Protocol for a systematic review and meta-analysis on utilisation of palliative care service and predictors among adult cancer patients in Ethiopia

Abstract

Introduction

Palliative cancer care is comprehensive, specialised medical care of patients that aims to alleviate physical, mental and emotional distress based on patients’ needs rather than on prognosis. In Ethiopia, the federal ministry of health started palliative care (PC) in 2016. Since then, services have been developed and integrated as important components of the Health Sector Transformation Plan II. However, there is a scarcity of nationally summarised data regarding PC service utilisation in Ethiopia. Therefore, this protocol describes a planned systematic review and meta-analysis that will evaluate utilisation of PC services and its predictors among adult cancer patients in Ethiopia.

Methods and materials

The online databases of PubMed, Hinari, EMBASE, CINHAL, Science Direct, Scopus and Google Scholar will be comprehensively searched from inception to 31 February 2025. To assess the quality of included studies, the Joanna Briggs Institute critical appraisal tools will be used. The statistical software STATA V.17 will be used for data analyses. To examine the heterogeneity between studies, inverse variance (I²) will be used. To calculate the pooled prevalence of PC service utilisation, a fixed or random effects meta-analyses model will be used with a 95% CI, depending on the presence or absence of heterogeneity between included studies. To look for publication bias, a visual inspection of the funnel plot and Egger and Begg’s regression test and a 5% level of significance will be used.

Ethics and dissemination

Ethical approval is not applicable. The results will be disseminated to academic beneficiaries and the public.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study adhered to the guideline of Preferred Reporting Items for Systematic Review and Meta-Analysis.

• To ensure transparency and rigour, it was registered on International Prospective Register of Systematic Reviews.

• It will include both published and unpublished studies.

• The limitation of our study may be the absence of sufficient studies on the magnitude of palliative care service utilisation among adult cancer patients in Ethiopia.

Introduction

Rationale

Palliative care (PC) refers to comprehensive care of the patient’s physical, mental and emotional well-being and is integral to the psychosocial care of the patient.¹ It is implemented at any stage of the disease and is not limited to end-of-life or hospice care.² End-of-life care is care specifically provided during the final stages of life, whereas hospice care is a specific type of end-of-life care that is provided to patients who have a life expectancy of 6 months or less.³ Throughout a life-threatening illness, PC emphasises the management of symptoms and quality of life.⁴ Regardless of whether the care is inpatient or outpatient, understanding of symptom management, clear communication and end-of-life care are critical.⁵ PC encompasses controlling symptoms, end-of-life management, facilitating open communication with families and establishing care goals that ensure dignity in death and decision-making power.⁶

Worldwide, over 29 million people died in 2017 as a result of conditions that could have benefited from PC. Of these, 9.6 million deaths were cancer patients. As they approached the end of their lives, a total of 20.4 million people were predicted to require PC. Of those who required PC, 94% were adults and 69% were older than 60 years. Importantly, 78% of those in need of PC reside in low- and middle-income countries.^{7 8}

In Ethiopia, the federal ministry of health started PC in 2016. Since then, services have been developed and integrated as important components of the Health Sector Transformation Plan II. A study also reported that two health institutions located in Addis Ababa integrated PC into the healthcare services. Additional initiatives, such as Hospice Ethiopia and Strong Hearts, also provide vital PC services in the country.⁹ The establishment of a PC unit at Jimma University Medical Center is another positive development.¹⁰

Even though palliative treatment and support options have been improved, there is still great variation between regions. To address this, the Ethiopian National Cancer Control Plan aims to improve PC capacity of institutions and communities by providing skill training in the identification, assessment and treatment of distressing symptoms among cancer patients and capacity building of healthcare providers and caregivers in PC. This component of PC given may include surgery, chemotherapy and radiation with pharmacological interventions to counter cancer treatment effects and non-pharmacological interventions directed at maintaining function, independence and psychological well-being.¹¹

Although cross-sectional studies have been conducted on PC utilisation among cancer patients in Ethiopia, the results exhibit variations. The reported PC service utilisation rates range from a minimum of 26%¹² to a maximum of 57.2%.¹³ There is also no nationally completed systematic review on the subject, which could deter the design of effective intervention strategies to enhance utilisation of PC services. This systematic review and meta-analysis is therefore designed to evaluate utilisation of PC services among adult cancer patients in Ethiopia as well as its predictors. The finding of this study will guide the direction of future research, inform targeted interventions to improve utilisation of PC services and aid policy-makers in the effective resource allocation to improve adult cancer patients quality of life in Ethiopia and similar contexts.

Objectives

Primary objective

To determine the pooled prevalence of PC service utilisation among adult cancer patients in Ethiopia.

Secondary objectives

To identify factors associated with utilisation of PC service among adult cancer patient in Ethiopia

Methods and analysis

Guidelines and registration

We have written this protocol in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) declaration¹⁴ (online supplemental material 1).

The protocol of this systematic review is registered in the International Prospective Register of Systematic Reviews (CRD42024554748).

