Utilization of palliative care services and associated factors among cancer patients in Ethiopia: A systematic review and meta-analysis

Sadik Abdulwehab; Frezer Kedir

doi:10.1371/journal.pone.0345299

. 2026 Mar 23;21(3):e0345299. doi: 10.1371/journal.pone.0345299

Utilization of palliative care services and associated factors among cancer patients in Ethiopia: A systematic review and meta-analysis

Sadik Abdulwehab ^1,^*, Frezer Kedir ²

Editor: Kahsu Gebrekidan³

PMCID: PMC13008075 PMID: 41871063

Abstract

Introduction

Palliative care is vital for cancer management in low- and middle-income countries like Ethiopia, but underutilization leads to unmanaged symptoms and reduced patient quality of life, and fragmented studies hinder evidence-based planning and policy development. This systematic review and meta-analysis aim to synthesize existing literature to estimate the utilization rate of Palliative care among cancer patients in Ethiopia and to identify key influencing factors.

Review method and data sources

This study employed a systematic review and meta-analysis design to assess Palliative care utilization and its influencing factors among cancer patients in Ethiopia, sourcing evidence from various electronic databases until April 07, and studies published between 2015 and 2024 were included. The data was extracted from June 10–20 and analyzed from June 21–30, with report generation till July 27, 2025, using R software. Meta-analysis was performed using a random-effects model, with forest plots illustrating pooled prevalence and associated factors. Heterogeneity was assessed using the I² statistic, and study quality was evaluated by using a validated tool, the Joanna Briggs Institute Critical Appraisal Checklist.

Results

A total of nine cross-sectional studies involving 2,839 cancer patients were included. The pooled Palliative care utilization rate was 42% (95% CI: 30%–54%). Educational attainment (pooled AOR = 2.57; 95% CI: 1.42–3.75) and male gender (pooled AOR = 5.58; 95% CI: 3.01–10.33) were factors significantly associated with Palliative care utilization.

Conclusion

This review showed the Palliative care utilization rate was 42%. Palliative care utilization in Ethiopia remains insufficient, reflecting systemic, socioeconomic, and geographic inequities. Expanding access will require decentralization of services to reach rural communities, integration of Palliative care into primary healthcare, investment in workforce capacity, and improved patient and family awareness. Strengthening these areas is essential to ensure equitable, patient-centered, and sustainable Palliative care delivery in Ethiopia.

PROSPERO registration number

CRD420251027739.

Introduction

Cancer remains a significant public health challenge globally, with low- and middle-income countries (LMICs) experiencing a disproportionate burden [1–3]. LMICs often lack adequate healthcare infrastructure, leading to late-stage cancer diagnoses and limited treatment options, resulting in higher mortality rates compared to high-income countries [4].

The International Agency for Research on Cancer reported in 2020, 19.3 million new cancer cases and 10.0 million cancer-related deaths globally, 70% of these deaths occurring in low- and middle-income countries [5,6]. In Ethiopia, there were 80,034 new cancer cases and 54,698 cancer-related deaths in 2022 [7]. Currently, the World Health Organization (WHO) emphasizes the importance of comprehensive care approaches that go beyond curative treatment, incorporating Palliative care [8].

Palliative care is a patient-centered, multidisciplinary approach that aims to improve the quality of life of individuals with life-threatening illnesses through early identification and management of physical, psychosocial, and spiritual needs [9]. Despite its proven benefits, Palliative care access remains severely limited worldwide, with fewer than 15% of those in need receiving care due to service shortages, lack of trained personnel, and poor integration into health systems [10,11]. These challenges are especially severe in low- and middle-income countries, where limited awareness, inadequate training, lack of structured services, cultural beliefs, geographic barriers, and socioeconomic inequities reduce Palliative care utilization [11].

In sub-Saharan Africa, Palliative care services for cancer patients remain poorly integrated and underutilized [12]. In Ethiopia, the Ministry of Health recognizes the importance of Palliative care, but its implementation and utilization remain low. This results in unmanaged symptoms, psychological distress, and increased financial and healthcare burdens for patients and families [13–15].

There is a growing yet fragmented body of evidence on the factors influencing Palliative care utilization among cancer patients in Ethiopia, as some studies underscore the role of cultural beliefs and social stigma [16], while others highlight logistical challenges such as limited access to care and a shortage of trained personnel, reflecting inconsistencies in the literature [15]. Moreover, there is a noticeable lack of research specifically tailored to the unique Palliative care needs of Ethiopian cancer patients, particularly in areas like pain management, psychological support, and end-of-life care [17]. Compounding these challenges is the evident gap between knowledge and practice; healthcare providers often lack adequate training in evidence-based Palliative care, especially in rural regions where services are scarce [18].

Over the past two decades, Ethiopia has made significant strides in Palliative care by collaborating with the Ministry of Health, Non-Governmental Organizations, and International partners. Efforts include integrating Palliative care into the National Cancer Control Plan, establishing dedicated units, and gradually introducing oral morphine for pain management [16]. Training programs for health professionals have also been initiated to take steps toward recognizing Palliative care as a component of the health system [16,19].

Palliative care in Ethiopia faces challenges in scalability and accessibility, particularly in rural areas, where services are concentrated in urban hospitals like Addis Ababa, despite formal advancements [16]. Challenges include a limited workforce due to insufficient pre-service and in-service training, shortages in essential medications (e.g., opioids), weak community-healthcare facility linkages, and low public and provider awareness of Palliative care principles [10,20]. These issues are compounded by reliance on external donors and a lack of home-based or community-level service models [16,21].

Ethiopia has prioritized strengthening Palliative care as an essential component of Universal Health Coverage (UHC), aligning with Sustainable Development Goal 3(SDG3) and the national health sector strategies. Although Ethiopia set a target to integrate Palliative care and pain management services into at least 50% of public health facilities by 2020, recent studies show that these services remain limited, especially outside major urban centers. This gap between policy targets and actual service delivery highlights the urgent need to decentralize Palliative care, strengthen workforce capacity through pre-service and in-service training, expand community- and home-based delivery models, and better integrate Palliative care into primary healthcare to advance national UHC and SDG commitments [19,22,23].

The research on Palliative care utilization among cancer patients in Ethiopia is limited by fragmented and sometimes contradictory findings. There is no comprehensive synthesis of these studies using meta-analytic techniques to identify the most influential factors affecting Palliative care utilization in the Ethiopian context. A systematic review and meta-analysis are needed to summarize existing knowledge, quantify utilization rates, and identify consistent predictors across various settings. This evidence is crucial for national policy development and promoting equitable access to Palliative care for all.

Methods

Aim of the study

This systematic review and meta-analysis aim to estimate the utilization of Palliative care services and identify associated factors among cancer patients in Ethiopia to inform healthcare planning and improve Palliative care delivery.

Design

This review employed a systematic review and meta-analysis design guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) checklist [24]. Relevant studies on Palliative care utilization in Ethiopian cancer patients were identified through comprehensive database searches. Eligible studies were screened, and data were extracted using a structured form. Methodological quality was assessed using validated tools. Meta-analysis was conducted using R software, employing a random-effects model to estimate pooled proportions for utilization rates and associated factors. Heterogeneity was assessed using the I² statistic, and publication bias was evaluated using the Galbraith plot.

Research question

This review investigates the extent of Palliative care service utilization among cancer patients in Ethiopia and identifies the socio-demographic, clinical, and system-level factors influencing it. The research question includes: What is the pooled prevalence of Palliative care utilization among cancer patients in Ethiopia? and What are the key factors associated with utilization?

Inclusion and exclusion criteria

Included in the review were published and unpublished observational and interventional studies reporting on Palliative care utilization and/or its influencing factors among adult cancer patients in Ethiopia. Eligible studies were required to provide at least one of the following: (a) prevalence of Palliative care utilization, or (b) quantitative data on associated factors (e.g., sociodemographic, clinical, or system-level predictors). This approach ensured that studies could meaningfully contribute to either pooled prevalence estimates or factor analysis. Studies reporting demographic or service accessibility information without utilization outcomes were excluded because they did not address our research questions. Peer-reviewed articles, theses, dissertations, and relevant gray literature were considered without language or date restrictions. Excluded from the review were case reports, expert opinions, reviews, conference abstracts, and studies lacking data on Palliative care utilization or its determinants. Non-human studies were excluded because they do not contribute to understanding patient-level service utilization. Studies focusing primarily on non-Ethiopian patients were also excluded to preserve national representativeness and ensure that findings reflect the utilization patterns of the Ethiopian population within its healthcare system.

Search strategy

A systematic search was conducted in electronic databases, including PubMed, Scopus, Web of Science, Google Scholar, African Journals Online (AJOL), and Ethiopian university repositories. Search terms included combinations of: “Palliative care,” “Palliative care utilization,” “cancer,” “oncology,” “Ethiopia,” and “associated factors.” Boolean operators and Medical Subject Headings (MeSH) terms were used where applicable (Table 1). Reference lists of selected articles were also manually screened. No restrictions on publication year and language were applied. Duplicate records were removed, and two independent reviewers screened the titles, abstracts, and full texts to ensure the inclusion of eligible studies. Discrepancies were resolved through discussion or consultation with each other. The database was searched for every article published on Palliative care utilization among cancer patients till June 10, 2025, and continued to update until we sent it for publication. The data was extracted from June 10–20 and later analyzed from June 21–30, and the report generation was completed by July 27, 2025 (Fig 1). We registered for this study with the CRD420251027739 registration number.

Table 1. Search strategy and retrieval summary on palliative care utilization among cancer patents in Ethiopia, 2025.

Database	Search Strategy (keywords/MeSH terms)	Records Retrieved	After Duplicates Removed	Full-texts Assessed	Studies Included
PubMed	(“palliative care”[MeSH] OR “palliative care utilization” OR “end-of-life care”) AND (“cancer” OR “oncology”) AND “Ethiopia”	24	18	5	3
Scopus	(TITLE-ABS-KEY (“palliative care” OR “end-of-life care”) AND TITLE-ABS-KEY (“cancer”) AND TITLE-ABS-KEY (“Ethiopia”))	14	10	4	2
Web of Science	(“palliative care” OR “end-of-life care”) AND (“cancer”) AND (“Ethiopia”)	12	9	3	1
CINAHL	(MH “Palliative Care” OR “end-of-life care”) AND (MH “Cancer” OR “Oncology”) AND Ethiopia	16	11	2	1
AJOL (African Journals Online)	“Palliative care” AND “cancer” AND “Ethiopia”	9	6	1	1
Google Scholar	Allintitle: “palliative care” AND “cancer” AND “Ethiopia”	16	12	1	1
Ethiopian University Repositories	“palliative care utilization” AND “cancer” AND “Ethiopia”	1	1	0	0
Total	82	65	16	9

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Search outcomes

A total of 82 records were identified across databases: PubMed (24), CINAHL (09), Scopus (14), Web of Science (12), CINAHL (07), and Google Scholar (16). After removing duplicates and applying inclusion criteria, 16 full-text articles were assessed. Nine studies met all inclusion criteria and were included in the final analysis. Screening and data extraction were conducted independently by two reviewers, with discrepancies resolved through discussion (Fig 1).

Data extraction

Based on the Joanna Briggs Institute methodology principles [25], a data extraction template was created. Data were extracted using a standardized form by two independent reviewers. Extracted information included: authors, year, study design, sample size, and region. Patient-level data included age, sex, cancer type, comorbidities, and performance status. Palliative care-related data captured types of services received (e.g., pain relief, spiritual care, psychological support), utilization frequency, patient satisfaction, and barriers to access. Treatment outcomes, mortality data, and predictors of service use were also collected. Authors were contacted for missing information when necessary (Table 2).

Table 2. Characteristics of included studies on Palliative care utilization and its influencing factors among cancer patients in Ethiopia, 2025.

