Health-related quality of life and associated factors among cancer patients in Ethiopia: Systematic review and meta-analysis

Tadele Lankrew Ayalew; Belete Gelaw Wale; Kirubel Eshetu Haile; Bitew Tefera Zewudie; Mulualem Gete Feleke

doi:10.1371/journal.pone.0277839

. 2022 Dec 1;17(12):e0277839. doi: 10.1371/journal.pone.0277839

Health-related quality of life and associated factors among cancer patients in Ethiopia: Systematic review and meta-analysis

Tadele Lankrew Ayalew ^1,^*, Belete Gelaw Wale ¹, Kirubel Eshetu Haile ¹, Bitew Tefera Zewudie ², Mulualem Gete Feleke ¹

Editor: José Luiz Fernandes Vieira³

PMCID: PMC9714884 PMID: 36454902

Abstract

Introduction

Cancer is the main cause of morbidity and mortality in every part of the world, regardless of human development. Cancer patients exhibit a wide range of signs and symptoms. Being diagnosed with cancer has a variety of consequences that can affect one’s quality of life. The term "health-related quality of life" refers to a multidimensional concept that encompasses a person’s whole health. The availability of data on the prevalence of poor quality of life among cancer patients in Ethiopia is critical in order to focus on early detection and enhance cancer treatment strategies. In Ethiopia, however, there is a scarcity of information. As a result, the aim of this study was to determine the pooled estimated prevalence of quality of life among cancer patients in Ethiopia.

Materials and methods

This systematic review and meta-analysis were searched through MEDLINE, Pub Med, Cochrane Library, and Google Scholar by using different search terms on the prevalence of health-related quality of life of cancer patients and Ethiopia. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument was used for critical appraisal of studies. The analysis was done using STATA 14 software. The Cochran Q test and I² test statistics were used to test the heterogeneity of studies. The funnel plot and Egger’s test were used to show the publication bias. The pooled prevalence of health-related quality of life of cancer with a 95% confidence interval was presented using forest plots.

Results

A total of 12 studies with 3, 479 participants were included in this review and the overall pooled estimates mean score of health-related quality of life among cancer patients in Ethiopia was 57.91(44.55, 71.27, I² = 98.8%, p≤0.001). Average monthly income (AOR:3.70;95%CI:1.31,6.10), Stage of cancer (AOR:4.92;95% CI:2.96,6.87), Physical functioning(AOR:4.11;95%CI:1.53,6.69), Social functioning(AOR:3.91;95% CI:1.68,6.14) were significantly associated with quality of life. Subgroup meta-analysis of health-related quality of life of cancer patients in Ethiopia done by region showed that a higher in Addis Ababa 83.64(78.69, 88.60), and lower in SNNP region16.22 (11.73, 20.71), and subgroup analysis done based on the type of cancer showed that higher prevalence of health-related quality of life among cancer patients was breast cancer 83.64(78.69, 88.60).

Conclusion

This review showed that the overall health related quality of life was above an average. Furthermore, average monthly income, cancer stage, physical, and social functioning were all significant determinants in cancer patients’ QOL.as a result, this review suggests that quality of life evaluation be incorporated into a patient’s treatment routine, with a focus on linked components and domains, as it is a critical tool for avoiding and combating the effects of cancer and considerably improving overall health. In general, more research is needed to discover crucial determining elements utilizing more robust study designs.

Introduction

Cancer is a leading cause of morbidity and mortality across the globe in every world region and irrespective of the level of human development [1]. Cancer is the second leading death worldwide behind cardiovascular disease [2]. Cancer is emerging as a formidable challenge in low-income countries that have limited logistics supply to protect the quality of life of citizens [3]. In developing countries, the burden of cancer overlaps with the magnitude of communicable diseases including HIV/AIDS, hepatitis virus, and human papillomavirus, which can contribute to the pathogenesis of cancer [4, 5]. Cancer is caused by both external factors (tobacco smoking, chemicals, radiation, and infectious organisms) and internal factors (inherited mutations, hormones, and immune conditions). These causal factors may act together or in sequence to initiate or promote carcinogenesis. The development of most cancers requires multiple steps that occur over many years. Certain types of cancer can be prevented by eliminating exposure to tobacco and other factors that initiate or accelerate this process. Other potential malignancies can be detected before cells become cancerous or at an early stage when the disease is most treatable [6, 7]. People living with cancer develop a variety of symptoms [8, 9]. Being diagnosed with cancer certainly has different sequelae which hamper their quality of life [4, 10, 11]. Health-related quality of life is a multidimensional concept concerning a person’s general health conditions. It is a national representative tool for cancer survivors and examines lifestyle characteristics. It consists of domains related to social functioning, emotional, mental, and physical well being which are impaired in cancer patients. Following early screening and treatment of cancer, patients have certainly improved as a person’s view of life, satisfaction, and pleasure with their life, cancer survivors still face many challenges, including long-term complications of treatment that hamper their health-related quality of life [4, 11, 12]. Studies showed that cancer career patients experience a poor health-related quality of life than the general population [13, 14]. Understanding the comprehensive prevalence health-related quality of life of cancer patients is vital to provide supplementary information for healthcare workers, improve approaches to care, modify therapies, and provide supportive care for the duration of the illness and enhance the quality of life of cancer patients.

Cancer is one of the diseases that has a global impact on patients’ health-related quality of life. On the other hand, health-related quality of life is a technique used to assess the treatment outcome in cancer patients individually [1, 15]. Estimating the prevalence of a patient’s health-related quality of life helps health care providers and policymakers assess the success of cancer management and intervention.

