Healthcare providers’ awareness, perceptions and experiences in integrating palliative care for women with HIV and cancer in Nigeria: a qualitative study on barriers and facilitators

Abstract

Background

Women living with HIV face an increased risk of cancer due to compromised immune systems, necessitating integrated care approaches that include palliative care (PC). However, in resource-limited settings such as Nigeria, significant gaps in integrating PC into community healthcare persist, resulting in suboptimal outcomes for women managing HIV and cancer conditions. Understanding the barriers to and facilitators of PC integration from the perspective of healthcare providers is essential for improving care delivery.

Methods

A qualitative study was conducted across Nigeria’s six geopolitical zones, involving 24 healthcare providers from primary and secondary facilities affiliated with the Nigeria Implementation Science Alliance-Model Innovation and Research Centers (NISA-MIRCs). Key informant interviews (KIIs) and in-depth interviews (IDIs) were used to collect data, which were analyzed thematically via NVivo 14.

Results

Key barriers included distance to healthcare facilities, inadequate training and resources, sociocultural stigmas, and fragmented care systems. The facilitators highlighted were healthcare worker incentives, community engagement, patient education, and infrastructural improvements. The participants advocated for holistic and standardized integration of PC into healthcare services to enhance patient outcomes.

Conclusion

Significant gaps in the integration of PC into community healthcare systems in Nigeria impede the delivery of holistic care to women managing HIV and cancer. Addressing these gaps requires targeted policy interventions, healthcare worker training, and resource allocation to improve access to and delivery of PC services. These findings provide actionable insights for strengthening PC infrastructure in resource-limited settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14029-9.

Introduction

Women living with HIV face a greater risk of certain cancers, including cervical cancer and Kaposi’s sarcoma, due to immune suppression [1–3]. Treating these conditions requires both antiretroviral therapy (ART) and cancer care, such as chemotherapy, radiotherapy, or surgery. In resource-limited settings, however, access to such treatments is often restricted, making palliative care (PC) crucial for symptom management and quality of life [4, 5].

Despite the high cancer burden among women with HIV, PC is rarely integrated into care in low-income countries [5–10]. These settings often prioritize HIV control through ART while neglecting cancer, which is commonly diagnosed late due to limited screening and diagnostic resources [5–8]. Late diagnoses reduce treatment options, increasing the need for PC. In places where PC is available, it significantly improves patient outcomes [11], yet multiple barriers persist, such as weak health systems, poor infrastructure, and a lack of funding [5, 7, 12, 13].

Many facilities are under resourced, with limited diagnostic tools, medications, and personnel [8, 9, 14–17]. Women may also face geographic and financial hurdles in accessing care, as services are often urban-based and travel costs are prohibitive [18]. Fragmented care systems where HIV and cancer services operate in silos further hinder PC access [5, 19–21]. This disconnect often results in inadequate care for women with comorbid conditions, compounded by delays and poor health outcomes [13, 22] Healthcare providers also struggle with limited training, poor communication, and negative attitudes [5, 13, 15, 23].

Sociocultural barriers, such as religious beliefs, a lack of patient autonomy, and stigma surrounding both HIV and cancer, further deter women from seeking PC [5, 24–28]. Misinformation linking PC solely with terminal illness reinforces this stigma and discourages access [28–31].

Nonetheless, several facilitators improve PC delivery in resource-limited settings. These include community engagement [29–31], incentives [32–34], support groups [35–37], and patient education, which enhance participation and quality of life [38–41]. Infrastructure development and provider training are also critical. For example, telehealth-based PC models benefit from technological support and staff education [42]. Broader public awareness and healthcare worker training help foster acceptance and improve PC outcomes [9].

In Nigeria, where HIV and cancer burdens are high among women [43], few studies have explored the intersecting barriers to and facilitators of PC. Existing studies often focus on either HIV or cancer, neglecting women with dual diagnoses [5, 44–48]. Furthermore, little is known about healthcare providers’ experiences with and motivations for PC delivery.

