers.docx

pone.0294230.s003.docx^{(25.6KB, docx)}

Attachment

Submitted filename: Reviewer Comment 2.docx

pone.0294230.s004.docx^{(13.4KB, docx)}

Attachment

Submitted filename: Response to Reviewers.docx

pone.0294230.s005.docx^{(22.6KB, docx)}

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Submitted filename: Response to Reviewers.docx

pone.0294230.s006.docx^{(24.1KB, docx)}

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Submitted filename: Response to Reviewers.docx

pone.0294230.s007.docx^{(24.7KB, docx)}

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Submitted filename: Response to Reviewers.docx

pone.0294230.s008.docx^{(26.1KB, docx)}

Data Availability Statement

All relevant data are within the manuscript and its Supporting Information files as well as we attached our SPSS data. But if you request at any time we will send any other data.

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PERMALINK

Palliative care service utilization and associated factors among cancer patients at oncology units of public hospitals in Addis Ababa, Ethiopia

Nigus Afessa

Dagmawit Birhanu

Belete Negese

Mitiku Tefera

Roles

Abstract

Background

Objective

Methods

Result

Conclusion and recommendation

Introduction

Fig 1. Schematic presentation of conceptual framework of palliative care service utilization among cancer patients in Addiss Abeba, Ethiopia.

Methods

Study design, setting and period

Population

Source population

Study population

Eligibility criteria

Inclusion criteria

Exclusion criteria

Sample size determination and Sampling procedure

Fig 2. Demographic presentation of sampling procedure on palliative care service utilization among cancer patients in Addis Abeba, Ethiopia.

Data collection methods

Study variables

Dependent variable

Independent variables

Predisposing factors

Data quality management

Data processing and analysis

Operational definitions

Knowledge about Palliative care

Attitude to Palliative care

Satisfaction

Severity of pain

Ethical consideration

Result

Predisposing factors

Sociodemographic characteristics

Table 1. Socio-demographic characteristics of adult cancer patients receiving palliative care services in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Health belief factors (knowledge, attitude)

Knowledge

Table 2. Knowledge status of adult Cancer patients towards palliative care service utilization in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Attitude

Table 3. Attitude status of adult Cancer patients towards palliative care service utilization in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Health need factors

Cancer site

Fig 3. Cancer site of Patients received palliative care service utilization in Tikure Anbessa specialized hospital and saint paul;s hospital in Addis Abeba, Ethiopia.

Severity of pain and treatment side effects

Table 4. Severity of pain & treatment side effects of adult cancer patients receiving palliative care services in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Enabling factors

Occupation, monthly income & satisfaction

Table 5. Jobs held by adult cancer patients and their monthly wages in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Table 6. Satisfaction of adult Cancer patient with institutional services and family support in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Health system factors

Table 7. Responses of adult cancer patients to health system factor questions in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Prevalence of Palliative care service utilization (PCSU)

Fig 4. Palliative care service utilization status among adult cancer patients in Tikur anbessa specialized hospital and Saint Paul’s Hospital Millennium Medical College Addiss Abeba, Ethiopia.

Table 8. Responses of adult cancer patients to outcome measuring variables of palliative care service utilization in Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addiss Abeba, Ethiopia (n = 404).

Factors associated with palliative care service utilization

Table 9. Factors associated with Palliative Care Service Utilization at Tikur Anbessa Specialized Hospital and Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia (n = 404).

Discussion

Conclusion

Consent for data collection

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Tariku Shimels

Roles

Author response to Decision Letter 0

Decision Letter 1

Tariku Shimels

Roles

Author response to Decision Letter 1

Decision Letter 2