In impoverished nations, such as Ethiopia, cancer is one of the leading causes of morbidity and mortality. To our knowledge, this is the first meta-analysis of its sort in Ethiopia to assess the pooled prevalence of health-related quality of life among all types of cancer patients. As a result, the findings of this study will assist health care providers in maintaining cancer patients’ health-related quality of life in addition to their pharmacological therapy. The findings of this review are useful in developing a strategy for focusing on the most important areas of cancer patients’ health-related quality of life. After treating cancer patients, the healthcare workers measure work effectiveness by different methods. Collective information on the prevalence of health-related quality of life among cancer patients in Ethiopia is to be considered vital to focus on early diagnosis and improve the treatment method of cancer. Health-related quality of life is one of the tools used to measure self-perceived approaches to evaluate patients’ views of their health status. It is assessed by a standard structured questionnaire called the quality of life questionnaire prepared by the European Organization for Research and Treatment of Cancer. However, there are scarce data in Ethiopia. Therefore, the present review aimed to assess cancer patients’ health-related quality in Ethiopia.

Materials and methods

Search strategy and review process

This systematic review and meta-analysis was conducted from published researches on the prevalence of health-related quality of life among cancer patients in Ethiopia. The studies were retrieved through internet search from the databases of MEDLINE, PubMed, Cochrane Library, and Google Scholar. We used the 2020 Preferred Reporting Items for Systematic and Meta-analysis (PRISMA) protocol to estimate the prevalence of health-related quality of life among cancer patients in Ethiopia [16]. We checked the database (http://www.library.UCSF.edu) and the Cochrane library to ensure this had not been done before and to avoid duplication. We also checked whether there was any similar ongoing systematic review and meta-analysis in the PROSPERO database and there had been no previous similar studies undertaken in Ethiopia.

The search was done using the following search terms; prevalence, health-related quality of life among cancer patients, and Ethiopia. The reference lists of already identified studies were screened to retrieve articles. All published articles up to October 10, 2021, were included in this review.

Eligibility criteria

Inclusion criteria

Studies were included in this review of the study;

Participants: Included participants who are living in Ethiopia.
The design was cross-sectional, cohort, case-control, etc.
Was conducted on health-related quality of life among cancer patients in Ethiopia.
Was published in English.
Study design: All observational study designs (cross-sectional, case-control, and cohort) were included.
Setting: Studies were only conducted in Ethiopia.
Study: All studies (published and unpublished) that were published in the form of journal articles, master’s thesis, and dissertations until the final date of data analysis were included.
Language: Only the English language was considered in this study.

Exclusion criteria

We excluded articles that were not fully accessible after at least two email contact with the principal authors.

Operational definition

Health related quality of life

Is defined as an individual’s satisfaction with their physical, psychological, social relationships, environment, and spiritual aspects of life, and it is one of the major factors in assessing the health and health-related well-being of cancer patients It usually used to measure in chronic conditions and frequently impaired to a great extent of the patients [17].

Comorbid disease

A chronic disease with a confirmed diagnosis of a disease other than cancer disease [18].

Alcohol intake

Individuals consume more than three units of alcohol per day [19].

Quality assessment and data collection

Joanna Brings Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used for critical appraisal of the study.

Joanna retrieved studies and was assessed for inclusion using their title and abstracts. Then a full review of articles for the quality of assessment was done before selecting for the final review. The details of studies that met the inclusion criteria were imported into the Joanna Briggs Institute’s System for the Unified Management, Assessment and Review of Information (JBI SUMARI, The Joanna Briggs Institute, Adelaide, Australia) critical appraisal tools to evaluate the quality of all studies [20]. All authors independently assessed the article title and abstract for inclusion in the review based on established article selection criteria, appraising the quality of the studies by criteria adapted for reporting prevalence data and cross-sectional studies. Studies were considered low risk if a score of 7 and above on the quality assessment indicators (Table 1). Any discrepancy which arose between the reviewers were in the review process was solved through discussion with other reviewers.

Table 1. Critical appraisal results of eligible studies in the systematic review and meta-analysis on the prevalence of health-related quality of life among cancer patients in Ethiopia, 2021.

S.no	Author	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Total
1	Hassen A., et al [11]	Y	Y	Y	N	Y	Y	Y	Y	Y	8
2	Ayana B., et al [22]	Y	N	Y	Y	U	Y	Y	Y	Y	7
3	Baraki A., et al [23]	Y	Y	Y	Y	N	Y	Y	Y	Y	8
4	Erku D., et al [24]	Y	Y	Y	Y	Y	Y	Y	Y	Y	9
5	Koboto D., et al [25]	Y	N	Y	Y	U	Y	Y	Y	Y	7
6	Ababa A., et al [26]	Y	Y	Y	Y	Y	Y	Y	Y	Y	9
7	Gebretekle G., et al [27]	Y	N	Y	Y	Y	Y	Y	Y	Y	8
8	Tadele N [28]	Y	Y	Y	Y	Y	Y	Y	Y	N	8
9	Aberaraw R., et al [29]	Y	Y	Y	Y	Y	Y	Y	Y	Y	9
10	Sibhat S., et al [30]	Y	Y	Y	Y	U	Y	Y	Y	Y	8
11	Abegaz T., et al [4]	Y	Y	Y	N	Y	Y	U	Y	Y	7
12	Zeleke N., et al [31]	Y	Y	Y	Y	Y	Y	Y	Y	Y	9

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Y = Yes, N = No, U = Unclear; JBI Critical Appraisal Checklist for Studies Reporting

Data extraction

The data extraction was done using a tool developed by the 2014 Joanna Brings Institute Reviewers’ Manual data extraction form by three authors (TL, BT, and MG) [20]. The data extraction tool includes information on the title, author, year of study, publication year, study design, sample size, study participants, study area, response rate, and the proportion of health-related quality of life among cancer patients in Ethiopia. Articles that fulfilled the predefined criteria were used as a source of data for the final analysis. The reviewers cross-checked it to ensure consistency. Any discrepancy was solved through discussion with other authors and the procedure was repeated to overcome the difference which resulted during extracting every single study.