This study addresses these gaps by exploring healthcare professionals’ knowledge, perceptions, and experiences regarding PC in Nigeria, particularly for women with HIV and Cancer. In this study, integration of palliative care refers to its careful and systematic incorporation into Nigeria’s primary and secondary healthcare systems via the following: (1) training of general healthcare workers to deliver PC services through task-shifting, (2) formalizing linkages between community clinics and specialist PC providers via referral pathways, (3) embedding PC existing HIV and Cancer care units [i.e., service co-location] and (4) adding PC to critical services packages at the primary care levels [i.e., policy inclusion]. Also, awareness is described as healthcare providers’ understanding of PC principles and practices, while perception refers to providers’ attitude and beliefs about PCs role in managing HIV and cancer. Equally, experiences are described as providers’ firsthand encounter in delivering and integrating PC. The study aims to assess their understanding of PC, perceptions of accessibility and availability, and the barriers and facilitators affecting service delivery. These findings will contribute to improving PC integration and delivery for vulnerable populations.

Methods

Aim

This study explores healthcare providers’ knowledge, perceptions, and experiences regarding PC, focusing on access, availability, barriers, and facilitators influencing service delivery to women with HIV and cancer conditions in Nigeria.

Design

This study is a nested qualitative investigation of healthcare workers’ awareness and perceptions of PC in Nigeria. It is part of a broader project conducted across Nigeria’s six geopolitical zones, using 12 of the 21 Nigeria Implementation Science Alliance-Model Innovation and Research Centers (NISA-MIRCs). These centers, supported by PEPFAR and linked to six Regional Centers of Excellence and the IVAN Research Institute at the University of Nigeria, maintain a large cohort of women and children. This nested qualitative study focused on access, availability, and the barriers and facilitators that influence PC service delivery in Nigeria. Qualitative research is particularly beneficial when investigating how people make meaning of their experiences, and this aligns with this study’s focus on understanding the views of healthcare professionals regarding the provision of PC services.

Study setting

The study was conducted across Nigeria’s six geopolitical zones, with healthcare practitioners from various facilities affiliated with the NISA-MIRCs. Nigeria is divided into six geopolitical zones namely; Northwest, Northeast, Northcentral, Southwest, Southeast, and South-south. These zones reflect significant regional diversity in terms of cultural practices, healthcare infrastructure, socioeconomic status, and disease burden [49]. For example, among adults aged 15–49 years, the South-South region records the highest HIV prevalence at 3.1%. This is followed by the North Central zone with a prevalence of 2.0%, and the South East zone at 1.9%. In contrast, lower prevalence rates are observed in the South West and North East zones, both at 1.1%, while the North West zone has the lowest prevalence at 0.6% [50]. This diverse geographical representation allows for the accumulation of differing opinions on PC. By incorporating observations from these regions, this study highlights specific barriers and facilitators that healthcare professionals encounter while delivering PC to WLWH and cancer.

Sample size and sampling approach

The sample for this study included 24 healthcare workers, including doctors, nurses and community health extension workers (CHEWs) from primary and secondary health facilities, who were chosen to reach a point of saturation where no new information emerged from the interviews. Saturation occurs when the collection of new data does not yield further insights (i.e., keywords, patterns, themes, and codes), indicating that sufficient data have been gathered to address the research questions [51–55]. We determined data saturation through iterative team discussions during the coding process. After each batch of 4–5 interviews, three researchers (NIA, JOJ, IAO) independently reviewed transcripts and met to compare: (1) emergence of new codes, (2) depth of understanding for each theme, and (3) repetition of key concepts.

The participants were selected via a purposive sampling method. The participants were selected because they provided care for people living with HIV and cancer. This approach is especially beneficial for studying specialized subjects since it draws on existing relationships in healthcare settings, enriching the data acquired.

Data collection

The data collection instruments employed in this study included key informant interviews (KIIs) and in-depth interviews (IDIs) (appendix 1), which are recognized as effective methods for eliciting rich, qualitative data [56, 57]. This study employed both Key Informant Interviews (KIIs) and In-Depth Interviews (IDIs) to capture a comprehensive understanding of palliative care integration. KIIs provided macro-level insights from administrators on key structural constraints, while IDIs explored micro-level experiences of frontline healthcare workers, revealing practical and sociocultural barriers in service delivery. The distinct participant roles enabled data triangulation across health system tiers. These instruments were specifically designed to examine healthcare professionals’ awareness and perceptions of palliative care, evaluate their views on its accessibility and availability, and identify barriers and opportunities encountered in caring for women with HIV and cancer conditions. The In-depth Interview and Key Informant Interview guides were developed by the research team exclusively for this study, reviewed thoroughly for content relevance and coherence, and pilot-tested at one primary and one secondary healthcare facility comparable to the NISA-MIRCs sites. Following the pilot testing, minor revisions were implemented to ensure face validity, clarity, and logical flow before full deployment in the study.

