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Table 1 Main characteristics of the included studies

From: Health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa: a systematic review

Title Authors Year of publication Country Study design Research method Age group
(Years. Median/Mean)
Participants Sample size Diagnostic interval Treatment interval Diagnostic and treatment intervals Cited limits WHO building blocks addressed
(1) Delays in Breast Cancer Presentation and Diagnosis at Two Rural Cancer Referral Centers in Rwanda Lydia E. Pace et al 2015 Rwanda Cross-sectional study Quantitative and qualitative 49 - Women with pathologically confirmed breast cancer 144 5 Months NA* NA - Doubt about the accuracy of the delays noted by patients
- Likelihood to not assess all the important contributors to delay
- -Included patients might not be representative of all patients with breast cancer in Rwanda
- Limited power to detect small differences in patient or system factors that might have been associated with delays
- Service delivery
- Health workforce
- Information systems
(2) Barriers to early presentation of breast cancer among women in Soweto, South Africa Maureen Joffe et al 2018 South Africa Cross-sectional survey Quantitative and qualitative > 18 - Female patients who were newly diagnosed with stage 0-IV breast carcinoma 499 NA NA NA - Information about delays in care seeking and numbers and types of healthcare visits is based on patient survey responses. Rather than administrative data. Which may be biased or less accurate
- Limited generalizability
- Service delivery
- Health workforce
(3) Access to Breast Cancer Treatment Services in Mombasa County. Kenya: A Quality of Care Analysis of Patient and Survivor Experiences Sultane Sherman and Vincent Okungu 2018 Kenya Cross-sectional descriptive study Quantitative and qualitative 36–55 - Breast cancer patients and survivors 72 NA NA NA - The study was conducted in an organized group of cancer survivors and patients and their level of access to services may not entirely reflect the realities of the county where other patients survive without support systems - Service delivery
- Health workforce
- Health financing
(4) Factors associated with time to first healthcare visit. Diagnosis and treatment, and their impact on survival among breast cancer patients in Mali Grosse Frie K et al 2018 Mali Prospective cohort study Quantitative and qualitative 45 (Mean) - Female patients with Breast Cancer 64 6.4 months (mean) 2.5 months (mean) NA - Relatively small sample size
- This study did not include breast cancer patients who did not go to the hospital for diagnostic services
- Women who were lost after the first healthcare visit or never sought healthcare were unknown
- These limitations effect the generalizability of the results
- Service delivery
- Health workforce
(5) Financial barriers related to breast cancer screening and treatment: A cross-sectional survey of women in Kenya Subramanian S et al 2019 Kenya Cross-sectional survey Quantitative and qualitative 46.1 (Mean) - 400 Women with breast cancer
- 400 Women without a diagnosis of breast cancer
800 NA NA NA - Women were interviewed by research assistants. Which could have also introduced
bias
- The analysis was based on responses provided by the women themselves. Which may be subject to recall or other biases
- All women who participated in this cohort study were identified from the regions within or in close proximity to Nairobi County therefore our findings might not be generalizable
- Non-random selection
process could have introduced selection bias
- Small sample of women with private insurance limited the ability to conduct a stratified analysis to evaluate potential differences by type of insurance coverage
- Health financing
- Medication access
(6) Factors linked to late diagnosis in breast cancer in sub-Saharan Africa: Case of Côte d’Ivoire M. Toure et al 2013 Ivory Coast Retrospective study Quantitative 42 (Median) - Female patients with breast adenocarcinoma 350 <  6–14 Months NA NA NA - Service delivery
- Health workforce
- Health Financing
(7) Financial barriers to utilization of screening and treatment services for breast cancer: an equity analysis in Nigeria Okoronkwo IL et al 2015 Nigeria Descriptive study Quantitative 34.69 (Mean) - women with breast cancer 270 NA NA NA - The respondents were recruited from one hospital only and therefore the study cannot be generalized - Health Financing
(8) From symptom discovery to treatment - women’s pathways to breast cancer care: a cross-sectional study Moodley J. et al 2018 South Africa Cross-sectional study Quantitative 54 - Women with breast cancer 201 28 days (median) 37 days (median) NA - Low recruitment of population targets due to logistic constraints
- The timing of interviews
could have resulted in difficulty in putting the journey into perspective if women were not emotionally prepared
- Interviews conducted in a hospital setting could have resulted in a social desirability bias with under-reporting of time delays
- Time intervals reported
are unlikely to be representative of intervals seen in public sector settings in SA without a tertiary centre based one-stop breast clinic
- Retrospective recall could have affected accurate reporting of symptoms and health seeking behaviours in this study
- Service delivery