Methodological quality assessment of studies

The methodological quality of included studies was appraised using a modified and predefined checklist to assess the methodological quality aspect quality of life among cancer patients reported.

A score of yes was given for an item if meeting the methodological criteria. A score of no was given for an item is not meeting the methodological criteria, and if an item neither met the criteria nor described the related parameter sufficiently was give unclear. Here, we use the above terms to screen the eligible articles for systematic review and meta-analysis. The point is that both ‘‘No and neither yes or no” articles illegible for this systematic review and meta-analysis. Here the JBI-MAStARI requires for the use as a methodological tool, specifically for assessing risk of bias with 9 items modified quality of life assessment checklist. According to Newcastle-Ottawa quality assessment Scale (NOS) score 7 or more for cross- sectional studies was accepted. Based this a score of 7 or more out of 9 acceptable for this review [21].

List of questions to assess the methodological quality of studies on QOL of cancer patients

Q1 = was the sample frame appropriate to address the target population?
Q2. Were study participants sampled appropriately?
Q3. Was the sample size adequate?
Q4. Were the study subjects and the setting described in detail?
Q5. Was the data analysis conducted with sufficient coverage of the identified sample?
Q6. Were the valid methods used for the identification of the condition?
Q7. Was the condition measured in a standard, reliable way for all participants?
Q8. Was there appropriate statistical analysis?
Q9. Was the response rate adequate, and if not, was the low response rate managed appropriately?

Outcome measurement

Quality of life among cancer patients is the primary outcome of this review and meta-analysis. Mean is the summary measure of this outcome.

Publication bias and heterogeneity

The existence of heterogeneity was assessed by using the funnel plot test, I², and its corresponding p-value. A value of 25%, 50%, and 75% was used to declare the heterogeneity test as low, medium, and high heterogeneity. For results with statistically significant heterogeneity, a random effect model of analysis was used. Egger regression asymmetry test was used to assess the statistical significance of publication bias [25].

Data analysis

The data were entered using Microsoft Excel. The Meta-analysis was conducted using Stata 14 software. Forest plots were used to present the combined estimate with the 95% confidence interval (CI). The estimated pooled prevalence of health-related quality of life among cancer patients in Ethiopia was computed with 95% CI. Subgroup analysis was done by region, year of the study period, and study participants. Additionally, a univariate meta-regression model was applied by taking the sample size, publication year, and quality scores of each primary study to investigate the sources of heterogeneity. Finally, a forest plot figure was used to present the point proportions with their 95% CI of the primary studies. The heterogeneity of included studies was evaluated with I² statistics. Based on I² statistics, a value less than 25% were considered low heterogeneity, between 50 and 75% medium heterogeneity and greater than 75% were considered as high heterogeneity [32].

Results

Studies identified

A total of 3583 articles were retrieved through internet searching. One hundred six were identified through other sources. A total of 3,666 articles were retrieved. Out of these, 201 duplicate records were removed from the review. Of the total articles, 3,125 were due to inaccuracy title and 253 articles were due to absence similarity of abstracts were excluded from the review. After a full review of the articles, 74 were excluded by eligibility criteria. Finally, twelve studies were included in this meta-analysis (Fig 1).

Characteristics of included studies

This systematic review and meta-analysis included 12 articles with 3,479 study participants. All studies employed a cross-sectional study design. Most of the regions in Ethiopia were represented in this review. Seven studies were from Addis Ababa city, four studies from the Amhara region, and two from SNNRP, region respectively. Studies were conducted from 2015 to 2020. The sample size of studies ranged from 140 [22] to 403 in a study conducted in Addis Ababa [11], and the response rate ranged from 93% to 100%. Overall, this review included a total of 3,483 health-related quality of life among cancer patients in Ethiopia (Table 2).

Table 2. Characteristics of studies included in a systematic review on the prevalence of health-related quality of life among cancer patients in Ethiopia, 2021.

Author	Year	Region	Study area	SD	Study period	Measurement tool	Type of ca	Sample size	Cases	Prevalence HRQOL
Hassen A., et al [11]	2019	AA	TASH	CS	Feb-Apr 2018	EORTC QLQ-C30	breast cancer	403	214	52.98
Ayana B., et al [22]	2018	AA	TASH	CS	Jan-June 2014	EORTC QLQ-C30	Cervical cancer	140	57	40.95
Baraki A., et al [23]	2020	Amhara	FHRH	CS	Apr-May 2019	PHQ-9	All ca	302	214	70.86
Erku D., et al [24]	2016	Amhara	UOGTRH	CS	Oct 2015 -Febr 2016	EORTC QLQ-C30	All ca	154	122	79
Koboto D., et al [25]	2020	SNNPR	HU	CS	Apr- June 2019	WHOQOL-BREF	Breast Cancer	259	42	16.1
Ababa A., et al [26]	2020	AA	TASH	CS	Mar-May 2017	CQOLC	All ca	291	239	82.23
Gebretekle G., et al [27]	2016	Amhara	UOGTRH	CS	Jan-June 2014	EORTC QLQ-C30	All ca	395	312	78.9
Tadele N [28]	2020	AA	TASH	CS	Jan-June 2018	EORTC QLX245D	cervical cancer	379	183	48.3
Aberaraw R., et al [29]	2015	AA	TASH	CS	Mar- May 2013	EORTC QLQC30	Breast cancer	388	114	29.4
Sibhat S., et al [30]	2020	AA	TASH	CS	Mar-Apr 2019	EORTC-C30	Breast cancer	214	179	83.61
Abegaz T., et al [4]	2019	AA	TASH	CS	Dec 2017-Feb 2018	EORTC LBR235D	Breast cancer	404	240	59.32
Zeleke N., et al [31]	2018	Amhara	UOGTRH	CS	Jan-Aug 2017	EORTC QLQ-C30	All ca	150	79	52.7