Research assistants were trained virtually through a series of structured online sessions conducted over a two-week period. The training covered qualitative interviewing techniques, such as active listening, probing, and maintaining neutrality, as well as ethical considerations, including informed consent, confidentiality, and data protection. Interactive components, such as role-playing exercises and mock interviews, were incorporated to simulate real-world scenarios and ensure competency.

Questions were posed, and probing tactics were employed to extract deeper insights, clarify responses, and urge participants to elaborate on their ideas, thereby increasing the richness and depth of the data obtained. Data was collected via audio-recorded interviews lasting 30–45 minutes, with trained research assistants taking notes throughout the sessions. This technique guaranteed that participants’ replies were thoroughly documented while also allowing them to freely voice their opinions. Following the interviews, the recorded data were transcribed verbatim, maintaining fidelity to the original discussions and preparing the data for further study. This comprehensive approach to data gathering is consistent with accepted qualitative procedures, ensuring that the findings correctly reflect healthcare professionals’ experiences and perceptions of PC.

Data reliability

Data reliability in this study was established through the principles of credibility, dependability, confirmability, transferability, and authenticity. To attain credibility, member checks were used, allowing participants to verify and evaluate their responses and interpretations, ensuring that the data were accurate. Dependability was addressed via a rigorous audit trail that documented the study process, including data-gathering methods and analysis procedures. This transparency enables external scrutiny, which strengthens the study’s trustworthiness [58, 59].

Furthermore, confirmability was achieved by maintaining a reflexive journal, enabling researchers to reflect on their biases and influences throughout the study, ensuring that findings emerged from the data rather than researcher preconceptions [60, 61]. Transferability was assisted by providing comprehensive, detailed descriptions of the context and participants, allowing readers to assess the applicability of the findings to different samples and settings [62]. Finally, authenticity was prioritized by presenting a balanced view of participants’ perspectives, capturing diverse experiences to reflect the complexity of PC provision [58–60]. Collectively, these steps enhance the trustworthiness of the study’s findings.

Data analysis

The qualitative data analysis followed Braun and Clarke’s six-step thematic analysis framework, which is widely recognized for its approach to analyzing qualitative data [63, 64]. The steps taken are described below. Initially, the researchers explored the data to gain deeper familiarity by reading the transcripts multiple times to gain a thorough understanding of the participants’ responses. The second step involved generating codes, which identified patterns and concepts that later formed the foundation for themes. In the third step, these codes were organized into broader, more comprehensive themes, which encapsulated the core ideas in the data. The fourth step required refining and reviewing these themes to ensure consistency and coherence. Next, the themes were named and defined, reflecting abstract insights beyond surface-level content. Finally, the themes were transformed into a structured narrative that aligned with the study’s objectives, supported by relevant quotes for interpretation and discussion. Although KII and IDI data were initially coded separately to retain method-specific and role-based nuances, we employed a thematic synthesis approach to integrate the datasets during analysis. This allowed us to identify how system-level challenges (e.g., training shortages highlighted in KIIs with doctors and nurses) translated into operational gaps in frontline care (e.g., skill deficits reported by CHEWs in IDIs). This integrative method aligns with established qualitative approaches that emphasize multi-perspective synthesis for understanding complex health system barriers and enablers [65, 66].

The themes for this study were predetermined (a priori) on the basis of the research objectives and informed by literature, providing a structured framework to explore the integration of PC into HIV and cancer care. Broad themes included training, infrastructure, community engagement, multidisciplinary collaboration, and funding. During the analysis, several subthemes emerged, such as patient-centered care, empathy, and practical support. To mitigate researcher bias, subthemes were independently identified by the research team (NIA, JOJ, IAO), merged, and deduplicated, and consensus was reached on overarching subthemes, ensuring analytical rigor and coherence.