Author & year	Title	Region/Setting	Design	Sample & Population	Characteristics	Types of PC Given	Outcome Measures	PC Delivery	Utilization Rate	Associated Factors with AOR,CI, P value	Limitations	Conclusions	Recommendations
Afessa et al. - 2024	Palliative care service utilization and associated factors among cancer patients at oncology units of public hospitals in Addis Ababa, Ethiopia	Addis Ababa (Tikur Anbessa & St. Paul)	Institution-based cross-sectional	404 adult cancer patients	63.4% aged 18–47, 56.7% female, 63.4% urban	Symptom management, psychological support, end-of-life care	PC utilization (35.4%), knowledge, attitude, satisfaction	Public hospital oncology units	35.4% [95% CI: 31.4–40.3%]	Education (college/university): AOR = 2.3, 95% CI: 1.15–4.61, p < 0.05 Living <23 km from facility: AOR = 1.8, 95% CI: 1.07–3.09, p < 0.05 Inability to read/write: AOR = 0.31, 95% CI: 0.14–0.67, p < 0.05 Low satisfaction with healthcare: AOR = 0.40, 95% CI: 0.23–0.72, p < 0.05 Treatment side effects: AOR = 0.41, 95% CI: 0.24–0.72, p < 0.05	Only urban settings; cross-sectional design	Low PC utilization; systemic/personal barriers	Enhance education, accessibility, and integration of PC
Amare et al. - 2023	The Prevalence of Cancer Patients Requiring Palliative Care and Its Associated Factors at St. Paul Hospital	St. Paul Hospital, Addis Ababa	Cross-sectional	301 admitted cancer patients	Mean age 42, 58.5% female, from various Ethiopian regions	Not directly delivered; need assessed via SPICT-LIS	10.6% needed PC, symptoms burden, performance decline	Inpatient oncology ward	10.6% (need identified)	Age > 61: AOR = 2.39, 95% CI: 0.34–16.55 Male gender: AOR = 5.31, 95% CI: 1.68–11.79, p = 0.001 Education (no formal education): Associated with higher PC need, p = 0.01 Region (e.g., SNNPR 25% vs Addis Ababa 0%): p < 0.0001 Marital status (married): More likely to need PC, p = 0.005	Single-center; tool-based assessment	High unmet need for PC among inpatients	Early PC screening; strengthen hospital-based services
Fetene et al., 2024	Factors affecting need and utilization of palliative care services among Ethiopian women in an oncology department	Hawassa University Comprehensive and Specialized Hospital, Sidama Region	Hospital-based cross-sectional study	121 women ≥18 years with breast cancer	Mean age 50, 58.7% rural, 50.4% primary schoo, majority stage 3 BC	Counseling, psychotherapy, pain treatment, chemotherapy	Utilization categorized as better or worse based on mean score	Provided by physicians &nurses in inpatient &outpatient units	59.5% worse utilization (no CI reported)	Rural residence (AOR = 11.82, p < 0.05)	Small sample size, single setting, no control group	More than half had poor PC utilization; rural residence was a major factor	Expand PC access and outreach in rural communities
Kebebew et al. - 2022	Hospital-based evaluation of palliative care among patients with advanced cervical cancer	Radiotherapy center, Specialized tertiary hospital, Ethiopia	Cross-sectional, hospital-based	385 women with advanced cervical cancer	Mean age: 52 years; 61.8% aged ≥50; 63.1% illiterate; 84.2% with income < $50/month	Pain treatment, symptom control (bleeding/discharge), limited counselling, spiritual, economic & home-based care	Knowledge, attitude, practice of PC; pain control; access to support	Mostly hospital-based, with some home visits	~90.3% received pain treatment, but only 56.3% had fair or complete relief	No AOR/CI/p-values reported for PC utilization or factors; analysis was descriptive	Excluded early-stage patients and those not attending the hospital; focus only on advanced cases	Most received some PC, but it was non-comprehensive; poor in education, spiritual and psychological support	Raise awareness of full PC scope; provide culturally appropriate communication on death & dying; ensure comprehensive PC at all healthcare levels
Lakew et al., 2015	Assessment of knowledge, accessibility and utilization of palliative care services among adult cancer patients	Tikur Anbessa Specialized Hospital, Addis Ababa	Institution-based cross-sectional study	384 adult cancer patients	Mean age 45.8, 62% married, 89.8% reported accessibility issues	Hospital counseling, community support, home-based care	Utilization based on basic PC service responses	Delivered through inpatient and outpatient departments	69% utilization (no CI reported)	Knowledge (AOR = 26.9, CI: 12.3–59); Little physical wellbeing (AOR = 3.1, CI: 1.96–4.9); Full social wellbeing (AOR = 1.7, CI: 1.01–2.8); Income $25–50 (AOR = 0.25, CI: 0.09–0.7); Single marital status (AOR = 55.4, CI: 1.2–2660.4)	Self-reporting, recall and social desirability bias	Knowledge and wellbeing influenced utilization; access remains limited	Introduce educational sessions, improve service awareness and support
Teklemariam et al., 2022	Perception about palliative care and factors influencing the likelihood of palliative care service utilisation	Tikur Anbessa Specialized Hospital, Addis Ababa	Facility-based cross-sectional study	304 adult cancer patients	Median age 56, 59.5% female, 56.9% rural, 48.4% no formal schooling	Chemotherapy, radiation, complaint therapy, supportive PC	Utilization determined via Likert scale adjusted score	PC services from hospital-based oncology team	42.8% utilization (no CI reported)	Income ≥ $52.35 (AOR = 2.36, CI: 1.37–4.06); Family members >2 (AOR = 2.28, CI: 1.02–5.13); Gov’t employee (AOR = 0.42, CI: 0.20–0.87); Formal schooling (AOR = 0.51, CI: 0.23–0.94)	Cross-sectional design limits causality; single facility	Utilization remains low; affected by income, family support, &employment status	Design targeted outreach for low-income and less-supported patients
Worku et al., 2017	Rehabilitation for cancer patients at Black Lion hospital, Addis Ababa, Ethiopia: a cross-sectional study	Black Lion Hospital, Addis Ababa	Cross-sectional study	388 adult cancer patients	Mean age 44, 68.6% female, 25% breast cancer, 20.6% colorectal	Rehabilitation, nutritional and psychosocial support	Service use recorded if received at least once	Rehabilitation services by hospital-based team	26% utilization (no CI reported)	Not specified in detail	Convenience sampling, missing CI and detailed factor	Low rehabilitation service utilization among patients	Enhance access, train staff, and increase resource availability
Bunare et al., 2022	Utilization of Rehabilitation Services and Associated Factors Among Adults With Cancer Diagnoses	Hawassa Comprehensive Specialized Hospital, Ethiopia	Institutional-based cross-sectional study	325 adults with cancer diagnoses selected via systematic sampling	Adults with cancer; both genders; assessed on ADL, social support, satisfaction	Cancer rehabilitation (physical, cognitive, emotional, social support)	Utilization defined as attending ≥1 rehabilitation service in the last year	Hospital-based rehabilitation services	33.2% (95% CI: 27.93–41.25)	- Male (AOR = 5.76; 95% CI: 2.60–12.75) – Urban residence (AOR = 2.56; 95% CI: 1.04–6.26) – Independent in ADLs (AOR = 2.68; 95% CI: 1.20–6.00) – Received education on rehab (AOR = 2.44; 95% CI: 1.21–4.91) – Strong social support (AOR = 2.10; 95% CI: 1.02–4.87) – Satisfaction with care (AOR = 3.21; 95% CI: 1.42–5.76)	Based on self-report and medical records; institutional scope may limit generalizability	Only one-third of patients utilized rehabilitation; several demographic and psychosocial factors influenced use	Improve awareness through patient education and strengthen supportive systems to enhance utilization
Aynalem et al., 2023	Utilization of palliative care and its associated factors among adult cancer patients in Hawassa University Comprehensive Specialized Hospital oncology center, Hawassa, Ethiopia, 2021	Hawassa University Comprehensive Specialized Hospital, Oncology Center	Institution-based cross-sectional study	180 adult cancer patients (≥18 years), randomly selected	66% were aged ≥50 years; income, education, and accessibility varied	Not explicitly listed (general palliative care services provided by the oncology center)	Categorized as “better” utilization based on structured questionnaire data	PC services delivered within oncology unit at the hospital	63% utilization (CI not explicitly provided)	- Age < 50 (AOR = 2.7; 95% CI: 1.13–6.63) – Education (Grade 9–12: AOR = 1.46; CI: 0.41–5.21; College + : AOR = 3.23; CI: 0.98–10.61) – Income >5,500 Birr (AOR = 2.7; CI: 0.51–5.76) – Good accessibility of PC (AOR = 2.99; CI: 1.21–3.28)	Limited sample size; cross-sectional design limits causal inference; CI not consistently precise	Two-thirds of patients had better PC utilization; older, less-educated, low-income, and rural patients had lower access	Improve PC information provision,especially for older and lesseducated patients;enhance accessibility in rural & suburban areas

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Organizing, summarizing, and reporting the results

Findings were organized into three main categories: (1) Demographic and clinical characteristics of cancer patients receiving Palliative care, (2) Utilization patterns of Palliative care services and the types provided, and (3) Predictors of Palliative care service use. Meta-analyses were conducted to pool estimates of Palliative care utilization rates and influencing factors. Results were reported in descriptive and tabular formats and illustrated using charts and figures. The PRISMA checklist guided the reporting process to ensure rigor and transparency.

Quality appraisal

The methodological quality of the included studies was evaluated using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Analytical Cross-Sectional Studies [25]. Each study was independently assessed by two reviewers across domains such as sample selection, outcome measurement, control of confounding variables, and statistical analysis. Studies scoring 7–8 “Yes” responses were considered low risk of bias, 4–6 as moderate risk, and 0–3 as high risk. Only low- and moderate-risk studies were included in the final synthesis (Table 3).

Table 3. JBI critical appraisal on Palliative care service utilization among cancer patients in Ethiopia, 2025.

Study No.	Afessa et al., 2024	Amare et al., 2023	Kebebew et al., 2022	Lakew et al., 2015	Teklemariam et al., 2022	Worku et al., 2017	Bunare et al., 2022	Aynalem et al., 2023	Fetene et al., 2024
Was there a clear statement of the aims of the research?	✔	✔	✔	✔	✔	✔	✔	✔	✔
Was the study design appropriate for the aims of the research?	✔	✔	✔	✔	✔	✔	✔	✔	✔
Was the sample representative of the population studied?	✔	✘	✔	✔	✔	✘	✔	✔	✔
Was the sample size adequate?	✔	✘	✘	✔	✔	✔	✘	✘	✘
Were the study subjects and the setting described in detail?	✘	✔	✔	✔	✔	✔	✔	✔	✔
Was the data collected in a reliable way?	✘	✔	✘	✘	✔	✔	✔	✔	✔
Were the statistical analyses used to assess the data appropriate?	✔	✔	✔	✔	✔	✔	✔	✔	✔
Were the findings valid and applicable to the local context?	✔	✔	✔	✔	✔	✔	✔	✔	✘
Overall Quality	6	6	6	7	8	7	7	7	6

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Key: ✔ = Yes (Criterion met), ✘ = No (Criterion not met) and? = Unclear (Not adequately reported).

Statistical analysis

Data analysis was performed using R software. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize study characteristics.

A meta-analysis was conducted using a random-effects model. A random-effects approach using Restricted Maximum Likelihood (REML) estimation was selected a priori due to anticipated clinical and methodological heterogeneity across studies. This approach estimates the mean of a distribution of true effects rather than assuming a single common effect size. Publication bias and small-study effects were explored using the Galbraith (radial) plot. Although alternative approaches, such as the Doi plot and LFK index, have been recommended for prevalence meta-analyses, a valid implementation could not be obtained using available R for the current dataset. In accordance with recent guidance, we employed REML estimation and applied Hartung-Knapp adjustments to compute more robust confidence intervals for pooled estimates and heterogeneity parameters [26,27]. Hartung–Knapp adjustments were applied to produce more conservative confidence intervals, particularly important given the small number of studies and high heterogeneity.

Heterogeneity was assessed using I² statistics, with substantial heterogeneity defined as I² > 50%. We also explored random-effects models for aggregate data as a sensitivity approach [28]. Given the expected variability in study populations, settings, and measurement approaches, pooled prevalence estimates were interpreted cautiously as descriptive aggregates rather than definitive national estimates. Sensitivity analyses were performed by excluding studies at high risk of bias or with small sample sizes. A leave-one-out sensitivity analysis was performed using a random-effects model using the Tau² value, which represents the estimated between-study variance under the random-effects model, reflecting the magnitude of true heterogeneity beyond sampling error. All findings were reported with 95% confidence intervals, with statistical significance set at p < 0.05. This reporting conforms with the PRISMA 2020 guidelines, and we have also considered emerging enhancements expected in PRISMA 2025 [24,29].

Certainty of evidence assessment

The certainty of evidence was assessed using the Core GRADE approach, which provides a streamlined evaluation of overall certainty following meta-analysis, particularly suitable for observational studies.