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AA = Addis Ababa, CS = Cross-sectional, UOGTRH = University of Gondar teaching referral hospital, TASH = Tinkur Ambesa Specialized hospital, FHRH = Felege-Hiwot referral Hospital, PHQ-9 = patient health questionnaire-9, CQOLC = Caregiver Quality of Life Index-Cancer, EORTC QLQ-C30 and QLQBR23 = European organization for research and treatment of cancer core 30 and quality of life questionnaire specific to breast EORTC QLQ-CX24 and EQ-5D = European Organization for Research and Treatment of Cancer module (EORTC QLQ-C30), cervical cancer module (EORTC QLQ-CX24), and Euro Quality of Life Group’s 5-Domain Questionnaires 5-Levels (EQ-5D) questionnaires

Health related quality of life measurements

A wide range of health related quality of life evaluation measurements were utilized in these 12 revised articles. The findings of the health related quality of life measures were employed in each reviewed articles (Table 3).

Table 3. WHOQOL related finding of quality of life among cancer patients in Ethiopia.

Author	QOL measurement tool	Reported Domain	WHOQOL Related Findings
Hassen A., et al [11]	Selected items of EORTC QLQ-C30 and EORTC QLQ-BR23.	Overall QOL	Mean global health status (QOL) = 52.98 (SD = 25.61).
		Psychological functioning	emotional functioning ((± SD) 47.61 ± 25.83)
		Psychological functioning	cognitive functioning ((± SD) 80.06 ± 22.89)
		Social relations functioning	patients scored worse in sexual functioning (85.8%)
		Social relations functioning	only 16.6% participants had poor body image
Ayana B., et al [22]	EORTC QLQ-C30	Overall QOL	Global Health Status score was 40.95(SD ± 24.35)
		Physical	had higher score in fatigue (65.24, SD±22.59)
		Role function	Active coping and religious coping were positively correlated with emotional well being (50.12, SD± 35.11)
		Emotional function	Active coping and acceptance were positively correlated with functional well-being (55.48, SD±30.32)
		Cognitive	had poor cognitive functioning (88.21, SD = 18.49)
		Social function	had higher score in fatigue, pain, dyspepsia, financial difficulties and constipation (42.26, SD = 32.08)
Baraki A., et al [23]	PHQ-9	Overall QOL	Patients with cervical cancer reported better QOL than patients with breast cancer.
		Physical	Sleeping difficulties (44.3%).
		Psychologica	Depression (27.8%) and loss of confidence (3.5%).
		Independence	Inability to work (30%).
Erku D., et al [24]	Structured questionnaire and EORTC QLQ-C30	Overall QOL	Excellent overall QOL (14%).
		Physical	Pain (72%), lack of energy (78%), sleeping difficulties (63%).
		Psychological	Loss of confidence (30.9%), difficulty in concentration (46%),
		Independence	Difficulties in daily activities (75%).
		Social	Social support (56.6–67.1%), sexual functioning (11.2%).
Koboto D., et al [25]	WHOQOL	Overall QOL	overall global health scale was 75.3 (SD±17.1)
	BREF	Environmental	93.31 (SD±19.76)
		Physical health	88.26 (SD±21.61)
		Psychological	68.2 (SD±19.07)
		Social related	36.69 (SD±7.62)
Ababa A., et al [26]	CQOLC	Overall QOL	overall mean score of the QOL was 82.23 (±16.21).
		burden	burden was 24.49 (±7.83),
		disruptiveness	for disruptiveness was 16.63 (±5.69),
		adaptation	for positive adaptation was 18.58 (±3.42),
		financial	for financial concern was 9.29 (±3.27)
		other	for other subscale scores was 12.94 (±4.18)
Gebretekle G., et al [27]	EORTCQLQ-C30	Overall QOL	overall mean score of the QOL was (54.86±4.67)
Tadele N [28]	EORTC QLQ-CX24	Global health status/QoL	Mean global health statu scale scores were 48.3 ± 23.77, 0.77
Aberaraw R., et al [29]	EORTC QLQC30	GQOL	mean of global health status/QoL was 57.28 (SD = 25.28).
		Physical	physical functioning had a mean of 62.71 (SD = 34.86).
		Role	Role functioning had a mean of 43.36(SD = 43.32),
		Emotional	emotional functioning had a mean of 45.88 (SD = 42.28)
		Social	social functioning had a mean of 39.69(SD = 39.69)
Sibhat S., et al [30]	Selected items of EORTC QLQ-C30 and EORTC QLQ-BR23.	Overall QOL	Low overall QOL (mean: 48.25).
		Physical Capacity	High level of postoperative breast symptoms (mean: 19.1) and arm symptoms (mean:24.5).
		Psychological	High level of body image (mean: 69.3); Low level of perspective toward the future (mean: 40.3)
		Social Relations	Low level of sexual functioning (mean: 85.3).
Abegaz T., et al [4]	EORTC QLQ-C30	Overall QOL	Global health status 52.7 (20.1)
Zeleke N., et al [31]		Physical	Physical functioning 53.27 (22.9)
		Role	Role functioning 43.32 (26.7)
		Social	Social functioning 46.31 (25.5)
		Emotional	emotional functioning 61 (25.5)
		Cognitive	Cognitive functioning 59.31 (43.6)

