Pathways-to-Care Analysis of Non-Hodgkin Lymphoma in Ethiopia: A Mixed-Methods Study.

Abstract

Detailed understanding of patient pathways and barriers to care is essential in devising context-appropriate cancer care strategies in low-income countries. We conducted a mixed-methods study nested within a case-control study among patients newly diagnosed with non-Hodgkin lymphoma (NHL; N = 174) in two referral centers in Ethiopia. Structured interviews and chart reviews were followed by in-depth interviews in a subsample (n = 17). Care intervals were defined via Andersen's model and determinants of delay were assessed with logistic regression; thematic analysis was used for qualitative data. Mean age at diagnosis was 51.4 years (standard deviation, 13.70); 67% had advanced disease. Median patient, primary health care, and tertiary care intervals were 86.5, 15, and 47 days, respectively. Median diagnostic interval was 66.5 days. Delay was associated with lower education (adjusted odds ratio [AOR], 6.3 [95% CI, 1.3 to 25]) and indolent lymphoma (AOR, 2.9 [95% CI, 1.3 to 6.2]). Treatment abandonment was 16.8%, and 9.8% were dead at 3 months. Loss to follow-up (21.8%) was associated with study site (AOR, 6.1 [95% CI, 2.6 to 29.9]) and diagnostic delay >30 days (AOR, 4.8 [95% CI, 1.6 to 14.3]). Qualitative analysis identified symptom misappraisal, misdiagnosis, long waits, high out-of-pocket costs, and long travel distances. Delays across Ethiopia's NHL care continuum reflect low health literacy, diagnostic bottlenecks, and persistent financial barriers.