(9) Prevalence and Factors Contributing to Late Diagnosis of Breast Cancer among Women Attending Tikur Anbessa Specialized Hospital. Oncology Unit, Addis Ababa, Ethiopia. 2017 Bedada T et al 2018 Ethiopia Cross-sectional study Quantitative 41.6 - Newly diagnosed and on-follow-up female breast cancer patient 215 NA NA NA NA - Service delivery
- Health workforce
(10) Educational Opportunities for Down-Staging Breast Cancer in Low-Income Countries: An Example from Tanzania Yang K et al 2019 Tanzania Cross- sectional study Quantitative 51.6 - Female breast cancer patients. 18 years of age and older. Newly
referred to Ocean Road Cancer Institute (ORCI) for treatment
196 NA NA NA - Possible recall bias
- The medical records did not contain information regarding the previous primary care visits that may have been made
- Service delivery
- Health workforce
(11) Time intervals experienced between first symptom recognition and pathologic diagnosis of breast cancer in Addis Ababa. Ethiopia: a cross-sectional study Gebremariam A. et al 2019 Ethiopia Cross-sectional study Quantitative 44.4 (Mean) - women newly diagnosed with breast cancer 441 2.3 (median) NA NA - The retrospective nature of collecting information about dates of symptom recognition and medical consultations is prone to recall bias
- The interviews were conducted in a hospital setting. Which could have resulted in a social desirability bias leading to under-reporting of time interval before medical consultation and over-reporting of desirable behaviours such as self-breast examination
- Service delivery
- Health workforce
(12) Impact of Primary Care Delay on Progression of Breast Cancer in a Black African Population: A Multicentered Survey Agodirin O. et al 2019 Nigeria Cross-sectional study Quantitative 48.35 (Mean) - Breast cancer patients 237 NA NA NA - Although measures were taken to reduce recall bias in the study design. This survey was still limited in that triangulation with the primary care records was impossible because of poor record keeping. - Service delivery
- Health workforce
(13) Inequities in Breast Cancer Treatment in sub-Saharan Africa: Findings from a Prospective Multi-Country Observational Study Foerster M. et al 2019 -Namibia
-Nigeria
-Uganda
Prospective Multi-Country Observational Study Quantitative 50.7 (Mean) - Women newly diagnosed with breast cancer 1335 NA NA NA - Difficult to disentangle whether untreated proportions were attributable to the country or the specific hospital setting in this specific country
- Breast cancer patients who do not reach this level of the health system. and may be more likely to go untreated were not included
- Service delivery
- Health financing
- Medication access and technologies
(14) Barriers to timely surgery and early surgical outcomes for breast cancer patients in a setting with limited resources F. Ntirenganya 2019 Rwanda Cross-sectional study Quantitative 48 (Median) Patients who underwent surgery for breast cancer 69 NA NA 3 months (Mean) -All patients received standard and adequate therapy according to their diagnosis and staging
-The study was conducted in 2 hospitals. With 2 different surgical teams. This can constitute a bias and influence the outcomes
- Service delivery
(15) Presentation Intervals and the Impact of Delay on Breast Cancer Progression in a Black African Population Agodirin O et al 2020 Nigeria multicentred survey Quantitative 50.6 (Mean) Female breast cancer patients who were newly diagnosed 420 NA NA NA -This Study was limited in that the primary outcome was patient-reported; hence it might be influenced by recall bias - Service delivery
- Health workforce
(16) Dissecting the journey to breast cancer diagnosis in sub-Saharan Africa: Findings from the multicountry
ABC-DO cohort study
Foerster M et al 2020 -Namibia
-Nigeria
-Uganda
-Zambia
Prospective multi-country observational study Quantitative 50.1 (Mean) women aged ≥18 years with histologically confirmed or suspected breast cancer 1429 NA NA NA -Weaknesses include the fact that participants were recruited in public
tertiary referral centres and. Thus. might be unrepresentative as not all breast cancer patients are referred to these hospitals or can reach them
-The self-reported length of the diagnostic journey might have been affected by between-woman variation in the ability to recognize symptoms across settings
- Health financing
- Health workforce
- Service delivery
(17) Social barriers to diagnosis and treatment of breast cancer in patients presenting at a teaching hospital in Ibadan, Nigeria Pruitt L et al 2014 Nigeria Qualitative study Qualitative 51 (Median) 31 women with a diagnosis of breast cancer
5 physicians
36 NA NA NA -This study did not capture the experiences of patients who never made it to tertiary care for breast cancer treatment
-The medical setting may also have reduced willingness to speak about complementary and alternative medicine for fear of being judged by their physicians or the belief that such an admission might affect their treatment
-Follow-up questions were limited by the use of a translator
- Service delivery
- Health workforce
- Health financing
- Medication access and technologies
(18) Breast Cancer Diagnosis and Factors Influencing Treatment Decisions in Ghana Aziato. L. and Clegg-Lamptey 2014 Ghana Qualitative descriptive Qualitative 31–60 years Women diagnosed with breast cancer who had undergone a single or bilateral mastectomy 12 NA NA NA NA - Health workforce
