Received: 31 March 2021 Revised: 17 August 2022 Accepted: 27 September 2022

DOI: 10.1111/ecc.13735

ORIGINAL ARTICLE

Perception about palliative care and factors influencing the

likelihood of palliative care service utilisation among adult
cancer patients in Ethiopia

Miheret Fikre Teklemariam 1 | Mesfin Addise 2 | Gashaye Asrat 2 |

Zenawi Hagos Gufue 3

1
Armauer Hansen Research Institute, Addis
Ababa, Ethiopia Abstract
2
Department of Reproductive Health and Purpose: This study aims to assess the perception about palliative care and factors
Health Service Management, School of Public
Health, College of Health Sciences, Addis
influencing the likelihood of palliative care service utilisation among adult cancer
Ababa University, Addis Ababa, Ethiopia patients in Tikur Anbessa Specialized Hospital, Ethiopia, 2019.
3
Department of Public Health, College of
Methods: A facility-based cross-sectional study was conducted among 304 systemati-
Medicine and Health Sciences, Adigrat
University, Adigrat, Ethiopia cally selected adult cancer patients receiving palliative care service in Tikur Anbessa
Specialized Hospital, Ethiopia. A multivariable binary logistic regression model was
Correspondence
Zenawi Hagos Gufue, Department of Public carried out to identify the independent factors associated with palliative care service
Health, College of Medicine and Health utilisation, and P-value < 0.05 was used to declare statistical significance.
Sciences, Adigrat University, Adigrat, Ethiopia.
Email: zenawi.2009@gmail.com Results: One hundred thirty (42.8%) adult cancer patients utilise the available pallia-
tive care service in the hospital, and those who earn monthly income ≥$52.35
Funding information
This research received no specific grant from (AOR = 2.36, 95% CI 1.37,4.06) and those who have family members of more than
any funding agency in the public, commercial
two (AOR = 2.28, 95% CI 1.02,5.13) were associated with higher utilisation, but
or not-for-profit sectors.
being a governmental employee and having formal schooling were the factors nega-
tively associated with palliative care service utilisation with (AOR = 0.42, 95% CI
0.20, 0.87) and (AOR = 0.51, 95% CI 0.23, 0.94), respectively.
Conclusions: A significant number of cancer patients were not utilising palliative care
services, and higher monthly income and having more than two family members were
the factors strongly associated with higher palliative care service utilisation.

KEYWORDS
adult cancer, Ethiopia, palliative care, service utilisation

1 | I N T RO DU CT I O N which also affects the quality of life of the patient by increasing psy-
chological distress and economic hardship (ACTION Study Group
Globally, there is a significant disparity in the availability, accessibility et al., 2015).
of cancer treatment options and patient survival (Fidler & Bray, 2018); According to the World Health Organisation (WHO) definition,
in sub-Saharan Africa, the cancer burden is underestimated due to palliative care is an approach that improves the quality of life (QoL) of
lack of appropriate diagnosis, poor access to care and absence/ patients and their families facing the problem associated with a life-
shortage of well-trained human resources and infrastructure threatening illness through the prevention and relief of suffering using
(Morhason-Bello et al., 2013). Expenses for cancer treatment are a early identification and impeccable assessment and treatment of pain
major cause of poverty; this is due to the financial catastrophe (>30% and other problems including physical, psychosocial and spiritual prob-
out-of-pocket healthcare expenditure) following treatment for cancer, lems (Worldwide Palliative Care Alliance & World Health

Eur J Cancer Care. 2022;31:e13735. wileyonlinelibrary.com/journal/ecc © 2022 John Wiley & Sons Ltd. 1 of 10
https://doi.org/10.1111/ecc.13735
2 of 10 TEKLEMARIAM ET AL.