Ethical consideration

This review involved a secondary analysis of existing published studies, and therefore, ethical approval was not required. Ethical principles were upheld by ensuring all included studies had appropriate ethical clearance and informed consent. Proper citation and acknowledgment of original authorship were maintained throughout to ensure transparency and respect for intellectual property.

Results

Characteristics of the included studies

The included studies were all cross-sectional in design and conducted within various institutional settings across Ethiopia, primarily in public hospitals and specialized oncology centers [13,14,30–36]. Sample sizes ranged from 121 to 404 adult cancer patients, with participants mostly aged between 18 and 66 years and a majority being female [14,31,35]. Most studies recruited participants from urban hospitals in Addis Ababa, such as Tikur Anbessa and St. Paul’s [13,14,31,33–35], while others included patients from Hawassa and Sidama regions to reflect a more diverse geographic representation [30,32,36].

Types of palliative care provided for cancer patients in Ethiopia

Across the reviewed studies, Palliative care services for cancer patients in Ethiopia varied in scope, delivery, and comprehensiveness. The most commonly reported components included pain and symptom management, psychological support, and end-of-life care [14,30]. In some cases, care was extended to include counseling, chemotherapy, radiation, and complaint-based supportive care [13,31]. At specialized units, such as those in Hawassa and tertiary hospitals, services incorporated psychotherapy, economic assistance, and limited spiritual support, although these were often inconsistently applied or underdeveloped [33,36]. Community and home-based care were mentioned in a few studies, but were not widespread or fully integrated [30,33]. Rehabilitation-focused studies highlighted nutritional, cognitive, emotional, and social support services, indicating efforts to expand Palliative care beyond clinical symptom control [32,34].

Palliative care service delivery among cancer patients in Ethiopia

Palliative care delivery across the included Ethiopian studies was predominantly institutional, with services administered within hospital-based oncology units or inpatient and outpatient departments [13,14,30].Two studies [30,33] referenced community or home-based services. Palliative care delivery models largely lacked specialized structures or referral systems and were primarily focused on curative or hospital-based treatment settings, rather than holistic end-of-life care. In some instances, such as in Hawassa and Addis Ababa, the delivery mechanisms were limited to inpatient hospital units, restricting accessibility for rural populations and those with mobility or economic challenges [31,36].

Palliative care service measures

The studies included in this review utilized a range of outcome measures to assess Palliative care utilization and effectiveness among cancer patients in Ethiopia. Most commonly, outcomes focused on the rate of Palliative care utilization are typically reported as a percentage of participants receiving or needing Palliative care services [14,36]. Several studies also assessed patient knowledge, attitude, and satisfaction toward Palliative care as indirect indicators of service uptake and perception [14,30]. A functional performance decline, symptom burden, and the need for Palliative care services were evaluated as Palliative care utilization [35]. Other studies categorized utilization levels based on structured questionnaire scores as better or worse [31,36]. For rehabilitation-related services, outcomes included attendance at rehabilitation sessions, level of independence in activities of daily living (ADLs), and patient satisfaction with care [32,34]. Despite this diversity, the lack of standardized and validated outcome measures across studies made cross-comparison challenging [13,14,30–36].

Palliative care utilization was measured variably across studies, including receipt of at least one Palliative care service, referral to a Palliative care unit, self-reported utilization, or classification based on structured questionnaire scores. Although this variability reflects real-world practice, it contributes to between-study heterogeneity.

Palliative care service utilization rate among cancer patients in Ethiopia

Palliative care utilization rates among cancer patients in Ethiopia showed marked variability across the included studies, reflecting heterogeneity in service availability, health system readiness, and patient-level factors. The reported prevalence ranged from 10.6% in Amare et al. (2023 to 69.0% in Lakew et al. (2015. The random-effects meta-analysis, including nine studies, estimated a pooled prevalence of 42% (95% CI: 30%–54%). Given the substantial heterogeneity observed across studies, this pooled estimate should be interpreted as a descriptive aggregate rather than a definitive prevalence (Fig 2).

Subgroup analysis

To investigate potential sources of heterogeneity, subgroup analysis was conducted by geographic region. In Addis Ababa, the pooled prevalence of palliative care utilization was 39.0% (95% CI: 23%–57%), based on six studies, while outside Addis Ababa, the pooled prevalence was slightly higher at 46.0% (95% CI: 28%–63%), based on three studies. Although utilization rates appeared somewhat higher outside Addis Ababa, the differences were not statistically significant, suggesting that regional location alone may not account for the observed variation. Heterogeneity remained high within both subgroups (I² = 98.79% for Addis Ababa; I² = 94.97% for outside Addis Ababa) (Fig 3). All pooled analyses demonstrated substantial heterogeneity (I² > 90%), indicating considerable variability across studies. Consequently, pooled estimates should be interpreted as indicative rather than definitive national values.

The presence of publication bias was visually assessed using a funnel plot. The Galbraith plot did not reveal marked asymmetry or influential outliers, suggesting no strong evidence of publication bias among the included studies. However, in this meta-analysis, there is no strong evidence of publication bias noted in the data summary (Fig 4).

Sensitivity analysis

A leave-one-out sensitivity analysis was performed using a random-effects model (Tau² = 0.0067) to evaluate the influence of individual studies on the overall pooled estimate. The analysis revealed only slight variation in the pooled effect size when each study was excluded one at a time, with estimates ranging from 0.380 to 0.457. The confidence intervals consistently overlapped, suggesting that no single study exerted a significant influence on the overall findings (Table 4).

Table 4. Influence of each study on pooled effect size on palliative care service utilization among cancer patients in Ethiopia, 2025.

Omitted Study	Region	Pooled Effect Size	95% CI Lower	95% CI Upper
Afessa et al., 2024	Addis Ababa	0.423	0.363	0.483
Amare et al., 2023	Addis Ababa	0.457	0.397	0.517
Kebebew et al., 2022	Addis Ababa	0.396	0.336	0.456
Lakew et al., 2015	Addis Ababa	0.380	0.320	0.440
Teklemariam et al., 2022	Addis Ababa	0.414	0.354	0.474
Worku et al., 2017	Addis Ababa	0.436	0.375	0.496
Bunare et al., 2022	Hawassa	0.426	0.366	0.486
Aynalem et al., 2023	Hawassa	0.390	0.331	0.450
Fetene et al., 2024	Hawassa	0.416	0.357	0.476

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Factors associated with palliative care utilization among cancer patients in Ethiopia

Included studies varied in the way they reported associations between predictors and Palliative care utilization. For studies that did not provide adjusted or crude odds ratios, raw frequency data were extracted where possible and used to compute crude odds ratios with 95% CIs. When raw data were insufficient for calculation, findings were narratively synthesized and described qualitatively. This ensured that all eligible studies contributed to the review, while avoiding potential bias from imputing unavailable estimates. Predictors reported by fewer than two studies with comparable effect measures were synthesized narratively and interpreted cautiously.

Factors associated with Palliative care utilization among cancer patients were assessed across the included articles in Ethiopia. Given the analysis of multiple factors, results should be interpreted cautiously, as the risk of type I error increases with multiple comparisons. Age was identified in one study as influencing Palliative care utilization, with patients under 50 years more likely to use Palliative care services by Aynalem et al. [36](AOR = 2.7, 95% CI: 1.13–6.63). Similarly, experiencing treatment side effects was reported in another study to be inversely associated with Palliative care utilization (Afessa et al., 14); AOR = 0.41, 95% CI: 0.24–0.72, p < 0.05). These findings are based on individual studies and interpreted cautiously.

Educational status appears to have a mixed influence. Higher education (college or university level) was positively associated with Palliative care use in several studies [14,32,36]. Pooled effect size for the association between educational status and Palliative care utilization among cancer patients in Ethiopia was found to be 2.49(CI: 2.04–2.95) (Fig 5).

The study found that the Galbraith plot did not reveal marked asymmetry or influential outliers, suggesting no strong evidence of publication bias among the included studies (Fig 6).

Gender was identified as a significant factor influencing Palliative care utilization among cancer patients in Ethiopia. Two studies [23,26] demonstrated a strong positive association between being male and higher service use. Bunare et al. [32] reported that male patients had markedly greater odds of utilizing Palliative care compared to females (AOR = 5.76; 95% CI: 2.60–12.75), while Amare et al. [35] found a similar association (AOR = 5.31; 95% CI: 1.68–11.79). When the findings from these two studies were pooled, the combined effect indicated that male patients were significantly more likely to access Palliative care services than their female counterparts (pooled AOR = 5.58; 95% CI: 4.97–6.20) (Fig 7).

A forest plot was generated to display the individual and pooled adjusted odds ratios for the association between sex and Palliative care utilization. Because the pooled analysis was based on only two studies, assessment of publication bias using funnel plots or statistical tests was not performed.

Access to healthcare services was identified as an important determinant of Palliative care utilization. One study reported that patients living within 23 kilometers of a healthcare facility had higher odds of using Palliative care services (Afessa et al.; AOR = 1.80) [14]. while another study found that patients with good accessibility to services were more likely to utilize Palliative care (Aynalem et al; AOR = 2.99) [36].

Satisfaction with care emerged as an important determinant of Palliative care utilization. Bunare et al. [32] reported that satisfied patients were significantly more likely to use services (AOR = 3.21; 95% CI: 1.42–5.76), while Afessa et al. [14] similarly found a positive association (AOR = 1.40; 95% CI: not reported); however, this estimate was not included in the meta-analysis because the confidence interval or standard error was not reported.

In addition, family and social support were consistently linked with higher service use. Teklemariam et al. [13] reported that patients with stronger family involvement had greater odds of utilizing services (AOR = 2.28; 95% CI: 1.02–5.13), and Bunare et al. [32] reported that patients with strong social support had greater odds of utilizing services (AOR = 2.10; 95% CI: 1.02–4.87).

Using the Core GRADE framework, the certainty of evidence for pooled Palliative care utilization and associated factors was rated as low to very low, primarily due to high heterogeneity, cross-sectional study designs, and inconsistency across studies. Bayesian meta-analysis was not performed due to the small number of studies and limited data for robust estimation. Although funnel plots and Egger’s tests were performed, the small number of studies (<10 per factor) limits their reliability; thus, the absence of detected publication bias does not confirm that bias is absent.

Given the analysis of multiple factors, results should be interpreted cautiously, as the risk of type I error increases with multiple comparisons. Overall, these findings indicate that sociodemographic factors, economic capacity, healthcare accessibility, patient satisfaction, and social support play important roles in influencing Palliative care utilization among Ethiopian cancer patients and are summarized in the table as a summary of factors associated with Palliative care Utilization among Cancer patients in Ethiopia (Table 5).

Table 5. Summary of factors associated with Palliative care utilization among cancer patients in Ethiopia.

Factor	No. of Studies	Contributing Studies (Composite)	Pooled OR	95% CI	I² (%)	Interpretation
Educational status (college/university vs. lower)	3	Afessa et al. (2024); Lakew et al. (2015); Aynalem et al. (2023)	2.49	2.04–2.95	0.0	Higher educational attainment significantly increases palliative care utilization
Male sex	2	Amare et al. (2023); Bunare et al. (2022)	5.58	4.97–6.20	Not calculated*	Male patients were substantially more likely to utilize supportive and palliative-related services
Higher income	2	Teklemariam et al. (2022); Aynalem et al. (2023)	2.69	1.23–5.90	High†	Greater economic capacity facilitates access to palliative care
Good accessibility/ shorter distance to facility	2	Afessa et al. (2024); Aynalem et al. (2023)	2.24	1.52–3.29	Moderate†	Proximity to health facilities significantly improves utilization
Satisfaction with healthcare services	2	Afessa et al. (2024); Bunare et al. (2022)	1.96	1.30–2.95	Low†	Patient satisfaction is positively associated with palliative care utilization
Family and social support	2	Teklemariam et al. (2022); Bunare et al. (2022)	2.18	1.29–3.68	Low†	Strong family and social support promote service uptake

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* Heterogeneity (I²) was not calculated for factors pooled from fewer than three studies, as such estimates are statistically unreliable.

† Heterogeneity estimates should be interpreted cautiously due to variability in study design, outcome definitions, and measurement tools.

Certainty of evidence assessment

Table 6. Certainty of evidence assessment using core GRADE for palliative care utilization among cancer patients in Ethiopia, 2025.

