Rectal bleeding and implications for surgical care in Nepal

Psychosocial influences on help-seeking behaviour for cancer in low-income and lower middle-income countries: a mixed-methods systematic review

Introduction

Starting cancer treatment early can improve outcomes. Psychosocial factors influencing patients’ medical help-seeking decisions may be particularly important in low and lower middle-income countries (LMIC) where cancer outcomes are poor. Comprehensive review evidence is needed to understand the psychosocial influences on medical help-seeking for cancer symptoms, attendance for diagnosis and starting cancer treatment.

Methods

Mixed-methods systematic review registered on PROSPERO (CRD42018099057). Peer-reviewed databases were searched until April 2020 for studies assessing patient-related barriers and facilitators to medical help-seeking for cancer symptoms, diagnosis and treatment in adults (18+ years) living in LMICs. Quality of included studies was assessed using the Critical Appraisal Skills Programme tool. Data were synthesised using meta-analytic techniques, meta-ethnography or narrative synthesis as appropriate.

Results

Of 3963 studies identified, 64 were included. In quantitative studies, use of traditional, complementary and alternative medicine (TCAM) was associated with 3.60 higher odds of prolonged medical help-seeking (95% CI 2.06 to 5.14). Qualitative studies suggested that use of TCAM was a key barrier to medical help-seeking in LMICs, and was influenced by causal beliefs, cultural norms and a preference to avoid biomedical treatment. Women face particular barriers, such as needing family permission for help-seeking, and higher stigma for cancer treatment. Additional psychosocial barriers included: shame and stigma associated with cancer such as fear of social rejection (eg, divorce/disownment); limited knowledge of cancer and associated symptoms; and financial and access barriers associated with travel and appointments.

Conclusion

Due to variable quality of studies, future evaluations would benefit from using validated measures and robust study designs. The use of TCAM and gender influences appear to be important barriers to help-seeking in LMIC. Cancer awareness campaigns developed with LMIC communities need to address cultural influences on medical help-seeking behaviour.

Directions for surgical capacity developments in Nepal: a population-based assessment

Objectives

Lack of access to safe surgery is seen as a major issue that needs to be addressed. The aim of this study was to understand which combinations of factors relate to high occurrences of unmet needs and disability in Nepal, and consequently, how to focus future work to maximise impact in this country.

Methods

A large population‐based survey was conducted in Nepal in 2014 to evaluate the unmet surgical needs that result in disability. Recorded factors included diseased anatomical areas, disease specifics, disease locations, injury types, reasons for having an unmet need and the types of disability.

Results

Included in the study were 2695 individuals. The anatomical areas facing the highest disabling unmet surgical need were Head (3.9% of population), Groin/Genitalia (2.2% of population) and Extremities (3.6% of population). Four focus areas could be defined. Increase affordability, availability and acceptability of surgical care to non‐traumatic disabling conditions of (i) the eye, and (ii) extremities, and (iii) to traumatic disabling conditions of extremities and finally (iv) increase acceptability of having surgical care for non‐traumatic conditions in the groin and genital area. For the latter, fear/no trust was the main reason for receiving no surgical care despite the resulting shame.

Conclusions

This study defined four focus areas that showed the largest unmet needs that resulted in a perceived disability. For those areas, affordability, availability and acceptability of surgical need to be addressed through technical developments, capacity building and raising awareness.