To facilitate data management and enhance the analysis, the transcribed data were input into NVivo 14 (NIA), a qualitative data analysis software that serves as an assistive tool for coding, organizing, and retrieving data [67]. Both digital and manual procedures were used in the analysis. NVivo digital analysis helped with data categorization and visualization, whereas manual procedures provided more in depth, interpretative knowledge of the intricacies of the data. Finally, a codebook was created with NVivo 14 and then manually updated (IAO, JOJ) to represent the major issues in the elicited data. The combination of these methodologies meant that the analysis was complete, accurate, and anchored in facts [68]. This dual approach also enhanced the rigor of the thematic analysis process.

Result

According to the analysis, the IDI participants included 1 male (8.3%) and 11 females (91.7%), primarily CHEWs, whereas the KII participants included 2 males (16.7%) and 10 females (83.3%), including nurses and doctors. There were 12 CHEWs (50%), 8 nurses (33.3%), and 4 doctors (16.7%), with equal representation across zones. The analysis revealed four broad themes and fifteen subthemes that are presented below in line with the study objectives.

Theme 1: healthcare professionals’ understanding of PC

Limited awareness and understanding of PC

One of the most striking findings was the limited awareness and understanding of PC among healthcare professionals. Both the KIIs and IDIs revealed that healthcare professionals often associate PC exclusively with end-of-life care or terminal illnesses such as cancer. For example, one interviewee defined PC as follows:

The care given to patients whose disease conditions do not have a cure or total treatment, so this care is given to them to help them manage the illness, something like pain, especially when we talk about palliative care in cancer patients in their stage four (HCW, South-East [KII]).

This definition, while somewhat accurate, reflects a limited understanding of the broader scope of PC, which includes psychosocial, spiritual, and nutritional support for patients with HIV and cancer. Similarly, another interviewee stated, “palliative care is special care given to patients living with HIV and AIDS” (Nurse, South‒South [IDI]), indicating the conflation of PC with HIV management.

In the IDIs, this narrow conceptualization was further reinforced. As one participant stated,

Palliative care is a kind of service or a mode of treatment not just with medicine but also involves both physical and psychological support that is rendered to a patient. Most at times, people consider it as care given to a terminally ill patient like those people who have cancer(CHEW, South‒South [IDI]).

Another significant misunderstanding highlighted in IDIs is the perception that PC is primarily about providing financial assistance rather than holistic, multidimensional support. For example, a CHEW from the North‒West [IDI] offered insight into this financial-centered interpretation: “In my own understanding, palliative care may be care given to a patient or a client that does not have money to support himself or herself when his or her condition is already a serious case.” This response illustrates a common misconception where PC is perceived as economic aid (palliatives) for patients in dire health conditions rather than a comprehensive approach encompassing physical, psychological, and social support. Such misconceptions are capable of resulting in the underutilization of PC services, specifically in cases where patients could benefit from early interventions that increase their well-being and alleviate suffering throughout the course of their illness.

Theme 2: views on the accessibility and availability of PC

PC as largely unavailable

Many of the healthcare professionals reported that PC services were not available in their facilities. They noted that their facilities lacked the necessary infrastructure, equipment and trained practitioners that could offer such care. A recurring theme across both KIIs and IDIs is the absence of PC services in many healthcare facilities. Healthcare providers consistently reported that their facilities lack the infrastructure, equipment, and trained personnel needed to deliver PC. For example, one participant stated, “No, I won’t say [patients] have access to palliative care. We don’t have palliative care for them” (Doctor, South-East [KII]). The lack of availability extends to essential components of PC, such as pain management, psychosocial support, and spiritual care. As one interviewee explained, “We offer some basic services such as counseling and pain management, but it’s not comprehensive. We don’t have the resources to provide the full range of palliative care services” (Nurse, North-Central [KII]).

In some cases, PC is offered on an ad hoc basis, depending on the availability of resources and the willingness of healthcare providers: “We try to provide palliative care when we can, but it’s not standardized. It depends on the resources we have at the time” (Doctor, South-East [KII]).