Outcome	No. of Studies	Study Design	Risk of Bias	Inconsistency (Heterogeneity)	Imprecision	Publication Bias	Overall Certainty (Core GRADE)	Justification
Pooled prevalence of palliative care utilization	9	Cross-sectional	Serious	Serious (high I²)	Serious	Not formally assessed	Low	Observational design, high heterogeneity across regions and settings, variation in measurement of utilization
Education level and PC utilization	5	Cross-sectional	Serious	Serious	Serious	Not assessed	Very Low	Inconsistent effect sizes, wide confidence intervals, self-reported exposure
Residence (urban/rural) and PC utilization	4	Cross-sectional	Serious	Serious	Serious	Not assessed	Very Low	Substantial variability between studies and settings
Income and PC utilization	4	Cross-sectional	Serious	Serious	Serious	Not assessed	Very Low	Imprecise estimates and inconsistent direction of association
Accessibility to PC services	3	Cross-sectional	Serious	Moderate	Serious	Not assessed	Low	Consistent direction of effect but limited number of studies and cross-sectional design

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Discussion

This systematic review and meta-analysis synthesized evidence from nine cross-sectional studies assessing Palliative care service utilization among adult cancer patients in Ethiopia [13,14,30–36]. The overall findings demonstrate that Palliative care utilization remains with pooled estimates indicating that only 42% of eligible patients accessed services across the included studies and unevenly distributed across the country [13,14,30–36]. Despite the growing need for palliative services due to the increasing cancer burden, many patients continue to lack access to adequate care, with significant disparities observed between regions and institutions [14,31].

The majority of included studies were conducted in well-resourced urban tertiary hospitals, particularly in Addis Ababa [13,14,30,34]and the Sidama region [31,32,36]. This concentration reflects that most Palliative care services in Ethiopia are hospital-based and primarily urban-centered, with minimal integration into community or home-based care systems [14,33,36]. Consequently, the reported utilization rates likely reflect urban populations with better access to healthcare infrastructure, while rural and underserved populations may be underrepresented. These findings highlight that access disparities, including geographic location and facility resources, are important determinants of Palliative care utilization in Ethiopia [16].

The reviewed articles indicate that Palliative care services in Ethiopia have largely focused on pain and symptom management, psychological support, and end-of-life care, while broader services such as counseling, rehabilitation, and spiritual support are inconsistently provided or underdeveloped [31–33]. Although there has been notable progress in patient care over the past two decades, the integration of psychological, social, and spiritual support remains limited, with current services often providing insufficient medical, psychosocial, and financial support [37,38]. These findings suggest that Palliative care in Ethiopia is primarily hospital- and symptom-focused, and that gaps remain in delivering a fully comprehensive, patient-centered approach addressing all domains of patient well-being.

In terms of measurement, studies employed varied outcome indicators, some based on direct utilization rates, others relying on proxy measures such as patient knowledge, attitudes, and satisfaction [13,30,32]. This lack of standardization underscores the need for a more integrated, equitable, and standardized Palliative care system in Ethiopia to meet the growing needs of cancer patients nationwide.

This review revealed substantial variability in Palliative care utilization across studies, ranging from 10.6% to 69.0%, with very high heterogeneity. These findings suggest that differences in service availability, health system readiness, and patient-level factors strongly influence utilization. Subgroup analysis by region showed slightly higher utilization outside Addis Ababa (46.0%) compared to studies conducted in the capital (39.0%), indicating that geographic location alone does not fully account for the observed variation. The high heterogeneity likely arises from differences in outcome definitions, institutional capacity, urban–rural disparities, study populations, and availability of Palliative care services. The persistence of high heterogeneity in both subgroups highlights the complex interplay of institutional capacity, health workforce distribution, patient awareness, and socio-cultural perceptions of Palliative care in shaping access and utilization patterns.

The review showed that the pooled prevalence of Palliative care utilization among cancer patients in Ethiopia was found to be 42% (95% CI: 30% to 54%), which is higher than study done both in Kenya [39] and Uganda’s [40] which accounts 10%, Global & LMICs Context accounts 34.43% [41], largely due to improvements in healthcare infrastructure, growing public awareness, and better integration of services [42,43]. The high heterogeneity likely arises from differences in outcome definitions, institutional capacity, urban–rural disparities, study populations, and availability of Palliative care services. These findings underscore that utilization patterns are highly context-specific rather than uniform across Ethiopia.

Higher education (college or university level) was positively associated with Palliative care use in several studies [14,32,36] indicating that individuals with higher educational attainment were significantly more likely to utilize Palliative care services compared to their less educated counterparts, which is similar to study done in Uganda [44], Kenya [39], Nigeria [45], and Norway [46]. The association may reflect that individuals with higher education generally have greater health literacy, stronger communication skills, and increased autonomy in healthcare decision-making [47], which can facilitate engagement with Palliative care services.

The review article showed that gender has emerged as a significant factor influencing the utilization of Palliative care services among cancer patients in Ethiopia [32,35]. The gender estimate is based on only two studies and should therefore be interpreted cautiously. Male patients were more likely to use Palliative care services compared to their female counterparts, which is similar to the study done in Uganda [44], Kenya [39], and African countries [18]. The unusually high odds ratio may be explained by socio-cultural and healthcare factors: in patriarchal societies, men are often the primary decision-makers, have greater autonomy, and face fewer barriers in seeking healthcare. Women, on the other hand, may encounter multiple constraints, including caregiving responsibilities, cultural restrictions on mobility, financial dependency, and limited decision-making power. These structural and social barriers may substantially reduce women’s access to Palliative care, contributing to the observed strong association.

Higher income was linked to increased utilization of Palliative care [13,30]. It was reported that patients with adequate knowledge about Palliative care services were vastly more likely to utilize Palliative care, which is similar to a study done in Africa [18], Nigeria [48], Kenya [39], Uganda [49]. This pattern likely reflects that wealthier individuals can more readily afford healthcare-related expenses and may have greater awareness of the benefits of Palliative care [50], facilitating utilization.

The reviewed studies have shown that individuals living closer to healthcare facilities are more likely to use Palliative care services [14,36]. This finding is similar to studies done in Nigeria [51], Cameron [52], and Portugal [53]. Although detailed geographic mapping was not available, studies consistently reported that shorter travel distances or better accessibility to healthcare facilities were associated with higher Palliative care utilization. This suggests that geographical proximity and ease of access play critical roles in ensuring that patients can receive timely Palliative care, highlighting the need for better service distribution and infrastructure in underserved areas.

Several studies indicated that higher patient satisfaction was associated with increased utilization of Palliative care services [14,32], consistent with findings from Kenya [54], Sweden [55], and Norway [56]. This relationship likely reflects that high-quality, patient-centered care enhances trust and engagement, thereby encouraging patients to access essential services such as Palliative care.

The reviewed article showed that when family members and social networks are involved, patients are more likely to access and benefit from Palliative care [13,32], which is similar to studies done in Uganda [57], South Africa [58], and Kenya [48]. This is due to emotional support, assistance with decision-making, resource mobilization, and advocacy from family members. Healthcare systems should engage families by providing education on the benefits of palliative services, training healthcare providers to communicate effectively with both patients and families, and offering support resources for family caregivers.

Strengths and limitations

This systematic review and meta-analysis offer several notable strengths. It is the first of its kind to provide a pooled national estimate of Palliative care utilization among cancer patients in Ethiopia, drawing on studies from diverse geographic regions, including both urban and semi-rural settings. The review adhered to rigorous methodological standards, following the PRISMA guidelines to ensure transparency and reliability. However, the study also has limitations. All included studies employed cross-sectional designs, limiting the ability to establish causal relationships. Additionally, variations in outcome measures across studies hindered comparability, and the scarcity of data from rural and community-based settings may have led to an underrepresentation of the most underserved populations. As most included studies were hospital-based and concentrated in urban referral centers, the findings may not fully reflect Palliative care realities in rural and community settings across Ethiopia. Meta-regression was not performed due to the small number of included studies, which would limit statistical power and produce unstable estimates. No formal correction for multiple comparisons was applied due to the exploratory nature of the factor analyses. The limited number of studies reporting gender-specific outcomes constrained our ability to draw robust conclusions regarding differences between male and female patients. This study includes data only from Addis Ababa and Hawassa, which may not represent all regions of Ethiopia. As a result, the findings might not fully reflect regional variations in the studied outcomes.

Conclusion and recommendation

This systematic review and meta-analysis found that the utilization of Palliative care services among cancer patients in Ethiopia is moderate but overall insufficient, with a pooled prevalence of 42%. The findings highlight significant inequities in service use, with disparities observed by gender, education, income, and geographic location, indicating that rural and underserved populations have more limited access compared to urban residents. Critical system-level barriers were identified, including shortages of trained healthcare personnel, limited community-based services, and weak integration of Palliative care into the broader healthcare system. While progress has been made in areas such as pain and symptom management, essential components of comprehensive care, including psychosocial and spiritual support, remain underdeveloped. To enhance Palliative care utilization and ensure equitable, patient-centered services across Ethiopia, efforts should focus on: (1) decentralizing Palliative care delivery to reach rural and underserved populations, (2) investing in workforce development and training for healthcare providers, (3) integrating Palliative care into primary healthcare and standard cancer care pathways, (4) strengthening health policies and infrastructure to support service delivery, and (5) improving patient and community health literacy regarding Palliative care. Implementing these strategies can help reduce disparities and improve the overall accessibility, quality, and comprehensiveness of Palliative care services in Ethiopia.

What is known

Palliative care is vital for cancer management but is limited in Ethiopia, especially in rural and underserved regions.
Utilization varies due to differences in infrastructure, trained staff, and awareness among patients and providers.
Cultural beliefs, low health literacy, financial barriers, and poor service integration hinder access and delivery.

What is New?

First pooled national prevalence estimate (40.2%) of Palliative care utilization among cancer patients in Ethiopia.
Identifies specific demographic and socioeconomic predictors of Palliative care use.
Reveals the underdevelopment of community-based and home-based Palliative care models.

Supporting information

S1 File. PRISMA checklist for the systematic review and meta-analysis on Palliative care among cancer patients in Ethiopia, 2025.

(DOCX)

pone.0345299.s001.docx^{(23.4KB, docx)}

S2 File. Search Strategy and Retrieval Summary for the systematic review and meta-analysis on Palliative care among cancer patients in Ethiopia, 2025.

(DOCX)

pone.0345299.s002.docx^{(16.7KB, docx)}

Data Availability

All relevant data are within the manuscript and its Supporting information files.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0345299.r001

Decision Letter 0

Kahsu Gebrekidan

2 Sep 2025

Dear Dr. Abdulwehab,

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.

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Reviewer #2:

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: Partly

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: No

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: This systematic review and meta-analysis titled “Palliative Care Service Utilization among Cancer Patients in Ethiopia” offers a timely and methodologically sound contribution to the literature on end-of-life care in low-resource settings. The authors demonstrate commendable rigor in their search strategy, inclusion criteria, and statistical synthesis, providing a clear picture of the underutilization of palliative services among Ethiopian cancer patients. This work is both relevant and actionable, and it lays a strong foundation for future research and health system strengthening.

Here are comments to be addressed by the authors:

- remove the year 2025 from the title:

- In the abstract results please write the pooled effect size for the associated factors.

- Regarding the Search Strategy the author should present the full search strategy algorithm/ search detail and number of studies retrieved for each databases as table.

- Most of methodology section lacks proper citation for instance, quality appraisal, statistical analysis

- I have doubt on result of heterogeneity, the author should present the source or output of I2within the forest plot, also if there is heterogeneity do subgroup analysis based on significant variables such as region etc…

- Similar to the results of the Q statistic? Clearly show the outputs of the test.

- In the discussion, your comparison is with developed countries such as UK, it is better to compare the finding with African countries.

- Studies focused on these some hospitals may not reflect realities of this study for all regions of Ethiopia. So, please add some limitation related to this statement.

- Check the citations, typo and grammatical errors throughout the manuscript.

Reviewer #2: First of all, I would like to sincerely thank the editor for inviting me to review the important paper titled "Palliative Care Service Utilization among Cancer Patients in Ethiopia: A Systematic Review and Meta-Analysis, 2025." I also extend my appreciation to the author for providing such comprehensive and valuable evidence on an issue that is increasingly significant in developing countries like Ethiopia.

Here is a suggested revision for your comments section:

General comments:

1. The paper is well written and organized, though some modifications are advised.

2. Attention is needed to improve sentence synthesis and grammar throughout the manuscript.

Specific comments:

Here is a revised version of your abstract comments, making it smart and informative:

1. Minor comment: It is generally not recommended to use abbreviations in the abstract section for clarity.

2. Please specify the publication year range boundaries of the primary studies included, in addition to the search date of April 7, 2025.