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QOL = Quality of life; FACT-G: Functional Assessment of Cancer Therapy-General; FACT-B: Functional Assessment of Cancer Therapy-Breast; EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire; EORTC QLQ-BR23: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Breast cancer;

PHQ-9 = patient health questionnaire-9, CQOLC = Caregiver Quality of Life Index-Cancer

The prevalence of health-related quality of life among cancer patients in Ethiopia

In Ethiopia, the prevalence of health-related quality of life among cancer patients in this review was high. A prevalence of health-related quality of life among cancer in SNNRP region 16.22% [25] in Addis Ababa 83.64% [29] were observed. The I² test result showed high heterogeneity (I² = 98.8%, p-value≤0.001) which is indicative to use a random-effects model of analysis. Therefore, using the random effect analysis, the overall pooled prevalence of health-related quality of life among cancer patients in Ethiopia was 57.91(44.55, 71.27, I² = 98.8%, p≤0.001) (Fig 2).

The funnel plot is symmetrical, the observation of the pooled prevalence of health-related quality of life among cancer patients was not affected by publication bias. The egger regression asymmetry test also demonstrated that no statistically significant publication bias may occur in this review (Egger’s test, b = 0. 026, p ≤ 0.938) (Fig 3).

Subgroup analysis

Subgroup meta-analysis of this review was done by using region and publication year showed that a higher pooled health-related quality of life among cancer patients was present when a study done in Addis Ababa 83.64(78.69, 88.60). The lower prevalence health-related quality of life among cancer patients was observed in the SNNP region16.22 (11.73, 20.71) (Fig 4).

The subgroup analysis was done by using a type of cancer and the authors showed that the higher prevalence of health-related quality of life among cancer patients was breast cancer 83.64(78.69, 88.60) (Fig 5).

Sensitivity analysis

To identify a single study influence on the overall meta-analysis, sensitivity analysis was performed using a random-effects model, and the results showed that there was no strong evidence for the effect of a single study on the overall meta-analysis result. The table shows that the estimate from a single study was closer to the combined estimate, which implies the absence of a single study effect on an overall study.

Factors associated with health related quality of life among cancer patients in Ethiopia

Association between average monthly income and health-related quality of life. Five papers were included in the meta-analysis to determine the relationship between health-related quality of life and average monthly income [11, 22, 24, 28, 30]. This meta-analysis found that having an average monthly income of more than 4,000 ETB was significantly associated with health-related quality of life among cancer patients. Patients with an average monthly income of 4,000 ETB were 3.10 times more likely to acquire a good quality of life than those with a lower monthly income (OR = 3.10, 95% CI: 1.31–6.10). Because a fixed effect model was adopted, the included studies showed no heterogeneity (I² = 0.001%, p = 0.383) (Fig 6).

Association between physical functioning and health-related quality of life. The meta-analysis includes five studies that showed between physical functioning and health-related quality of life [4, 11, 22, 27, 28]. Accordingly, cancer patients with good physical functioning were 4.11 times more likely to develop good quality of life than cancer patients with low physical function (OR = 4.11, 95% CI: 1.53–6.69) (Fig 7).

Association between social functioning and health-related quality of life. To demonstrate the association between quality of life and social functioning, six studies were chosen [4, 11, 22, 27–29]. Cancer patients with social functioning were 3.91 times more likely than cancer patients with poor social functioning to develop good quality of life (OR = 3.91, 95% CI: 1.88–6.14) (Fig 8).

Association between stage of cancer and health related quality of life. This meta-analysis included seven research to show the association between quality of life and cancer stage among cancer patients [4, 24, 27–30, 33], and two of the included studies found statistical significance between quality of life and disease stage [29, 30]. This finding indicated that patients with stage four cancer had a 4.92 times higher chance of developing poor quality of life than those with others (OR = 4.92, 95% CI: 2.96–6.87). As a result of using a fixed effect model, the included studies did not show heterogeneity (I² = 0.00%, p = 0.483) (Fig 9).

Discussion

The goal of this study was to determine the countrywide prevalence of cancer patients’ health-related quality of life. In this study, the overall pooled prevalence of cancer patients’ health-related quality of life was 57.91% (95% CI: 44.55, 71.27, I² = 98.8%, p≤ 0.001). The results of this meta-analysis are lower than those of Norwegian systematic reviews and meta-analyses [25, 31]. The possible reason could be attributable to differences in geographic location, medical service quality, and socioeconomic position.

However, this result is significantly greater than that of research conducted in Bangladesh (28.67%), Uganda and Mozambique and the United States [32]. The possible explanation for the observed variations might be due to differences in methodology and sample size used to assess the prevalence of health-related quality of cancer patients by individual studies conducted in each country. Moreover, the difference could be due to the difference in a geographical area, quality of medical service, and socio-economic status which have an unlimited effect to assess the prevalence of health-related quality of life of cancer patients.

In the current systematic review and meta-analysis, several factors were associated with health related quality of life among cancer patients. Regarding to socio-demographic characterstics, high average monthly income was significantly associated with good health-related quality of life. This review is supported by a study done in Nigeria, Pakistan, and Ethiopia [11, 22, 24, 28, 30]. The possible reason may be adequate access of information about cancer patients that can help them to give self-adjustment for the patient and they are high likely to communicate with healthcare provider. Because High average monthly income has been associated to a variety of features of improved patient care, including being less concerned about financial troubles and missing work [17]. Similarly patients facing difficulties with monthly income are at risk for experiencing upset of their quality of life [33]. Furthermore, in countries such as Ethiopia, this is made worse by the fact that there are only a limited number of facilities available for chemotherapy treatment, requiring all patients to travel significant distances to receive treatment, adding to the patients’ already high financial burden.