Eligibility criteria

The framework of Condition, Context, Population and Population, Exposure, Outcome will be used for determining the eligibilities of the study:

Condition

Utilisation of PC service

Context

Ethiopia

Population

Adults

Exposure

Cancer patients (no restriction on type of cancer and diagnosis stage)

Outcome

Utilisation of palliative care service.

This study will include any kind of observational studies (cross-sectional, case–control and cohort) that reported the prevalence of PC service utilisation among adult cancer patients in Ethiopia. All articles, published and unpublished, from inception to 31 February 2025, will be included in the review. Restriction of language will not be applied.

We will exclude studies without abstracts and full articles, reports, qualitative studies, editorials, newspaper and articles that did not report the magnitude of PC service utilisation. Before articles are included in the final review, they will be assessed for inclusion using their title and abstract, and then a full review will be done. Any disagreements and uncertainties among authors will be resolved through logical consensus, and the final consensus will be approved with the participation of the authors.

Outcome of the study

The main outcome of this review is the prevalence of PC service utilisation among adult cancer patients in Ethiopia. The secondary outcome will be factors associated with utilisation of PC services.

Information sources and search strategy

A comprehensive literature search will be done on PubMed, Hinari, EMBASE, CINAHL, Science Direct, Scopus and Google Scholar from inception to 31 February 2025. For this study, to search relevant articles, we will use the following search terms: ‘Palliative Care’ OR ‘Rehabilitation’ OR ‘Supportive care’ OR ‘Oncology care’ AND ‘Utilisation’ OR ‘Usage’ OR ‘Uptake’ AND ‘Cancer’ OR ‘Malignancy’ AND ‘Ethiopia’. The key terms will be used in combination using Boolean operators of ‘OR’ or ‘AND’ (online supplemental material 2).

Selection process

After eligible studies are imported to Endnote V.8.1, duplicates will be removed. Two independent reviewers (ADD and ADG) will complete the abstract and full-text reviews. Similarly, another two independent reviewers (AY and MA) will extract data by the Microsoft Excel spreadsheet using a standardised data extraction checklist adopted from the Joanna Briggs Institute (JBI). Any disagreements and uncertainties between the two authors will be resolved through logical consensus, and the final consensus will be approved with the participation of the authors. A PRISMA flow chart will be used to record and illustrate the reason for study exclusion and the selection process, respectively.¹⁵

Data extraction

All essential data will be extracted by Microsoft Excel spreadsheet using a standardised data extraction checklist adopted from the JBI. The following data will be extracted: author, publication year, study design, setting of study, type of cancer, sample size, response rate and magnitude of service utilisation. In the event of missing data, incomplete reports or any uncertainty, to obtain details, reviewers will email the authors of the article. Any disputes that arise during the selection process will be resolved by consensus among reviewers.

Quality analysis and risk of bias in individual studies

The JBI Critical Appraisal Checklist for reporting prevalence studies was used to assess the quality of studies. The critical appraisal checklist consists of nine criteria for prevalence studies scored on a 2-point Likert scale, with responses of yes (1) and no (0). The score of JBI ranges from 0 to 9, with scores of 0–4, 5–7 and 7–9 classified as low, medium and high quality, respectively. Prevalence studies that scored at least four will be considered to have acceptable quality and will be included in the review.¹⁶ A variety of sources (such as exploring the grey literature, citing relevant studies and reviewing pertinent reviews) will be checked to reduce the likelihood of reporting and publication bias. Meta-analysis may not be performed if there is bias, and variation among included studies will be reported. By using a funnel plot and a statistical test of Begg and Egger, publication bias will be assessed.

Patient and public involvement

None

Statistical data analysis

Extracted data will be exported from a Microsoft Excel spreadsheet into STATA/MP V.17¹⁷ statistical software for analysis. To summarise the main study, tables and figures will be used. To estimate the pooled prevalence of PC service utilisation, first we will fit a fixed-effect meta-analysis model, and then we will assess heterogeneity between included studies by using I² statistics. The presence of heterogeneity will be indicated by a p value of less than 0.05.¹⁸ I² values of 0–25%, 25–50% and 50–75% will represent heterogeneity levels as low, moderate and high, respectively.¹⁹ If there is a substantial heterogeneity among included studies (p<0.05), a random effects (DerSimonian–Laird) meta-analysis model will be used to estimate the pooled prevalence of PC service utilisation with a 95% CI. In accordance with the study’s design, the type of cancer, study setting and sample size, subgroup analysis will also be carried out. To identify factors associated with PC service utilisation, the pooled adjusted OR will be computed using either a fixed-effect or random meta-analysis model depending on the presence of heterogeneity.

Confidence in the cumulative evidence

To determine the confidence level, we have in the findings and recommendation, the Grading of Recommendations Assessment, Development and Evaluation²⁰ system will be used.

Ethics and dissemination

Ethical clearance is not needed for this review. Our review will be published in an open-access journal, and its results will be presented at different conferences. The datasets will be made available to the larger research community, and a workshop will be arranged with important stakeholders.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.