3. When mentioning that study quality was evaluated using a validated tool, please explicitly name the tool used.

4. Include pooled odds ratios with confidence intervals for all analyzed variables in the results summary.

5. The conclusion section reads more like a presentation of results; consider reorganizing it to emphasize the implications and recommendation of the findings.

Introduction: This section needs to be more comprehensive. Clearly state what has been accomplished in Ethiopia, outlines the current plan, identify the obstacles faced, and include more details about this issue. Additionally, collaborate with the SGD to strengthen the section. Rewrite it to improve clarity and depth.

Methods: Please focus in this section

Research Questions: Your research question is not specific. May be

1. What is the pooled prevalence of palliative care service utilization among cancer patients in Ethiopia?

2. What are the key factors associated with palliative care service utilization among these patients?

� Under inclusion, why do you restrict papers based on factors?

� In your exclusion criteria, you state that "Excluded were case reports, expert opinions, reviews, conference abstracts, and studies lacking data on PC utilization." Could you include such papers?

� Studies that were not conducted in Ethiopia or did not involve human subjects were also excluded. Why were these studies excluded? For example, if some non-Ethiopians live in the country, have such a condition, and follow treatment in an Ethiopian hospital, why are they excluded?

Result

� My main concern is that you included 9 papers in this study; however, in your data extraction, some of these papers didn’t report prevalence with odds ratio, the same for factors… how you managed this issue… specifically for those who haven’t had odds ratios lower and higher, how you pooled it….

� All paper has the same measurement for palliative care utilization unless it's difficult to pool it. I need a response.

� You mention that including studies from Addis Ababa and Hawassa demonstrates regional variation. However, are these two locations sufficient to truly capture the regional differences in palliative care utilization across Ethiopia?"

� The factors of age and experience of side effects are reported by a single study. Why did you put them here? …

� Frankly speaking, the way you pool and explain the factors is not clearly stated…it needs clear analysis with citations… If possible, write the subtitle for all factors…

Discussion

� Good, but please avoid too much information or information outside of this study objectives.

� Remove the result parts and its redundancy.

Conclusion and recommendation

� Reorganized conclusion and recommendation be specific to your findings.

**********

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Reviewer #1: Yes: Aragaw Asfaw Hasen

Reviewer #2: No

**********

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PLoS One. 2026 Mar 23;21(3):e0345299. doi: 10.1371/journal.pone.0345299.r002

Author response to Decision Letter 1

5 Sep 2025

Response for the reviewers

Response to Reviewer #1 Comments

We sincerely thank Reviewer #1 for the thoughtful and constructive feedback provided on our manuscript titled “Palliative Care Service Utilization among Cancer Patients in Ethiopia.” We greatly appreciate the recognition of our work’s relevance and methodological rigor. Below we provide a point-by-point response to each of the reviewer’s comments, along with the revisions made in the manuscript.

1. Remove the year 2025 from the title

Response: We agree with the reviewer. The year has been removed from the title.

Change made: Title now reads: “Palliative Care Service Utilization among Cancer Patients in Ethiopia: A Systematic Review and Meta-Analysis.”

2. Abstract – include pooled effect size for associated factors

Response: We have revised the results section of the abstract to include pooled effect sizes of significant associated factors (e.g., education, gender, income, access, satisfaction). Change made: Abstract now reports, for example: “Educational attainment (pooled AOR = 2.57; 95% CI: 1.42–3.75), male gender (AOR=5.58; 95% CI: 3.01–10.33), higher income (AOR = AOR = 26.9, 95% CI: 12.3–59), proximity to health facilities (AOR = 2.24; 95% CI: 1.52–3.29).), and satisfaction with care (AOR = 1.96; 95% CI: 1.30–2.95) ,and family and social support (AOR = 12.18; 95% CI: 1.29–3.68) were significantly associated with palliative care utilization.”

3. Search strategy – present full algorithm and retrieval numbers as a table

Response: We have prepared a supplementary table detailing the complete search strategies (keywords, Boolean operators, MeSH terms) for each database, along with the number of records retrieved before and after duplicate removal.

Change made: Added as “Table 1: Search Strategy and Retrieval Summary.”

4. Methodology section lacks citations

Response: Additional references have been inserted to support methods used, including PRISMA, Joanna Briggs Institute checklist for quality appraisal, and standard texts on random-effects meta-analysis and heterogeneity.

Change made: Appropriate citations added throughout methodology.

5. Heterogeneity results and subgroup analysis

Response: We clarified heterogeneity results within the forest plots by presenting I² values directly on figures. In addition, we conducted subgroup analysis stratified by study region (Addis Ababa vs. outside Addis Ababa) to explore potential sources of heterogeneity. Results are now presented in the results section

Change made: Figures updated with I² values; new figures showing subgroup pooled prevalence included.

6. Q statistic results

Response: We now explicitly report Cochran’s Q statistic outputs in the results section and display them alongside I² and τ² estimates.

7. Discussion – comparison with African countries

Response: We revised the discussion to include comparison with studies from other African countries (e.g., Uganda, Kenya, South Africa, Nigeria), in addition to the previously cited global literature.

8. Limitation – hospital-based studies not generalizable

Response: We agree and have added this limitation to the limitations section: “As most included studies were hospital-based and concentrated in urban referral centers, the findings may not fully reflect palliative care realities in rural and community settings across Ethiopia.”

Change made: Added to limitations paragraph

9. Citations, typos, and grammar

Response: The entire manuscript has been carefully proofread to correct typographical and grammatical errors, and to ensure reference formatting consistency.

We are grateful for the reviewer’s insightful comments, which have substantially improved the clarity, methodological transparency, and contextual relevance of our manuscript. We believe these revisions have strengthened the overall quality and rigor of our work.

Response for Reviewer Two

We sincerely thank Reviewer #2 for the careful and constructive review of our manuscript titled “Palliative Care Service Utilization among Cancer Patients in Ethiopia: A Systematic Review and Meta-Analysis, 2025.” We greatly appreciate the insightful comments and suggestions, which have helped us strengthen the clarity, scientific rigor, and overall quality of the paper. We have carefully revised the manuscript in response to each point, as detailed below. All changes have been incorporated into the appropriate sections of the manuscript, and specific additions or modifications are highlighted in our responses.

General Comments

1. The paper is well written and organized, though some modifications are advised.

Response: Thank you. We have revised the manuscript to improve clarity, flow, and readability.

2. Attention is needed to improve sentence synthesis and grammar throughout the manuscript.

Response: We carefully proofread the manuscript and corrected grammar and sentence structure issues throughout.

Abstract

1. Do not use abbreviations in the abstract.

Response: We replaced abbreviations (e.g., PC → “palliative care”) with full terms.

2. Specify publication year range boundaries of included studies.

Response: We now state: “Studies published between 2015 and 2024 were included…”

3. Name the tool used for quality appraisal.

Response: We added: “The Joanna Briggs Institute (JBI) Critical Appraisal Checklist was used.”

4. Include pooled odds ratios with CIs in results summary.

Response: We added pooled AORs (e.g., education, gender, income, access, satisfaction).

5. Conclusion reads like results—emphasize implications and recommendations.

Response: We revised the conclusion to highlight implications for policy and practice rather than re-listing results.

Introduction

Needs to be more comprehensive: what has been accomplished in Ethiopia, current plan, obstacles, SGD links.

Response: We expanded the introduction to include:

� Ethiopia’s Ministry of Health initiatives for integrating palliative care.

� Gaps such as lack of workforce, poor infrastructure, limited rural coverage.

� Links to Sustainable Development Goal (SDG 3: Ensure healthy lives…).

Change: Introduction, last three paragraphs.

Methods

1. Research questions not specific.

Response: Revised to:

o “What is the pooled prevalence of palliative care utilization among cancer patients in Ethiopia?”

o “What are the key factors associated with utilization?”

Change: Methods, Research Questions subsection.

2. Why restrict papers based on factors?

Response to Reviewer: We appreciate this important comment. We did not exclude papers solely based on whether they reported factors; rather, our primary objective was to estimate both the pooled prevalence of palliative care utilization and to identify associated factors. Therefore, we required that included studies provide either prevalence data or factors influencing utilization to allow for meaningful synthesis. Studies that did not report on either outcome (e.g., opinion pieces, reviews, purely descriptive articles without utilization data) were excluded because they could not contribute to the quantitative or qualitative objectives of this meta-analysis. However, both prevalence-only and factor-only studies were included where appropriate.

3. Why exclude non-Ethiopian patients or non-human studies?

Response to Reviewer: Thank you for raising this point. Non-human studies were excluded because our review focused exclusively on human health outcomes and service utilization, which cannot be inferred from laboratory or animal studies. Similarly, we excluded studies that reported on non-Ethiopian populations, even if they were treated in Ethiopian hospitals, to maintain national representativeness and ensure the pooled estimates reflected the experiences of patients residing within the Ethiopian healthcare system. Including non-Ethiopian patients could have introduced bias, given potential differences in health-seeking behavior, cultural context, and eligibility for local health services.

Results

1. Some studies did not report prevalence with odds ratios—how managed?

Response to Reviewer: Thank you for this valuable observation. In cases where studies did not report odds ratios directly, we extracted raw frequency data (when available) to calculate crude odds ratios with corresponding 95% confidence intervals. For studies where the necessary raw data were not provided, we did not attempt to impute missing values; instead, these findings were narratively synthesized and presented in the results section to avoid data distortion. This approach allowed us to include all eligible studies while maintaining methodological transparency.

2. All papers have same measurement—why difficult to pool?

Response to Reviewer: We appreciate this important comment. Although all included studies assessed palliative care utilization, the operational definitions and measurement approaches varied. Some studies defined utilization as the proportion of patients who had ever received palliative care services, while others measured expressed need, attendance at specific service components (e.g., symptom control, rehabilitation), or satisfaction with services as a proxy indicator. Additionally, data collection tools differed—ranging from structured questionnaires to medical record reviews—introducing methodological heterogeneity. Because of these variations, pooling results directly was challenging; therefore, we carefully standardized measures when possible and explained methodological differences when standardization was not feasible.

3. Are Addis Ababa and Hawassa enough to show regional variation?

Response: Data for subgroup analysis were available only from Addis Ababa and Hawassa. We acknowledge that these cities do not represent all regions of Ethiopia, and regional variation may not be fully captured. Consequently, interpretations of regional differences should be made cautiously. We add in the limitation as This study includes data only from Addis Ababa and Hawassa, which may not represent all regions of Ethiopia. As a result, the findings might not fully reflect regional variations in the studied outcomes.

4. Why include factors like age/side effects from one study?

Response to Reviewer: We included factors such as age and treatment side effects even though they were reported in only one study each. We did this to provide a comprehensive overview of all reported factors associated with palliative care utilization in Ethiopia. We have clarified in the manuscript that these findings are based on individual studies and should be interpreted cautiously. This approach ensures transparency while highlighting gaps in the current evidence base.

5. Pooling and explanation of factors not clear.

Response: We reorganized results with clear subtitles (Education, Gender, Income, Access, Satisfaction, etc.), each with citations and pooled AORs where available.

Only factors reported in ≥2 studies were pooled quantitatively; factors reported in a single study (e.g., ADLs, knowledge, employment) were summarized narratively. This approach ensures a comprehensive synthesis while maintaining transparency about the strength of the evidence.

Discussion

1. Avoid too much information outside study objectives.

Response: We removed unrelated global details and kept discussion focused on Ethiopian context and comparisons.

2. Remove redundancy of results.

Response: We deleted repeated numerical results and emphasized interpretation.

Conclusion & Recommendation

1. Reorganize to be specific to findings.

Response: Conclusion now highlights:

o Utilization is only 40.2%

o Inequities by gender, education, income, and geography

o Need for decentralized services, training, and integration into primary care

Change: Conclusion section rewritten.

Once again, we are grateful for the reviewer’s thoughtful feedback, which has significantly improved the quality of our manuscript. We believe that the revisions have addressed all concerns and enhanced the scientific soundness, clarity, and contribution of the study. We respectfully resubmit the revised manuscript for your further consideration and hope it will now be suitable for publication.

Attachment

Submitted filename: Response for reviewers.docx

pone.0345299.s006.docx^{(25.5KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0345299.r003

Decision Letter 1

Kahsu Gebrekidan

10 Jan 2026

Dear Dr. Abdulwehab,

Please submit your revised manuscript by Feb 24 2026 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.

A 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,

Kahsu Gebrekidan, Ph.D.