This comprehensive review and meta-analysis found that having good physical functioning helps cancer patients acquire a positive health-related quality of life. This finding is consistent with a prior study conducted in Ethiopia in various circumstances [34]. Poor physical functioning may increase the likelihood of poor quality of life due to a lack of daily activities and a lack of early care of any anomaly that may emerge in the daily foundation activities.

Social functioning was strongly associated with health related quality of life among cancer patients in Ethiopia. This review is supported with a prior studies [31, 35, 36]. The possible justification for this reason may be in Ethiopian societies, families, friends, relatives, and neighbors can all provide valuable social support. Furthermore, patients hold a strong religious belief and believe that if they receive good treatment, they will be cured.

The findings of this review also revealed that the advanced stage of cancer disease and length of time a patient has been diagnosed with cancer is one of the risk factors for low quality of life in cancer patients. This review and meta-analysis was supported by studies done previousely [31, 37]. As the stage of the disease increases, the likelihood of poor quality of life increases. This is owing to the fact that if the disease is not appropriately treated and controlled, it will worsen over time.

Strengths of this review

The strength of this study includes the use of multiple databases to search articles (both manual and electronic search) and the uniform abstraction of material in a predetermined manner by two separate reviewers helped to minimize error. This meta-analysis also included studies from different parts of the country that comprise both urban and rural populations.

Limitations

The number of studies included in this systematic review and meta-analysis was limited by the requirement that primary studies be written in English. This review was hampered by the fact that no primary articles were conducted that focused on cancer patients’ age category, gender based comparison, or socioeconomic status. Another drawback of this review was the small sample size due to few primary articles were included in meta-analysis. Furthermore, all of the studies included in this review used a cross-sectional study design, which means that the outcome variable could be influenced by other confounding variables, lowering the study’s power and making it more difficult to draw causal conclusions between associated factors and cancer patient quality of life.

Conclusion

Supporting information

S1 File

(DOCX)

Click here for additional data file.^{(48.2KB, docx)}

S1 Checklist

(DOCX)

Click here for additional data file.^{(30.2KB, docx)}

Acknowledgments

We would like to acknowledge the authors of the studies included in this review.

Abbreviations

CDC: Centers for Disease Control and Prevention
HRQOL: health related quality of life
SNNPR: Southern Nation, Nationalities and Peoples of Region
WHO: World Health Organization

Data Availability

All relevant data are within the paper.

Funding Statement

The authors received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0277839.r001

Decision Letter 0

José Luiz Fernandes Vieira

14 Apr 2022

PONE-D-21-39423Health-related quality of life among cancer patients in Ethiopia: Systematic review and Meta-analysisPLOS ONE

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Reviewer #1: There are several points that make the systematic review fragile, requiring an almost complete restructuring of methodology, results and especially discussion.

Minor questions

1- The submission code on the Prospero platform not found on the platform, as well as the title and keywords.

2- Disagreement between the results found in the PRISMA diagram, in the description of the results and the final number of analyzed articles.

Major questions

- When performing Quality assessment, a SCORE was used, JBIMAStARI does not use a score table, like other qualifiers, so it needs to indicate the use of the Modified Qualifier and as it was estimated that 7 points is a low risk assertive

2- Discuss how “No” and “Unclear” answers can directly affect the quality and risk of bias of the article.

3- Review the structure of the Meta-analysis, it has an extremely high heterogeneity (i² = 98.8%) which lowers the certainty of the evidence due to data inconsistency.

4- Demonstrate the concept of Quality of Life and the tools used in the articles in order to seek similarities and differences between them, as well as discuss which domains of quality of life they address.

5- Characterize the samples of articles taking into account Gender, Age, Socioeconomic level and discuss how this can directly change the certainty of the evidence.

6- Discuss the variability of cancer types, if this directly interferes in the context of this review

7- Discuss how the age limitation of study participants can be a bias in these studies and thus directly a bias in the statement of the systematic review.

8- With this review the conclusion, showing evidence of a high quality of life and the possibility of including suggestions for future studies carried out in this area.

With these corrections, resubmit the article for consideration, as it is a topic of extreme relevance.

Reviewer #2: Abstract section- how did you assess health related quality of life among cancer patients using pooled prevalence? since quality of life is assessed on the basis of score.

Method section- what was the rationale for including various study designs like case control and cohort studies.

which study tool was used to assess health related quality among cancer patients? this has not been mentioned anywhere in methodology.

Result section: somewhere it is mentioned 13 studies were included but in tables there are only 12 studies.

Also, there is no homogeneity among cancers in different studies. some studies have included only breast cancer, some have included included only cervical cancers and some have included all cancers. Therefore the results cannot be generalized to overall health related quality among all cancer patients. kindly justify ?

**********

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PLoS One. 2022 Dec 1;17(12):e0277839. doi: 10.1371/journal.pone.0277839.r002

Author response to Decision Letter 0

29 Jul 2022

Dear Editor of PLOS ONE

This is a point-by-point response letter that complements the responses of authors to reviewers’ comments regarding to our manuscript. We are pleased to resubmit the revised version of our paper entitled “Health-related quality of life among cancer patients in Ethiopia: Systematic review and Meta-analysis” Tadele lankrew Ayalew1*, Belete Gelaw1, kirubel Eshetu1 Bitew Tefera2, and Mulualem Gete1 which has a submission manuscript/identification number of PONE-D-21-39423 given by the journal. It is well-known that this manuscript has been reviewed by peer reviewers and sent back to authors for further revision as per the Journal Requirements and resubmission. We are so eager and thankful to work with you.