Limited accessibility for patients

Even in facilities where PC services are notionally available, accessibility remains a significant barrier for patients. Healthcare providers have identified several barriers that limit patients’ ability to access PC, including financial constraints, transportation issues, and stigma. One interviewee highlighted the financial barriers: “Many patients cannot afford transportation to the hospital. They miss appointments because they don’t have the money to travel” (Nurse, North-East [KII]).

Stigma, particularly around HIV and cancer, further complicates access to PC. As one participant explained, “Some patients prefer to travel far for treatment because they don’t want their community to know their status. This makes it hard for them to access care locally” (CHEW, North Central [IDI]). The lack of awareness of PC also contributes to its inaccessibility. For example, one participant noted, “Some patients don’t even know what palliative care is. They think it’s only for people who are about to die, so they don’t seek it out” (Nurse, South‒South [KII]). These barriers, which are financial, logistical, and social create significant barriers for patients in need of PC, even when services are theoretically available.

Referral as a substitute for accessibility

In the absence of PC services at primary and secondary health facilities, referrals to tertiary institutions are often the only option for patients. However, this referral system is fraught with barriers, including distance, cost, and delays. As one participant explained, “We refer patients to tertiary facilities for palliative care, but many cannot afford the cost of transportation or the services themselves” (Doctor, North-Central [KII]). The referral process is often inefficient and unreliable. A CHEW in the South-East [IDI] noted, “We refer patients to government hospitals, but the process is often delayed, and some patients don’t follow through.” While referrals are intended to bridge the gap in PC provision, they are not a reliable substitute for accessible and available services at the primary and secondary levels.

Theme 3: barriers and facilitators in providing care to women with HIV and Cancer

Barriers

Limited awareness of PC

A recurring barrier across both KIIs and IDIs is the limited awareness and understanding of PC among healthcare providers and patients. Many healthcare workers, particularly those in secondary and primary facilities, lack familiarity with PC concepts and practices. For example, a participant stated, “To the best of my knowledge, no, I’m not aware of palliative care services in this facility” (Doctor, South-East [KII]). This lack of awareness extends to patients, as highlighted by a nurse from North Central, “Patients are not aware of palliative care. We stumble upon them and take them to the facility to care for them”(Nurse, North-Central [KII]).

The IDI findings corroborate this, with participants expressing similar gaps in knowledge. As one participant remarked, “This is my first time hearing about palliative care. We don’t have something like that here. If they bring that kind of thing here, at least if we have any team of health workers, we can call the team” (CHEW, South‒South [IDI]). Patients also often misunderstand PC as end-of-life care, as noted by a nurse from Kaduna: “Some patients believe that palliative care is only for those who are dying. They feel that once you offer them palliative care, it means you are telling them bye-bye to their death” (Nurse, North‒West [IDI]).

Financial constraints and resource limitations

Financial and resource limitations have emerged as critical barriers to integrating PC. Many respondents highlighted the high cost of PC services, including pain management, nutritional support, and diagnostic tests. As one interviewee explained, “Funding is a major barrier. Patients struggle to pay for basic services, let alone palliative care. Even the cost of diagnostic tests such as creatinine tests is prohibitive for many” (Doctor, North-East [KII]).

The IDI findings further emphasize the lack of infrastructure and equipment. As one participant noted, “The structure we have is not good enough. Even the unit I am using for cervical cancer screening is not good enough. We don’t have doctors, and the space is limited” (Nurse, South‒South [IDI]). These financial and resource constraints highlight the need for sustainable funding mechanisms, infrastructure development, and equitable distribution of resources to support PC integration.

Stigma and sociocultural barriers

Stigma, particularly related to HIV, and sociocultural beliefs were identified as significant barriers to accessing PC by several participants. One provider explained, “Stigma is real. Some patients avoid coming to the hospital because they fear being recognized by someone they know” (Nurse, Noth-West [KII]). Cultural beliefs also play a role. In many parts of Nigeria, patriarchal norms and cultural practices significantly influence healthcare access, particularly for women in the northern part of the country. Gender-based decision-making often restricts women’s autonomy, requiring them to seek permission from male family members before accessing care. This dynamic can delay or prevent PC, as highlighted by a provider: “In our culture here, before a woman can even go to a hospital or go out, she needs to take permission from her husband.” (CHEW, North-East [IDI]).