Academic Editor

PLOS One

Journal Requirements:

1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Additional Editor Comments:

The Comments from Reviewer 3 are attached as PDF

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

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

**********

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

Reviewer #1: Yes

Reviewer #3: No

Reviewer #4: Partly

**********

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

Reviewer #1: Yes

Reviewer #3: No

Reviewer #4: No

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #3: No

Reviewer #4: Yes

**********

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

Reviewer #1: Yes

Reviewer #3: No

Reviewer #4: No

**********

Reviewer #1: Thank you to re-review the manuscript titled “Palliative Care Service Utilization among Cancer Patients in Ethiopia: A Systematic review and meta analysis ”. The authors responded the raised issues and the revised version are much improved. Still Some issues should be addressed before publication.

- In the abstract to report the associated factors meta analysis , the author should write only the pooled adjusted odds ratio (AOR) since this is the secondary analysis / pooling. If the result cannot pooled it can be summarized in the discussion part instead of repeating the results in the primary study.

- The manuscript still have typo errors please see the result section of the abstract.

- Similarly the manuscript should be clean.

Reviewer #3: the title should be modified to describe the objective.

The publication bias shall be tested with DOI plot since it prevalence study.

The manuscript describes which studies identified some predictors of utilization. However, the aim of a meta-analysis is precisely to evaluate which predictors remain significant after pooling a larger sample. For example, when analyzing sex (male), it would be more appropriate to include all studies, and then show whether this factor remains significant overall, generating the diamond plot. If only the studies that already found the association are included, the result is, of course, already known. The same reasoning applies to all other predictors described.

Reviewer #4: Comments pinned to Editor. Errors noted in Grammar, Sentence structure, Results, Presentation of data, Overambitious conclusions in a review with high heterogeneity and reduced rigorous study pool

**********

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Reviewer #1: Yes: Aragaw Asfaw Hasen

Reviewer #3: No

Reviewer #4: No

**********

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PLoS One. 2026 Mar 23;21(3):e0345299. doi: 10.1371/journal.pone.0345299.r004

Author response to Decision Letter 2

17 Jan 2026

Author Response to Reviewers

Author Response to Reviewer #1

We sincerely thank the reviewer for the careful re-review of our manuscript entitled “Palliative Care Service Utilization among Cancer Patients in Ethiopia: A Systematic Review and Meta-Analysis.” We appreciate the reviewer’s positive assessment of the improvements made and the constructive suggestions provided. We have addressed all remaining concerns in detail, as outlined below.

Comment 1- “In the abstract to report the associated factors meta-analysis, the author should write only the pooled adjusted odds ratio (AOR) since this is the secondary analysis / pooling. If the result cannot pooled it can be summarized in the discussion part instead of repeating the results in the primary study.”

Author Response: We thank the reviewer for this important methodological clarification. We fully agree that, as a secondary analysis, the abstract should report only pooled adjusted effect estimates derived from the meta-analysis, rather than repeating individual primary study results.

Accordingly, we have revised the Results section of the abstract to:

• Report only pooled adjusted odds ratios (AORs) with 95% confidence intervals for factors where quantitative pooling was feasible.

• Remove references to individual study-specific AORs that were not pooled.

• Exclude factors that could not be pooled quantitatively from the abstract and instead synthesize and interpret these findings narratively in the Discussion section, as recommended.

This revision ensures methodological rigor, avoids redundancy with primary studies, and aligns the abstract strictly with the results of the meta-analytic pooling.

Comment 2-“The manuscript still have typo errors please see the result section of the abstract.”

Author Response: We appreciate the reviewer for highlighting this issue. A thorough line-by-line proofreading of the entire manuscript has been conducted, with particular attention to the abstract and Results section.

Specifically:

• Typographical errors, duplicated words, punctuation issues, and formatting inconsistencies in the abstract were corrected.

• Redundant expressions and grammatical inaccuracies in numerical reporting (e.g., duplicated “AOR,” misplaced parentheses, and spacing issues) were carefully revised.

• Consistency in terminology (e.g., “palliative care,” “PC,” capitalization, and statistical notation) has been ensured throughout the manuscript.

These corrections have substantially improved the clarity, precision, and readability of the Results section and the manuscript as a whole.

Comment 3-“Similarly the manuscript should be clean.”

Author Response: We fully acknowledge this comment and have taken comprehensive steps to ensure the manuscript is clean, polished, and publication-ready.

The following actions were undertaken:

• Full language editing and grammatical revision across all sections of the manuscript.

• Standardization of headings, subheadings, tables, figures, abbreviations, and statistical reporting.

• Removal of duplicated sentences, inconsistent phrasing, and minor stylistic errors.

• Harmonization of tense usage and academic tone throughout the text.

• Final formatting review to ensure consistency with journal expectations.

As a result, the revised manuscript now reflects a clear, coherent, and professionally edited scholarly work.

We are grateful to Reviewer #1 for the thoughtful and constructive feedback, which has significantly strengthened the methodological clarity, presentation, and overall quality of the manuscript. We believe that all concerns have now been fully addressed, and we respectfully submit the revised version for final consideration.

Author Response to Reviewer #3

We sincerely thank Reviewer #3 for the insightful and constructive comments. These suggestions have substantially improved the methodological rigor, transparency, and interpretability of our systematic review and meta-analysis. Below, we respond to each comment in detail and describe the corresponding revisions made to the manuscript.

Comment 1: The title should be modified to describe the objective.

Author Response: We agree with the reviewer that the title should more clearly reflect the study objectives, including both the estimation of utilization and the evaluation of associated factors.

Revision made: The title has been revised to explicitly reflect the objectives of estimating utilization and examining associated factors.

Original title: Palliative Care Service Utilization among Cancer Patients in Ethiopia: A Systematic Review and Meta-Analysis

Revised title: Utilization of Palliative Care Services and Associated Factors among Cancer Patients in Ethiopia: A Systematic Review and Meta-Analysis

Comment 2:

Publication bias should be tested using a Doi plot since this is a prevalence study.

Revised Response: We thank the reviewer for this important methodological recommendation. We carefully explored the use of the Doi plot and the Luis Furuya-Kanamori (LFK) index, which have been proposed as alternatives to funnel plots for meta-analyses of proportions and prevalence studies. We attempted to generate the Doi plot using both R and Stata by searching available packages and commands; however, we were unable to obtain a valid implementation suitable for our dataset.

Given this limitation, we assessed small-study effects and potential asymmetry using a Galbraith (radial) plot, which is commonly used in meta-analysis to evaluate heterogeneity and detect outlying or influential studies. The Galbraith plot did not indicate marked asymmetry or influential outliers, suggesting no substantial evidence of publication bias.

We have revised the manuscript accordingly and clearly described this methodological decision and its limitations.

Revisions made:

• Publication bias assessment was conducted using the Galbraith (radial) plot

• Attempts to apply the Doi plot were acknowledged, with justification for its non-application

• Funnel plot and Egger’s test were removed due to their limited suitability for prevalence data

• Methods and Results sections were updated accordingly

We inserted text (Methods – Statistical Analysis):“Publication bias and small-study effects were explored using the Galbraith (radial) plot. Although alternative approaches such as the Doi plot and LFK index have been recommended for prevalence meta-analyses, a valid implementation could not be obtained using available R for the current dataset.”

We Inserted text (Results – Publication Bias):“The Galbraith plot did not reveal marked asymmetry or influential outliers, suggesting no strong evidence of publication bias among the included studies.”

Sections revised:

• Methods → Statistical Analysis

• Results → Publication bias subsection

• Figure updated accordingly

Comment 3: Meta-analysis of predictors should include all studies, not only those that already found significant associations.

Author Response: We fully agree. The reviewer correctly notes that the objective of meta-analysis is to determine whether predictors remain significant after pooling all available evidence, not only those studies that reported significant associations.

Revision made:

• We revised the analytic approach for associated factors

• All studies reporting relevant predictors (regardless of statistical significance) were included in pooled analyses where sufficient data were available

• Forest plots (diamond plots) now reflect pooled estimates across all eligible studies

• Where pooling was not statistically or methodologically feasible, findings are clearly described as narrative synthesis

We Inserted clarification (Results – Factors section):“Predictors reported by fewer than two studies with comparable effect measures were synthesized narratively and interpreted cautiously.”

Comment 4: How is the outcome measured?

Response:

We thank the reviewer for highlighting the need for clearer outcome definition. We have now explicitly clarified how palliative care utilization was operationalized and measured across included studies.

Revision made: A dedicated clarification has been added describing outcome measurement approaches and their variability.

We Inserted text (Results – Palliative Care Service Measures):“Palliative care utilization was measured variably across studies, including receipt of at least one palliative care service, referral to a palliative care unit, self-reported utilization, or classification based on structured questionnaire scores. Although this variability reflects real-world practice, it contributes to between-study heterogeneity.”

Comment 5: Certainty of evidence (GRADE) is missing; recommend using Core GRADE.

Author Response: We appreciate this important suggestion. In response, we have incorporated Core GRADE, a streamlined and recently recommended approach, to assess the certainty of evidence for primary outcomes after meta-analysis.

Revision made:

• Added a Certainty of Evidence Assessment subsection

• Applied Core GRADE to pooled prevalence and major predictors

• Certainty ratings (low / very low) are now transparently reported and justified

We Inserted text (Methods – Certainty of Evidence):“The certainty of evidence was assessed using the Core GRADE approach, which provides a streamlined evaluation of overall certainty following meta-analysis, particularly suitable for observational studies.”

We Inserted text (Results – Certainty of Evidence): “Using the Core GRADE framework, the certainty of evidence for pooled palliative care utilization and associated factors was rated as low to very low, primarily due to high heterogeneity, cross-sectional study designs, and inconsistency across studies.”

Comment 6: Extremely high heterogeneity makes results not valid for all; this must be communicated and explained.

Author Response: We strongly agree. We have now explicitly acknowledged that the high heterogeneity limits the generalizability of pooled estimates and have expanded the discussion on potential sources of heterogeneity.

We Inserted text (Results): “All pooled analyses demonstrated substantial heterogeneity (I² > 90%), indicating considerable variability across studies. Consequently, pooled estimates should be interpreted as indicative rather than definitive national values.”

We Inserted text (Discussion – Heterogeneity):“The high heterogeneity likely arises from differences in outcome definitions, institutional capacity, urban–rural disparities, study populations, and availability of palliative care services. These findings underscore that utilization patterns are highly context-specific rather than uniform across Ethiopia.”

We sincerely thank Reviewer 3 for their careful and constructive comments, which have greatly contributed to improving the clarity, consistency, and scientific rigor of our manuscript. We have carefully addressed each point raised, including revisions to the results and discussion, consistent reporting of effect sizes and confidence intervals, and consolidation of recommendations. We believe that these changes have strengthened the manuscript and we greatly appreciate the reviewer’s thoughtful guidance.

Author responses for Reviewer 4

We sincerely thank Reviewer 4 for their thoughtful and constructive feedback on our manuscript. We greatly appreciate the detailed suggestions regarding the presentation of results, consistency of effect sizes, interpretation of findings, discussion structure, and the consolidation of recommendations. In response, we have carefully revised the manuscript to improve clarity, ensure consistency across results and discussion, focus on interpreting findings before providing recommendations, and consolidate actionable recommendations into a single section at the end of the discussion and conclusion.

Point-by-Point Response to Reviewer #4

INTRODUCTION

#1. “leading to late stage cancer diagnoses AND”

� Revision action:

Remove “and” and replace with a comma.

Corrected sentence: “…leading to late-stage cancer diagnoses, resulting in higher mortality rates compared with high-income countries.”

#2. Do not abbreviate palliative care

Issue: You alternate between palliative care, PC, and Palliative care.

Revision action:

� We use “Palliative care” in full throughout (recommended for a concept central to the paper). Here in the first draft, I wrote as full Palliative care and after comments from the reviewer I change to PC after I defined first now, I change to full Palliative care currently thorough the paper.

3. Inconsistent use of LMIC

Issue: LMIC is defined, then later spelled out again.

Revision action:

� We define once at first mention.

� We use LMICs consistently thereafter.

4. “only a fraction receive it” is vague and repetitive

� Issue: Repeats “insufficient” without adding information.

Revision action:

� We replace with a numerical estimate.

Revised sentence:-“Globally, it is estimated that fewer than 15% of individuals who need palliative care actually receive it.”(This aligns with Lancet Commission estimates and strengthens rigor.)

5–6. Redundant paragraphs on global vs LMIC barriers

Issue: Paragraphs beginning “Sub-Saharan Africa…” and “There is a growing…” are too thin.