We would like to take this opportunity to thank the reviewers for their view and constructive comments. The reviewers’ comments and recommendations were important to improve the quality of our manuscript. Therefore, we have organized our response letter based on reviewers’ comments and questions. (Title, Abstract, introduction, methods, results, discussion, and conclusion). Under each section, the reviewers’ comments are given followed by authors’ response. The authors’ responses are also shown by the track changes in the revised version of our manuscript. The responses for each of the reviewers’ comments are addressed in the following pages using a point by point response format.

Our responses are written in yellow background words (highlighted with yellow).

We look forward to hearing from you at your earliest convenience.

With regards

Tadele Lankrew Ayalew

(On the behalf of all authors)

Comments to the Authors

The authors of this systematic review and Meta-analysis study have presented valuable data to determine the health-related quality of life among cancer patients in Ethiopia. Consequently, there are specific critical issues that the reviewers would like the authors to address for further improvement in the quality of our manuscript.

Authors’ response: we are very delighted to the reviewer’s appreciation of our efforts; and we have just given our respective responses to each of the specific reviewers concerns as detailed below. Please find below our response to the comments. All changes made in the document are highlighted in yellow word background.

Journal requirements:

We follow PLOS ONE's style requirements, including those for file naming. Since no funding source for this review we stated like “The authors received no specific funding for this work.”

For competing interest ,because of absence of conflict within authors we stated like “ The authors have declared that no competing interests exist."

Authors’ Responses to Reviewer's Questions

Comments to the Author

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

Thank you for your constructive comments. Really, we appreciate and accepted all the comments you raised for us. We have made correction to the revised manuscript accordingly.==>please line 48 `and 347.

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

Thank you for your constructive comments. We have accepted all the comments you raised. We have made correction based on your suggestion to the revised manuscript. In the revised manuscript statistical analysis have been performed including associated factors and domain of health related quality of life among cancer patients in Ethiopia. ==>Please see line from 281-309.

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

Thank you for your constructive comments and suggestions. Even if the PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, the summary statistics, the data points behind means, medians and variance measures were excluded from our study. Because our target was to analysis the pooled prevalence of health related quality of life among cancer patients. In addition to this there is no restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party. Because our study design is systematic review and meta analysis

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

Reviewer #1: Yes

Reviewer #2: Yes

Thank you for your constructive comments.

Reviewer #1: There are several points that make the systematic review fragile, requiring an almost complete restructuring of methodology, results and especially discussion.

Minor questions

1- The submission code on the Prospero platform not found on the platform, as well as the title and keywords.

Thank you so much for your comments. We means that we already registered on the Prospero platform with PROSPERO Registration message with CRD [284157]; , but still no conformation notification is provided. So we accepted your comment 100% and made correction on revised manuscript. ==>Please see line 114.

2- Disagreement between the results found in the PRISMA diagram, in the description of the results and the final number of analyzed articles.

Thank you for your suggestions and comments. After proof reading, the appropriate correction was made to the revised manuscript based on the given comment to make it consistent throughout the manuscript.

Major questions

Thank you for your critical comments. The table in our manuscripts helps as a tally sheet to counts the points of critical appraisal of the article. Here the JBI-MAStARI requires for the use as a methodological tool, specifically for assessing risk of bias with 9 items modified quality of life assessment checklist. According to Newcastle-Ottawa quality assessment Scale (NOS) score 7 or more for cross- sectional studies was accepted. Based this a score of 7 or more out of 9 acceptable for this review and meta-analysis. ===>please see line 144, and 177.

2- Discuss how “No” and “Unclear” answers can directly affect the quality and risk of bias of the article.

Thank you for your critical comments. At this manuscript, the methodological qualities of included studies were assessed based on a modified checklist developed to assess the methodological quality aspect of quality of life reporting. A score of yes , no or unclear was given for each item. A score of yes was given for an item if meeting the methodological criteria. A score of no was given for an item is not meeting the methodological criteria, and if an item neither met the criteria nor described the related parameter sufficiently was give unclear. Here , we use the above terms to screen the eligible articles for systematic review and meta-analysis. ===>please see line 172-180.

3-Review the structure of the Meta-analysis, it has an extremely high heterogeneity (i² = 98.8%) which lowers the certainty of the evidence due to data inconsistency.

Thank you for your suggestions. Absolutely! But the reason that the occurrence of high heterogeneity was the number of studies in this review and meta-analysis is small.

4-Demonstrate the concept of Quality of Life and the tools used in the articles in order to seek similarities and differences between them, as well as discuss which domains of quality of life they address.

Thank you very much. We have made the necessary correction. The concept Quality of life is the degree to which an individual is healthy, comfortable, and able to participate in or enjoy life events. It usually used to measure in chronic conditions and frequently impaired to a great extent of the patients. ===>please see line 135

Concerning measurement tool , Health related quality of life can be measured by patient health questionnaire-9, Caregiver Quality of Life Index-Cancer, European organization for research and treatment of cancer core 30 and quality of life questionnaire specific to breast , European Organization for Research and Treatment of Cancer module and Euro Quality of Life Group’s 5-Domain Questionnaires 5-Levels (EQ-5D) questionnaires were tools that use to differentiated the articles. ==>Please see table 2 and 3.