Religious beliefs play a significant role in shaping healthcare decisions in many Nigerian communities, often influencing patients’ acceptance of medical interventions. For some, faith and prayer are seen as primary solutions to illness, leading to skepticism or outright rejection of conventional medical treatments, including PC. One interviewee highlighted this barrier: “Some patients believe that prayer alone can cure their illness. They reject medical interventions, including palliative care” (Nurse, South‒South [IDI]). This reliance on spiritual healing, while deeply rooted in cultural and religious practices, can delay or prevent access to essential healthcare services.

Inadequate training and workforce capacity

The lack of trained healthcare professionals is a critical barrier to the effective delivery of PC in Nigeria. Many healthcare workers lack the necessary skills and confidence to manage complex palliative cases, which often require specialized knowledge in pain management, psychosocial support, and end-of-life care. One interviewee emphasized this gap: “We don’t have a palliative care team. Even basic training for existing staff would make a difference.”(Doctor, South‒South [KII]).

The shortage of qualified healthcare workers is a significant barrier in delivering PC, particularly in resource-constrained settings such as Nigeria. Many facilities operate with limited staff, often lacking specialists trained in PC, which compromises the quality of care provided. An interviewee highlighted this issue: “We don’t have enough qualified health workers and specialists trained in palliative care. I think there is only one nurse here, then the officer in charge who is a community health officer, and then the CHEWs”(CHEW, North-East [IDI]).

Theme 4: facilitators

Training and capacity building

A recurring theme across both KIIs and IDIs was the need for training and capacity building for healthcare workers to effectively deliver PC services. For example, one participant noted, “We need training for the staff, doctors, and nurses to be acquainted with how palliative care services are offered. Without proper training, it will be difficult to integrate these services effectively”(Nurse, South‒South [KII]).

Similarly, a nurse, South‒South [IDI], highlights the importance of specialized training: “Training of doctors, training of nurses, etc., is essential. If they are trained, they will know the exact thing to offer to clients. It will create an opportunity for patient-centered care”. Another interviewee emphasized the value of continuous education: “We need training and retraining. Most of what we do here is not what we studied, but we were trained to do them, and we are doing them perfectly” (CHEW, North-East [IDI]).

Infrastructure and resource availability

The availability of infrastructure and resources was another critical facilitator identified in both KIIs and IDIs. Many respondents noted that the lack of dedicated spaces, equipment, and essential supplies hindered the provision of PC. As one participant stated, “We need infrastructure such as pain management tools, monitoring equipment, and designated palliative care units. Without these, it’s difficult to provide comprehensive care.”(Doctor, North-East [KII]). Equally, one participant remitted this sentiment: “The government should provide basic amenities, structures, and equipment. Without these, it will be difficult to implement palliative care effectively”(CHEW, South‒South [IDI]).

Community engagement and advocacy

Community engagement and advocacy were identified as crucial facilitators of the acceptance and utilization of PC services. Many participants emphasized the need to educate communities about the benefits of PC and to address cultural and religious beliefs that may hinder access. As one participant explained, “We need to create awareness in the communities. Many people do not understand what palliative care is, and some believe it is against their religious or cultural beliefs.”(Nurse, South‒South [KII]).

Additionally, an interviewee highlighted the role of community leaders in driving acceptance: “We need to involve the community leaders, traditional rulers, and religious leaders. They have a great influence on the people, and their support will make it easier for the community to accept palliative care.”(CHEW, North‒West [IDI]).

Multidisciplinary collaboration

The importance of multidisciplinary collaboration was a recurring theme in both KIIs and IDIs. The participants emphasized that PC requires a team approach involving doctors, nurses, social workers, psychologists, and spiritual caregivers: “Palliative care is not a one-man show. We need a team of professionals working together to address the physical, emotional, and spiritual needs of patients.” (Doctor, North-Central [KII]). Additionally, an interviewee added, “Health is all about collaborative care. We all have our parts to offer. If we all put hands on deck, the stigma and challenges of palliative care will be reduced”(CHEW, North‒West [IDI]).