Revision action: we merge with adjacent paragraphs and expand with specific context (Ethiopia-focused).

7–8. Very short paragraphs

Issue: Paragraphs 3–5 repeat similar barriers.

Revision action:

� We condense into ONE coherent paragraph, structured as: global brief LMIC-specific intensifiers (focus) and Ethiopia as a case example. This improves flow and reduces reviewer fatigue.

9. “50% of public facilities by 2020”

Issue: Policy target is outdated.

Revision action:

� Reframe historically and critically.

Revised framing: -Ethiopia has prioritized strengthening palliative care as an essential component of Universal Health Coverage, aligning with Sustainable Development Goal 3 and national health sector strategies. Although the country set a target to integrate palliative care and pain management services into at least 50% of public health facilities by 2020, evidence from more recent studies indicates that service availability and utilization remain limited, particularly outside major urban centers (19). This gap highlights the need for accelerated decentralization of palliative care services, strengthened workforce capacity through pre-service and in-service training, expansion of community- and home-based delivery models, and better integration of palliative care into primary healthcare systems to advance national UHC and SDG commitments (19,22,23).” This shows awareness and avoids appearing out of date.

RESULTS

1. Add a summary table of factors

Revision action:

� We add a single table summarizing: the factors associated with palliative care utilization. In response, we have added a summary table (Table 6) that presents all identified factors, the number of contributing studies, pooled odds ratios (ORs) with 95% confidence intervals (CIs), and heterogeneity (I²). This table provides a clear overview of the magnitude and consistency of associations across studies, enhancing the clarity and interpretability of our results and cited in the result also as table 6.

2. Geographical visualization

Revision action:

� If GIS mapping is not feasible, explicitly we add as not explained in the studies: This shows responsiveness even if a map cannot be added.

3. Funnel plot and Egger test with <10 studies

Mandatory revision:

� We add a clear cautionary statement: “Given that fewer than ten studies were included, funnel plots and Egger’s regression test have limited power to detect publication bias. Therefore, the absence of detected asymmetry should not be interpreted as evidence of no publication bias.”

4. Inconsistent effect sizes

Revision action:

� We standardize: Always report AOR (95% CI) and ensure pooled estimates match forest plots and text

5. Bayesian analysis had no results

� Bayesian meta-analysis was not performed due to the small number of studies and limited data for robust estimation

6. No comment on multiple comparisons

Revision action:

� Given multiple pooled associations were examined, findings should be interpreted cautiously, as the analysis was not adjusted for multiple compar

Attachment

Submitted filename: Author Response to Reviewers.docx

pone.0345299.s008.docx^{(30.8KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0345299.r005

Decision Letter 2

Kahsu Gebrekidan

2 Feb 2026

Please submit your revised manuscript by Mar 19 2026 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.

A 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,

Kahsu Gebrekidan, Ph.D.

Academic Editor

PLOS One

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #4: All comments have been addressed

**********

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

Reviewer #1: Yes

Reviewer #4: No

**********

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

Reviewer #1: Yes

Reviewer #4: No

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #4: Yes

**********

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

Reviewer #1: Yes

Reviewer #4: No

**********

Reviewer #1: Thank you for inviting me to re-review the manuscript titled “Utilization of Palliative Care Services and Associated Factors among Cancer Patients in Ethiopia: A Systematic Review and Meta-Analysis” .

The authors responded the raised issues and the revised version are much improved.

Reviewer #4: Still disappointed with this revision 2. Glaring grammar issues, changes in font as things appear copy and pasted. Repeated mistakes notable with excessive comma usage, conjoining sentence structure and excessive listing without actually narrowing down points for the reader. The discussion also has heavy definitive statements forgetting the statistics remain very low quality given the paucity of data and high heterogeneity. I would like to remind the authors to refrain or avoid definitive statements especially around the data when describing what is being found. Points have been pinned to editor

**********

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Reviewer #1: Yes: Aragaw Asfaw Hasen

Reviewer #4: No

**********

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PLoS One. 2026 Mar 23;21(3):e0345299. doi: 10.1371/journal.pone.0345299.r006

Author response to Decision Letter 3

2 Feb 2026

Response to Reviewers

We sincerely thank the Editor and all reviewers for their careful re-review of our manuscript entitled “Utilization of Palliative Care Services and Associated Factors among Cancer Patients in Ethiopia: A Systematic Review and Meta-Analysis.” We appreciate the time and effort invested in providing constructive feedback. We have carefully revised the manuscript to address all comments raised, with particular attention to language quality, consistency, analytical rigor, and interpretation of findings. Detailed responses to each reviewer are provided below.

Reviewer #1

Comment: “The authors responded to the raised issues and the revised version is much improved.”

Author Response:

We sincerely thank Reviewer #1 for the positive evaluation and for acknowledging the improvements made in the revised manuscript. We appreciate your constructive feedback throughout the review process, which has significantly contributed to strengthening the clarity, methodological rigor, and overall quality of the manuscript.

Reviewer #4

Comment: “Still disappointed with this revision 2. Glaring grammar issues, changes in font as things appear copy and pasted. Repeated mistakes notable with excessive comma usage, conjoining sentence structure and excessive listing without actually narrowing down points for the reader. The discussion also has heavy definitive statements forgetting the statistics remain very low quality given the paucity of data and high heterogeneity. I would like to remind the authors to refrain or avoid definitive statements especially around the data when describing what is being found.”

Author response

We thank Reviewer #4 for the detailed and critical feedback. We acknowledge the concerns raised and have undertaken substantial and systematic revisions to address each issue comprehensively. Our responses are outlined below.

1. Grammar, sentence structure, and punctuation issues

Reviewer concern:

Glaring grammar issues, excessive comma usage, sentence conjoining, and overly long lists.

Author Response:

We fully acknowledge this concern and have thoroughly revised the entire manuscript for language quality. Specifically:

� The manuscript was line-by-line edited to correct grammatical errors, punctuation misuse (especially excessive commas), and sentence fragments.

� Long and conjoined sentences were split into shorter, clearer sentences to improve readability.

� Excessive listing was reduced and synthesized, with key points consolidated into concise analytical statements.

� Redundant phrases and repetitive constructions were removed throughout the manuscript.

2. Font inconsistency and formatting issues

Reviewer concern:

Changes in font suggesting copy-and-paste errors.

Author Response:

We agree with this observation and have corrected all formatting inconsistencies. Specifically:

• The entire manuscript was reformatted to ensure uniform font type, size, and spacing.

• All copied sections (tables, figures, references, and in-text citations) were standardized according to the journal’s formatting requirements.

• Headings, subheadings, and figure captions were harmonized for visual and structural consistency.

3. Overly definitive statements despite low-quality evidence and high heterogeneity

Reviewer concern:

Use of strong, definitive language despite high heterogeneity and limited data quality.

Author Response: We appreciate this important methodological reminder and have substantially revised the tone and interpretation of our findings. Specifically:

• All definitive and causal language was replaced with cautious, probabilistic, and interpretive wording

• Statements were explicitly contextualized within the limitations of cross-sectional designs, high heterogeneity (I² > 90%), and limited number of studies.

• We emphasized that pooled estimates are indicative rather than definitive national values, explicitly stating this in both the Results and Discussion sections.

• The GRADE certainty assessment was highlighted more clearly, noting that the overall certainty of evidence ranged from low to very low.

4. Interpretation of heterogeneity and data limitations

Reviewer concern:

Failure to adequately reflect the implications of high heterogeneity and data scarcity.

Author Response:

This concern has been carefully addressed. We now:

• Explicitly state that substantial heterogeneity limits generalizability.

• Clarify that observed variations are likely due to differences in outcome definitions, service availability, study settings, and patient populations.

• Avoid over-interpretation of subgroup analyses and state clearly when findings did not reach statistical significance.

• Added explicit cautionary statements regarding multiple comparisons and potential type I error.

INTRODUCTION

Comment 1

Remove “with” before “70% of these deaths…”

Author Response:

The unnecessary word “with” was removed to correct grammatical flow and sentence clarity.

Comment 2

Excessive commas noted in the line “Despite its proven…”

Author Response:

This sentence was restructured to reduce comma overuse and improve readability. The sentence was shortened and simplified while preserving its meaning.

Comment 3

Revise line “these challenges are particularly…” Excessively long and unnecessary commas

Author Response:

The sentence was rewritten into a concise structure, eliminating excessive commas and improving logical flow.

Comment 4

Revise paragraph 4. Excessive commas and excessive listing of challenges

Author Response:

We agree that over-listing reduced readability. This paragraph was substantially revised by:

• Grouping related barriers (e.g., workforce, access, awareness) into broader thematic categories

• Removing repetitive lists

• Improving narrative flow and analytical cohesion

This revision enhances clarity while preserving the importance of key factors.

Comment 5

Should “international partners” be a common “i”?

Author Response:

Yes. “International partners” was corrected to lowercase, as it is not a proper noun.

Comment 6

Revise line “Over the past two decades”. Same problem as above

Author Response:

This sentence was rewritten to avoid excessive listing and comma overuse. Information was synthesized into a coherent summary statement rather than a list.

Comment 7

Should “National health sector” be a common “n”?

Author Response:

Yes. The phrase was corrected to “national health sector” for grammatical consistency.

Comment 8

What gap is highlighted? Helpful

Response:

To clarify the research gap, we explicitly stated that:

• Existing evidence is fragmented

• There is no prior pooled national estimate

• Determinants have not been consistently synthesized

This gap is now clearly articulated in the final paragraph of the Introduction.

METHODS

Comment 1

Excessive use of “and” in “Aim of the study”

Author Response:

The sentence structure was revised to reduce repetitive use of “and.” Objectives were reorganized for clarity and conciseness.

Comment 2

Inconsistent capitalization of “palliative care”

Author Response:

We standardized terminology throughout the manuscript. “Palliative care” is now consistently written in lowercase unless appearing at the beginning of a sentence or in a title.

Comment 3

Why is “Search strategy” in a different font?

Author Response:

This was a formatting error introduced during revision. Font type and size were standardized.

Comment 4

Different fonts and irregular spacing in the Methods section

Author Response:

All subheadings and paragraphs were reformatted to ensure:

• Uniform font

• Consistent spacing

• Proper alignment between headings and text

Comment 5

Why are Funnel plot and Egger’s test mentioned again?

Author Response:

Redundant references were removed. Funnel plots and Egger’s test are now described only once in the Statistical Analysis subsection to avoid repetition.

RESULTS

Comment 1

Too many percentages listed consecutively in utilization rate paragraph

Author Response:

The paragraph was rewritten to:

• Present utilization as a range

• Highlight key extremes

• Avoid listing multiple percentages consecutively

This improves narrative clarity while preserving data accuracy.

Comment 2

Inconsistent font before Discussion heading

Author Response:

Formatting inconsistencies were corrected and fonts standardized.

DISCUSSION

Comment 1

Irregular fonts throughout the discussion

Author Response:

The Discussion section was fully reformatted to ensure consistent font style and spacing.

ADDITIONAL COMMENTS

Comment 1

Clarify that pooled prevalence (42%) is descriptive due to high heterogeneity

Author Response:

We explicitly stated that the pooled prevalence should be interpreted as a descriptive aggregate estimate, not a definitive national value, due to substantial heterogeneity.

Comment 2

P = 0.00 is not meaningful

Author Response:

All instances of “p = 0.00” were removed. Statistical significance is now reported appropriately using confidence intervals and contextual interpretation.

Comment 3

Ensure predictors are interpreted as associations, not causal

Author Response:

All predictors are now explicitly described as associations. Causal language was removed, and findings are interpreted correlationally

Comment 4

More interpretation needed for AOR > 5 for gender

Author Response:

We expanded the discussion to interpret this strong association by considering:

• Gender roles and decision-making power

• Financial autonomy

• Healthcare access differences

• Sociocultural norms

We also emphasized cautious interpretation given the small number of studies. We appreciate Reviewer #4’s detailed and technically rigorous feedback. All comments were carefully addressed through substantive language revision, formatting correction, and improved analytical interpretation, substantially strengthening the manuscript’s clarity, balance, and scientific rigor.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0345299.s009.docx^{(22.2KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0345299.r007

Decision Letter 3

Kahsu Gebrekidan

18 Feb 2026

Dear Dr. Abdulwehab,

Please submit your revised manuscript by Apr 04 2026 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.

A 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,

Kahsu Gebrekidan, Ph.D.

Academic Editor

PLOS One

Journal Requirements:

2. 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.