- Service delivery
(19) “My experience has been a terrible one. Something I could not run away from”: Zambian women’s experiences of advanced breast cancer ‘Johanna E. Maree
And J. Mulonda
2015 Zambia Qualitative descriptive Qualitative 48.2 (Mean) Women living with advanced breast cancer 10 NA NA NA -This was a qualitative study, and no other study reflects on the only true meaning of the narratives, as there could be more than one interpretation
-Women who were recruited received treatment at the same hospital
- Health workforce
(20) Understanding pathways to breast cancer diagnosis among women in the Western Cape Province. South Africa: a qualitative study Jennifer Moodley et al 2016 South Africa Qualitative Qualitative 52 (Mean) Patients with newly diagnosed breast cancer 20 3 Months (Average) NA NA -This study was conducted at one clinic in the Western Cape Province and this limits its generalizability
-Women who did not access tertiary healthcare were not included
- Health workforce
(21) A framework for improving early detection of breast cancer in sub-Saharan Africa: A qualitative study of help-seeking behaviors among Malawian women Kohler Racquel E. et al 2017 Malawi Qualitative Qualitative 47 (Median) Female breast cancer patients 20 NA NA NA -Many Malawian women with breast cancer may never reach a referral hospital (where patients were recruited)
-Some women initially experienced symptoms or were diagnosed a few years prior to being interviewed. Therefore, their recollection of events may not be as sharp
- Service delivery
- Health workforce
- Medication access and technologies
(22) Why Do Women with Breast Cancer Get Diagnosed and Treated Late in Sub-Saharan Africa? Perspectives from Women and Patients in Bamako. Mali Grosse Frie K et al 2018 Mali Qualitative study Qualitative 48 (Mean) 8 women with breast cancer
17 women without breast cancer
25 NA NA NA -Only a small number of women were analysed
-There might be further barriers. Particularly for women living
outside the capital city. Bamako
-Furthermore. experiences and
opinions of healthcare personnel and doctors should be researched. as they
might balance the views of patients and women
- Service delivery
- Health workforce
- Medication access
(23) Understanding the causes of breast cancer treatment delays at a teaching hospital in Ghana Sanuade OA et al 2018 Ghana Qualitative study Qualitative 40–49 (modal age range) Female breast cancer patients 20 NA NA <  1–3+ (Min-Max) - The main limitation of this study was that the number of participants included in the focus groups was very limited - Service delivery
- Health workforce
- Health financing
(24) Perceived Barriers to Early Detection of Breast Cancer in Wakiso District. Uganda Using a Socioecological Approach Ilaboya D et AL 2018 Uganda Qualitative study Qualitative NA -Woman who have experience in healthcare delivery or health research in relation to cancer care
-Community health workers
-Key informants
24 NA NA NA -This study involved only one sub-county; therefore, the results may not necessarily be generalizable - Governance/Leadership
- Service delivery
- Health workforce
(25) Fear of Mastectomy Associated with Delayed Breast Cancer Presentation Among Ghanaian Women Martei YM et al 2018 Ghana Qualitative Study Qualitative 47.12 (Mean) Women with a confirmed breast cancer diagnosis 31 NA NA NA - Purposive sampling
Only women seen at study site were interviewed
- Most of the women seen in the public sector are of lower socioeconomic status, therefore the information may not be generalizable
- Financial barriers to presentation and management could be even more significant than those reported in this study
- Health financing
- Medication access
(26) Identifying Barriers and Facilitators to Breast Cancer Early Detection and Subsequent Treatment Engagement in Kenya: A Qualitative Approach Robai Gakunka et al 2019 Kenya Qualitative Qualitative 30–60 years 6–11 women with breast cancer
6–11 women without breast cancer
2 Focus groups (6–11 per group) NA NA NA -Study was carried out in Nairobi and its environs where most of the cancer care services in Kenya are found and, Therefore, it may not be generalizable - Health financing
- Service delivery
- Health workforce
- Medication access
(27) Perspectives of patients, family members, and health care providers on late diagnosis of breast cancer in Ethiopia: A qualitative study Gebremariam A et al 2019 Ethiopia Qualitative study Qualitative study < 40 (Modal age range) 13 breast cancer patients
5 family members
5 health workers
23 NA NA NA Recall of past events with the foresight of experience may unconsciously make the stories of these women biased and inaccurate explanations of their experience - Service delivery
- Health workforce
- Health financing
- Medication access and technologies
(28) Perceived barriers to early diagnosis of breast Cancer in south and southwestern Ethiopia: a qualitative study Getachaw S et al 2020 Ethiopia Qualitative study Qualitative study 26–65 (Modal age range) 12 Breast cancer patients
13 care providers
25 NA NA NA This study used only in-depth interviews for data collection with a limited number of participants - Governance/Leadership
- Service delivery
- Health workforce
- Health financing
- Medication access and technologies
  1. NA* = Not Available