Patient-centered care and empathy

The participants emphasized the importance of patient-centered care and empathy in facilitating the integration of PC. Many healthcare providers acknowledge that the attitudes of healthcare workers play a significant role in patients’ willingness to access care. One participant stated, “A positive attitude from healthcare workers will facilitate the integration of palliative care. Patients need to feel cared for and supported” (CHEW, South‒South [IDI]). Similarly, a participant highlighted the impact of empathy: “When we show empathy and care, patients feel relieved. Even if we do not have all the resources, our attitude can make a difference” (CHEW, North-East [IDI]). This standpoint emphasizes the necessity of creating a culture of empathy and compassion among healthcare workers to increase patient trust and engagement in PC.

Incentives and support for patients

Providing incentives and support for patients was identified as a key facilitator for integrating PC. The participants suggested that financial support, transportation assistance, and nutritional aid could encourage patients to access care. As one participant explained, “If we can provide stipends or transportation money, it will motivate patients to come for care. Many of them struggle with the cost of transportation” (CHEW, North-East [IDI]). Another participant highlighted the importance of nutritional support: “HIV patients need nutritional support. If we can provide food or supplements, it will improve their health and adherence to treatment” (CHEW, South‒South [IDI]).

Discussion

This study reveals major gaps in PC integration within community healthcare in Nigeria, including limited availability, poor access, inadequate funding, infrastructure deficits, insufficient training, and sociocultural stigma. It also highlights facilitators such as government support, healthcare worker incentives, and community engagement. These findings build on the literature, offering deeper insight into the barriers and facilitators of delivering PC in resource-limited settings.

The findings revealed a limited understanding of PC among healthcare workers, with variations in misconceptions. Doctors often equate PC with end-of-life and pain management, whereas primary care workers link it to financial aid. These narrow views align with previous findings and underscore the need for training that promotes PC’s holistic approach and integrates both clinical and community perspectives [4, 6, 15, 18]. However, some studies have shown high percentages of knowledge and perceptions regarding PC among healthcare professionals [69, 70].

A key finding was the widespread unavailability of PC services, with facilities lacking infrastructure, equipment, and trained staff. This is consistent with other low-resource settings where PC is absent at the primary and secondary care levels. Limited funding and training remain major barriers in establishing PC programs.

Even where services exist, access is hindered by financial constraints, transport barriers, and stigma. These barriers echo studies showing that women with advanced conditions, such as cervical cancer, face compound burdens, especially when living with HIV. Dual stigma and poverty exacerbate access difficulties. However, studies suggest that PC access problems are multifaceted and influenced by systemic healthcare structures and resource distribution, requiring a broader understanding beyond stigma and financial constraints [71, 72].

Structural deficits such as inadequate resources and space further restrict PC delivery. Similar studies have shown that the lack of essential drugs, diagnostic tools, and skilled staff impedes comprehensive care. This highlights the urgent need for investment in healthcare infrastructure. Some studies, however, highlight the adaptability and resilience of PC in challenging environments, suggesting that care can still be effective despite systemic limitations [73, 74].

Another major barrier is insufficient training. Many participants lacked formal PC education or confused it with end-of-life care. Consistent with the findings of previous studies, this gap limits early intervention and holistic care. Training and awareness campaigns are critical for addressing these misconceptions.

Cultural beliefs also influence care-seeking behavior. Traditional practices and community norms often deter patients from accepting modern PC. Engaging community and religious leaders, as suggested in prior research, is key to overcoming resistance and building trust [10, 18].

Stigma from both communities and providers was another recurrent theme. Women with HIV and cancer often face discrimination, deterring them from seeking care [4, 9, 22]. Tackling stigma requires targeted interventions and public education.

Logistical and financial barriers such as transportation costs and a lack of patient incentives further restrict access, particularly in rural areas. This finding aligns with the literature and reinforces the need for support mechanisms such as transport and financial aid.

Training and capacity building emerged as critical facilitators. The participants emphasized the importance of specialized education to equip providers for quality PC delivery. This finding echoes studies showing improved awareness and patient outcomes after targeted training. Some studies suggest that while these programs improve providers’ awareness and attitudes, their translation into improved patient outcomes requires further investigation. This implies that education alone may not be sufficient without concurrent system-level changes and practical implementation opportunities [75].