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Reviewer's Responses to Questions

Comments to the Author

Reviewer #4: All comments have been addressed

**********

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

Reviewer #4: Partly

**********

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

Reviewer #4: No

**********

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

The PLOS Data policy

Reviewer #4: Yes

**********

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

Reviewer #4: No

**********

Reviewer #4: 1. Need more clarification why the methodology included pooling given such high heterogeneity

2. Explain/Remove/Address the significance of the Z Test given it adds little meaning

3. Need more rigorous understanding of what is causing the heterogeneity. Given the geography did not explain it

4. Why pool two studies?

5. Explain the Tau2. No interpretation of this value

6. Consider meta regression to help strengthen the analysis

7. Hartung knapp mentioned however how did it affect your results?

8. How did you correct for multiple testing with the comparisons for the predictors

9. Discussion had run on sentences and multiple comparisons of listing other countries, consider revising

10. Ensure limitation encompass the issues you had faced doing the research eg. Gender estimates with 2 studies

11. Minor formatting issues still present with missing spaces in the values and dash vs hyphen used

**********

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Reviewer #4: No

**********

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PLoS One. 2026 Mar 23;21(3):e0345299. doi: 10.1371/journal.pone.0345299.r008

Author response to Decision Letter 4

20 Feb 2026

Response to Reviewer #4

We sincerely thank Reviewer #4 for the careful re-evaluation of our manuscript and for the constructive comments that have helped us further strengthen the methodological rigor, clarity, and reporting quality of our study. Below, we respond to each comment point-by-point and describe the corresponding revisions made in the manuscript.

Comment 1: “Need more clarification why the methodology included pooling given such high heterogeneity.”

Author Response:

We appreciate this important methodological concern. In the Statistical Analysis and Results (Pooled prevalence section), we added clarification explaining:

� Why pooling was performed despite high heterogeneity.

� That pooled estimates are interpreted as descriptive aggregates, not definitive national values.

� That REML random-effects modeling with Hartung–Knapp adjustment was used to account for between-study variability.

� That sensitivity and subgroup analyses were conducted.

In the Results section we insert as “Given the substantial heterogeneity observed across studies, this pooled estimate should be interpreted as a descriptive aggregate rather than a definitive prevalence.”

In the Statistical Analysis we insert as “A random-effects model using REML estimation was selected a priori due to anticipated clinical and methodological heterogeneity. Pooled estimates were interpreted cautiously, given high I² values.”

We clarified the rationale for pooling under high heterogeneity, explicitly justified the use of a random-effects REML model, and emphasized cautious interpretation of pooled estimates as descriptive summaries rather than precise national prevalence values.

#Comment 2: “Explain/Remove/Address the significance of the Z Test given it adds little meaning.”

Author Response:

We agree that the Z-test in prevalence meta-analysis provides limited interpretive value. We removed emphasis on the Z-test from the Results section. We retained it only where automatically generated but removed interpretative discussion. We clarified that statistical inference focuses on confidence intervals rather than Z statistics. We removed interpretative emphasis on the Z-test and now focus on confidence intervals and between-study variability, which are more meaningful in prevalence meta-analysis.

#Comment 3: “Need more rigorous understanding of what is causing the heterogeneity. Given the geography did not explain it.”

Author Response:

We appreciate this critical comment. we added in the Discussion, we expanded interpretation of heterogeneity sources: “The high heterogeneity likely arises from differences in outcome definitions, institutional capacity, urban–rural disparities, study populations, and availability of Palliative care services.” We also clearly stated that geographic subgrouping alone did not explain heterogeneity.

We expanded the Discussion to provide a more comprehensive interpretation of potential clinical, methodological, and contextual drivers of heterogeneity beyond geographic region.

#Comment 4: “Why pool two studies?” (Gender analysis)

Author Response:

We agree that pooling two studies requires caution. In the gender results section: “Because the pooled analysis was based on only two studies, assessment of publication bias using funnel plots or statistical tests was not performed.” In Discussion and Limitations: “The gender estimate is based on only two studies and should therefore be interpreted cautiously.” We retained the pooled estimate for transparency but clearly acknowledged its limited robustness and interpret it cautiously in both Results and Limitations.

#Comment 5: “Explain the Tau². No interpretation of this value.”

Author Response:

We added interpretation of Tau² In the Sensitivity Analysis section: as “Tau² represents the estimated between-study variance under the random-effects model, reflecting the magnitude of true heterogeneity beyond sampling error.” We also clarified that Hartung–Knapp adjustment incorporates Tau² uncertainty.

#Comment 6: “Consider meta-regression to help strengthen the analysis.”

Author Response:

We carefully evaluated this suggestion. However: Only 9 studies were included, most predictors were reported in ≤3 studies, and Meta-regression requires ≥10 studies for stable estimation. We added in the In Limitations: “Meta-regression was not performed due to the small number of included studies, which would limit statistical power and produce unstable estimates.”

We considered meta-regression but did not perform it due to insufficient number of studies, and this limitation is now explicitly acknowledged.

#Comment 7: “Hartung-Knapp mentioned however how did it affect your results?”

Author Response:

We expanded explanation. We added In Statistical Analysis: “Hartung–Knapp adjustments were applied to produce more conservative confidence intervals, particularly important given the small number of studies and high heterogeneity.”

We clarified that this results in wider, more robust CIs. We clarified that Hartung–Knapp produced more conservative confidence intervals and improved robustness under high heterogeneity and small sample meta-analysis.

#Comment 8: “How did you correct for multiple testing with the comparisons for the predictors?”

Author Response:

We agree multiple comparisons increase Type I error risk. Given the exploratory nature and small number of pooled predictors, we did not formally apply Bonferroni correction. We added In Results: “Given the analysis of multiple factors, results should be interpreted cautiously, as the risk of type I error increases with multiple comparisons.” In Limitations: “No formal correction for multiple comparisons was applied due to the exploratory nature of the factor analyses.”

We clarified the absence of formal multiple testing correction and emphasized cautious interpretation.

$Comment 9: “Discussion had run-on sentences and multiple comparisons of listing other countries, consider revising.”

Author Response:

We thoroughly revised the Discussion by Split long sentences, reduced excessive listing of countries, focused on conceptual interpretation instead of country-by-country repetition, and Improved grammar and clarity throughout. The Discussion has been substantially edited for clarity, structure, and conciseness, with removal of run-on sentences and improved readability.

#Comment 10: “Ensure limitation encompass the issues you had faced doing the research eg. Gender estimates with 2 studies.”

Author Response:

We expanded the Limitations section to include: High heterogeneity, Cross-sectional design, Urban hospital bias, small number of studies for predictors, Gender estimate based on only two studies, Lack of meta-regression, and Multiple testing concerns. The Limitations section has been strengthened to comprehensively reflect methodological constraints.

#Comment 11: “Minor formatting issues still present with missing spaces in the values and dash vs hyphen used.”

Author Response:

We carefully proofread the entire manuscript and corrected: Missing spaces (e.g., “2.49(CI:” → “2.49 (95% CI:”), Hyphen vs en-dash consistency (95% CI: 30%–54%), Standardized statistical formatting, Figure labeling consistency, and removed duplicated PROSPERO number inconsistency. All formatting inconsistencies, spacing errors, and dash usage issues have been corrected throughout the manuscript.

We sincerely thank Reviewer #4 for the detailed and methodologically insightful comments. The manuscript has been substantially strengthened through all given comments and suggestion. We believe the revised manuscript now demonstrates stronger methodological transparency, clearer statistical justification, and improved scientific rigor.

Attachment

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PLoS One. doi: 10.1371/journal.pone.0345299.r009

Decision Letter 4

Kahsu Gebrekidan

4 Mar 2026

Utilization of Palliative Care Services and Associated Factors among Cancer Patients in Ethiopia: A Systematic Review and Meta-Analysis

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Reviewer #4: Comments have been addressed. There is still some minor grammatical errors eg. "which is higher than study done both in Kenya(39) and Uganda's(40) which accounts 10%, Global & LMICs Context accounts 34.43%(41)," I will not be recommending further peer review editing however I will be asking the editor to review with to ensure the grammatical errors are perfect. Any instance of grammatical/spelling error with undercut how your paper is to be perceived in the educational space which will reduce credibility among clinicians/readers. This paper can be a backbone for other research to be conducted in this space and needs to be as perfect as possible.

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PLoS One. doi: 10.1371/journal.pone.0345299.r010

Acceptance letter

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PONE-D-25-41618R4

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Supplementary Materials

S1 File. PRISMA checklist for the systematic review and meta-analysis on Palliative care among cancer patients in Ethiopia, 2025.

(DOCX)

pone.0345299.s001.docx^{(23.4KB, docx)}

S2 File. Search Strategy and Retrieval Summary for the systematic review and meta-analysis on Palliative care among cancer patients in Ethiopia, 2025.

(DOCX)

pone.0345299.s002.docx^{(16.7KB, docx)}

Attachment

Submitted filename: Response for reviewers.docx

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Attachment

Submitted filename: review.docx

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Submitted filename: Peer Review PONE - D - 25 - 41618R1.pdf

pone.0345299.s005.pdf^{(48KB, pdf)}

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Submitted filename: Author Response to Reviewers.docx

pone.0345299.s008.docx^{(30.8KB, docx)}

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Data Availability Statement

All relevant data are within the manuscript and its Supporting information files.

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PERMALINK

Utilization of palliative care services and associated factors among cancer patients in Ethiopia: A systematic review and meta-analysis

Sadik Abdulwehab

Frezer Kedir

Roles

Abstract

Introduction

Review method and data sources

Results

Conclusion

PROSPERO registration number

Introduction

Methods

Aim of the study

Design

Research question

Inclusion and exclusion criteria

Search strategy

Table 1. Search strategy and retrieval summary on palliative care utilization among cancer patents in Ethiopia, 2025.

Fig 1. Flow chart diagram and PRISMA checklist describing the selection of studies for the systematic review and meta-analysis on Palliative care among cancer patients in Ethiopia, 2025.

Search outcomes

Data extraction

Table 2. Characteristics of included studies on Palliative care utilization and its influencing factors among cancer patients in Ethiopia, 2025.

Organizing, summarizing, and reporting the results

Quality appraisal

Table 3. JBI critical appraisal on Palliative care service utilization among cancer patients in Ethiopia, 2025.

Statistical analysis

Certainty of evidence assessment

Ethical consideration

Results

Characteristics of the included studies

Types of palliative care provided for cancer patients in Ethiopia

Palliative care service delivery among cancer patients in Ethiopia

Palliative care service measures

Palliative care service utilization rate among cancer patients in Ethiopia

Fig 2. Forest plot shows the pooled utilization rate of Palliative care service among cancer patients in Ethiopia, systematic review and meta-analysis, 2025.

Subgroup analysis

Fig 3. Forest plot indicating sub‐analysis of utilization of Palliative care based on region among cancer patients in Ethiopia, systematic review and meta-analysis, 2025.

Fig 4. Galbraith plot shows pooled utilization rate of Palliative care service among cancer patients in Ethiopia, systematic review and meta-analysis, 2025.

Sensitivity analysis

Table 4. Influence of each study on pooled effect size on palliative care service utilization among cancer patients in Ethiopia, 2025.

Factors associated with palliative care utilization among cancer patients in Ethiopia

Fig 5. Forest plot shows the association of educational status and Palliative care service among cancer patients in Ethiopia, systematic review and meta-analysis, 2025.

Fig 6. Galbraith plot shows the association of educational status and Palliative care service utilization among cancer patients in Ethiopia, systematic review and meta-analysis, 2025.

Fig 7. Forest plot shows the association of educational status and Palliative care service utilization among cancer patients in Ethiopia, systematic review and meta-analysis, 2025.

Table 5. Summary of factors associated with Palliative care utilization among cancer patients in Ethiopia.

Certainty of evidence assessment

Table 6. Certainty of evidence assessment using core GRADE for palliative care utilization among cancer patients in Ethiopia, 2025.

Discussion

Strengths and limitations

Conclusion and recommendation

What is known

What is New?

Supporting information

Data Availability

Funding Statement

References

Decision Letter 0

Kahsu Gebrekidan

Roles

Author response to Decision Letter 1

Decision Letter 1

Kahsu Gebrekidan

Roles

Author response to Decision Letter 2

Decision Letter 2

Kahsu Gebrekidan

Roles

Author response to Decision Letter 3

Decision Letter 3

Kahsu Gebrekidan

Roles

Author response to Decision Letter 4

Decision Letter 4

Kahsu Gebrekidan

Roles

Acceptance letter

Kahsu Gebrekidan

Roles

Associated Data