Concerning the domain of quality of life, in this manuscript physical functioning, and social functioning significantly associated with quality of life among cancer patients in Ethiopia. ==>Please see line 292 and 297.

5-Characterize the samples of articles taking into account Gender, Age, Socioeconomic level and discuss how this can directly change the certainty of the evidence.

Thank you very much for your constructive comments. We would like to say sorry for the unclear expression. We didn’t address those points in this review and meta-analysis, however we included as a limitation of our study in the revised manuscript. Because all the above mentioned terms are out of our predefined and modified checklist or no primary study concerned for the mentioned variables. Further research is needed to fully assess the impact of variables like Gender, Age, Socioeconomic level on cancer patients. ==>Please see line 357

6- Discuss the variability of cancer types, if this directly interferes in the context of this review

We would like to say sorry for the unclear expression. Here our concern was not type cancer , but on the pooled prevalence of cancer. So type of cancer is not directly interferes in the context of this review. Here, we show that the lifetime risk of cancers of many different types is strongly associated with the health related quality of life. This is important not only for understanding the disease but also for designing strategies to limit the mortality it causes.

7- Discuss how the age limitation of study participants can be a bias in these studies and thus directly a bias in the statement of the systematic review.

Thank you for your critical comments. We apologize for the ambiguous phrase. Here our concern was on the age category of study participants. All primary articles included in this systematic review and meta analysis have no age category group. As a result, our review could be hampered.

8-With this review the conclusion, showing evidence of a high quality of life and the possibility of including suggestions for future studies carried out in this area.

With these corrections, resubmit the article for consideration, as it is a topic of extreme relevance.

Great thanks for your valuable suggestions.correction has made accordingly.

Reviewer #2: Abstract section- how did you assess health related quality of life among cancer patients using pooled prevalence? since quality of life is assessed on the basis of score.

Great thanks for your critical comment. We apologize for the ambiguous phrase. Corrections have made accordingly. After proof reading, the appropriate correction was made to the revised manuscript based on the given comment to make it consistent throughout the manuscript.

We corrected the term with pooled estimates mean score of health related quality of life among cancer patients based on standard tool results thorough the revised manuscript.

Method section- what was the rationale for including various study designs like case control and cohort studies.

which study tool was used to assess health related quality among cancer patients? this has not been mentioned anywhere in methodology.

Thank you very much for your valuable comment. Here, the rational of using various study designs like case control and cohort studies were if the outcome variable of the previous primary study was similar.

Concerning assessment tool of health related quality of life was measured by using WHOQOL-HIV BREF. ==>Please see line 243 and table 3

Result section: somewhere it is mentioned 13 studies were included but in tables there are only 12 studies.

Thank you for your critical view and we would like to say sorry for the error. After proof reading, the appropriate correction was made to the revised manuscript based on the given comment to make it consistent throughout the manuscript.

Thank you very much for your critical suggestion concerning to generalization. Here our goal is’’ to estimate the overall mean score of health-related quality of life’’ among any type of cancer patients because our source of population is made up of cancer patients in Ethiopia.

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

It means PLOS now offers accepted authors the opportunity to publish the peer review history of their manuscript alongside the final article. The peer review history package includes the complete editorial decision letter for each revision, with reviews, and your responses to reviewer comments, including attachments.

Attachment

Submitted filename: Response letter to reviewers.docx

Click here for additional data file.^{(28.8KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0277839.r003

Decision Letter 1

José Luiz Fernandes Vieira

17 Aug 2022

PONE-D-21-39423R1

Health-related quality of life among cancer patients in Ethiopia: Systematic review and Meta-analysis

PLOS ONE

Dear Dr. Tadele Lankrew

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

ACADEMIC EDITOR:

This is an interesting manuscript, but some questions point out by reviewers should be resolved.

Please submit your revised manuscript by 30/08/2022. If you need more time than this to complete your revision please reply to this massage or contact the journal office at plosone@plos.org.

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

When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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

We look forward to receiving your revised manuscript.

Kind regards,

José Luiz Fernandes Vieira

Academic Editor

PLOS ONE

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Reviewers' comments:

PLoS One. 2022 Dec 1;17(12):e0277839. doi: 10.1371/journal.pone.0277839.r004

Author response to Decision Letter 1

22 Sep 2022

Dear Editor of PLOS ONE

This is a point-by-point response letter that complements the responses of authors to reviewers’ comments regarding to our manuscript. We are pleased to resubmit the revised version of our paper entitled “Health-related quality of life and associated factors among cancer patients in Ethiopia: Systematic review and Meta-analysis” Tadele lankrew Ayalew1*, Belete Gelaw1, kirubel Eshetu1 Bitew Tefera2, and Mulualem Gete1 which has a submission manuscript/identification number of PONE-D-21-39423R1 given by the journal. It is well-known that this manuscript has been reviewed by peer reviewers and sent back to authors for further revision as per the Journal Requirements and resubmission. We are so eager and thankful to work with you.

Our responses are written in yellow background words (highlighted with yellow).

We look forward to hearing from you at your earliest convenience.

With regards

Tadele Lankrew Ayalew

(On the behalf of all authors)

Comments to the Authors

Journal requirements:

We follow PLOS ONE's style requirements, including those for file naming. Since no funding source for this review we stated like “The authors received no specific funding for this work.”

For competing interest ,because of absence of conflict within authors we stated like “ The authors have declared that no competing interests exist."

Authors’ Responses to Reviewer's Questions

Comments to the Author

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

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

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

On the other hand authors do not need to submit their entire data set and the raw data collected during an investigation. Because both were reported and used in the reported study as well as share data in the main manuscript of this article as the standard in the field that have been processed during analysis.

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

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