Community engagement also plays a vital role. Local leaders, religious figures, and support groups can promote PC awareness and acceptance. Prior research supports the effectiveness of community-driven approaches and highlights that inadequate preparation, including understanding community dynamics and communication strategies, can hinder the success of community participation programs. This underscores the need for thorough planning, including community engagement and cultural competence when implementing community-driven initiatives [76].

Infrastructure, adequate supplies, and a multidisciplinary team (MDT) approach were identified as essential facilitators of effective palliative care. The participants emphasized the need for well-equipped centers, stable funding, and essential materials, findings that align with previous research linking strong infrastructure to improved patient outcomes. Nonetheless, some studies suggest that infrastructure alone is insufficient; the quality of care also relies heavily on the effective use of available resources and the competence of healthcare providers [77]. Similarly, while collaboration among healthcare workers, social workers, and spiritual leaders within an MDT promotes comprehensive care, consistent with earlier studies, the effectiveness of this approach is often undermined by poor communication, unclear role definitions, and decision-making inefficiencies [78].

The participants also stressed the importance of empathy and patient-centered care, noting that provider attitudes significantly influence patient trust and willingness to engage in care. This aligns with existing research on the benefits of compassionate care. Yet even well-intentioned providers may struggle to consistently demonstrate empathy due to high workloads, limited time, and emotional burnout, highlighting the need for systemic reform alongside efforts to improve individual attitudes [79]. Additionally, incentives such as transport support or nutritional aid were viewed as vital for improving access to care, which is consistent with evidence that practical support enhances service utilization in underserved settings. Nevertheless, the effectiveness of such incentives may vary depending on the specific context in which they are applied [80].

Methodologically, the strength of this study lies in its diverse sample and qualitative depth, allowing rich insights into structural, cultural, and systemic barriers. However, focusing solely on provider perspectives may exclude patient experiences. While this limits generalizability, prior quantitative research complements these findings [5].

Overall, this study reinforces the urgent need for integrated PC models, especially for women with HIV and cancer. Policy actions should prioritize funding, infrastructure, and provider training. Future research should focus on patient perspectives and outcomes to guide holistic, inclusive care strategies.

Conclusion

This study makes a unique contribution to the field of PC by highlighting the compounded barriers faced by women living with HIV and cancer in Nigeria, a context where systemic inefficiencies, cultural barriers, and resource limitations intersect to create significant gaps in care. It underscores the critical need for integrated, patient-centered PC models that address not only the physical but also the emotional, social, and spiritual needs of patients. The study identifies the lack of healthcare worker training, inadequate infrastructure, and sociocultural stigma as key barriers, while emphasizing the potential of community engagement, multidisciplinary collaboration, and targeted investments in infrastructure and resources as facilitators. By focusing on the dual burden of HIV and cancer, this research fills a critical gap in the literature, offering evidence-based insights that can inform policy and practice in low-resource settings. The findings advocate for systemic reforms, including the integration of PC into national healthcare frameworks, standardized training programs, and grassroots advocacy, to ensure equitable access to holistic PC for vulnerable populations. This study not only advances scholarly understanding but also provides a roadmap for improving PC delivery in Nigeria and similar contexts, ultimately contributing to the global discourse on equitable and inclusive healthcare.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

NIA, TO, and EEE conceptualized the study. NIA and JOJ contributed to the study design. NIA and IAO led the data collection. JOJ, JOO, and IAO analyzed the data. NIA, JOJ and IAO wrote the first draft of the manuscript. EEE and JOO contributed to manuscript revision. All the authors reviewed the manuscript.

Funding

This study was funded under the Joint WHO African Region and TDR Impact Grants for Regional Priorities. The funding source played no role in the design of the study; in the collection, analysis, and interpretation of the data; in the writing of the report; or in the decision to submit the paper for publication.

Data availability

The data that support the findings of this study are available upon request from the corresponding author, IAO. The data are not publicly available, as they contain information that could compromise the anonymity of research participants.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval for this research was obtained from the Nigerian National Health Research Committee (NHREC/01/01/2007–18/03/2024). Informed consent was obtained from the participants before the commencement of qualitative data collection.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.