Organization, 2014). The main aim of palliative care is to optimise the in Africa are diagnosed when they are terminally ill, and only 5% can
comfort, function and social support of patients and their families at receive any chemotherapy (Wairagala, 2010).
all stages of the disease (World Health Organization, 2020). In Ethiopia, cancer accounts for about 5.8% of the total national
Palliative care is a multidisciplinary approach that neither hastens mortality, and the annual incidence of cancer is around 60,960 cases
nor postpones death, but it can positively influence the course of the and the annual mortality is more than 44,000.(Federal Ministry of
illness if it is started early. Early palliative care not only improves the Health, Ethiopia. National Cancer Control Plan 2016-2020, 2015)
QoL of patients but also reduces unnecessary hospitalisations and the Cancer incidence in Ethiopia at present is estimated to be 150,000
use of healthcare services (World Health Organization, 2018; Zhi & cases per year, of which less than 1% receive specialist treatment.
Smith, 2015). Palliative care is required for a wide range of diseases Access to palliative radiotherapy or chemotherapy is a major problem
and cancer is the second most common chronic disease among adults because currently there are only two cobalt units (one is not func-
in need of palliative care, which accounts for 34% of adults following tional) and four practising oncologists to serve such a large population
cardiovascular diseases, which accounts for 38.5% (World Health (Woldeamanuel et al., 2013).
Organization, 2018; Worldwide Palliative Care Alliance & World In Ethiopia, the previous studies conducted were mainly focused
Health Organization, 2014). on cancer patients' knowledge and perceptions of palliative care
The global need for palliative care among cancer patients is increas- (Lakew et al., 2015; Reid et al., 2018). The palliative care service and
ing at a rapid pace due to the world's ageing population (World Health its associated factors are not yet determined in our set-up. The objec-
Organization, 2018) and due to the increasing burden of modifiable tive of this study was to assess the perception about palliative care
risk factors for cancer such as smoking, overweight, physical inactivity and factors influencing the likelihood of palliative care service utilisa-
and adoption of western lifestyle, globalisation, urbanisation and tion among adult cancer patients in Tikur Anbessa Specialized Hospi-
economic development (GBD 2015 Mortality and Causes of Death tal, Ethiopia.
Collaborators, 2016). However, there remains a huge unmet need for
palliative care for those with chronic life-limiting health problems, and
cancer palliative care services are very limited in most parts of the world, 2 | M A T E R I A L S A N D M ET H O D S
particularly in sub-Saharan African countries (Downing et al., 2018).
According to the GLOBOCAN (Global Cancer Observatory) 2020 2.1 | Study area and period
report, there were 19.3 million new cancer cases and 10 million can-
cer deaths globally (Sung et al., 2021). It is projected that an estimated The study was conducted in the cancer unit of Tikur Anbessa Special-
over 26 million people will have cancer and 17 million people will die ized Hospital, Ethiopia, which is the only tertiary referral hospital in
of cancer in the year 2030 (Thun et al., 2010). There is a significant the country with over 700 beds, whereby palliative care services and
global disparity in the provision of palliative care services for individ- treatment virtually exist. The hospital has 20 beds devoted to cancer
uals with life-limiting illnesses, each year of the 40 million people care, and there are three inpatient and two outpatient rooms in the
globally in need of palliative care and 20 million people at the end of oncology department; on average, 10 adult cancer patients receive
life; just 14% receive it, most of which are adults and children in high- palliative care service from the cancer unit of the hospital daily
income countries (World Health Organization, 2020). (Dagne et al., 2019).
Developing countries account for 80% of the global cancer bur- The cancer unit provides chemotherapy, radiation therapy, com-
den, and more than half of them are living in Africa, which has only plaint therapy and other supportive and palliative care services. It is
5% of available medical resources used to diagnose, treat and provide the main centre for cancer registry, early detection, prevention, stan-
comprehensive palliative care (Sung et al., 2021). According to the dard treatment and palliative care in Ethiopia. It also acts as a training
Worldwide Palliative Care Alliance (WPCA) report, there is zero avail- centre for highly skilled undergraduate and postgraduate medical stu-
ability of palliative care services in 42% of the world's countries. The dents, dentists, radiologists and other allied health science profes-
critical absence of palliative care services in low-resource settings sionals (Addis Ababa University, 2019). The study was conducted
results in significant costs being absorbed by the individual, family and from 1 January to 31 March 2019.
local community (Worldwide Palliative Care Alliance & World Health
Organization, 2014).
The factors associated with poor palliative care service utilisation 2.1.1 | Study design
among cancer patients in developing countries are complex, multi-
dimensional, layered and inadequately understood (De Lima & A facility-based cross-sectional study was conducted.
Pastrana, 2016). In Africa, 346,203 adults (69.3/100,000 populations)
need palliative care services for major non-communicable diseases
(NCDs) at the end of life. There is a large gap between the number of 2.1.2 | Populations
people in need of palliative care services and those who receive them
(World Health Organization, 2018; Worldwide Palliative Care Alli- Systematically selected adult cancer patients (aged ≥18 years) diag-
ance & World Health Organization, 2014). Most patients with cancer nosed with any type of cancer at least 6 months before the actual
TEKLEMARIAM ET AL. 3 of 10

data collection period in the cancer unit of the hospital were included formula. The respondents who score above the mean of the adjusted
in the study. Those newly diagnosed cancer patients, critically ill score were considered those who received palliative care service, and
patients and those who have known hearing problems and are cogni- those respondents who scored below the mean of the adjusted score
tively impaired to give consent were excluded from the study. were considered those who do not receive palliative care service.
Data were collected by face-to-face interviews in a quiet and
confidential room at the cancer unit of the hospital after patients have
2.2 | Sample size determination received their respective services by four-degree holder nurses and
supervised by one master's degree holder nurse who was not provid-
The sample size was determined by applying a single population pro- ing palliative care service on the cancer unit of the hospital, and the
portion formula using Epi Info Version 7.2.3.1 software (Center for data collectors were independent of the usual care, and training was
Disease Control and Prevention, 2019), with the assumptions of a given for the data collectors on the contents of the questionnaire and
95% level of confidence and a 5% margin of error. Accordingly, the how to approach the respondents for 2 days before the data collec-
sample size was determined for each specific objective, the first spe- tion period by the principal investigator.
cific objective (perception about palliative care service) provided the
largest sample size to detect a statistically significant difference, and
palliative care utilisation among adult cancer patients was 26% 2.5 | Study variables
(Worku et al., 2017); with these assumptions, the sample size was
296, and after adding 10% non-response rate, the final sample size 2.5.1 | Dependent variable
was 329.
Perception about palliative care service.

2.3 | Sampling technique

2.6 | Independent variables
Systematic random sampling technique was used to select the study
participants, and the registration log book of adult cancer patients 1. Socio-demographic characteristics: Has 10 items
was obtained from the cancer unit of the hospital; in 2018, there were 2. Knowledge factors: Has 6 items
a total of 28,814 adult cancer patients who came to receive chemo- 3. Financial factors: Has 5 items
therapy and radiotherapy services, and over the last quarter of the 4. Communication factors: Has 4 items
same fiscal year, 6354 adult cancer patients received chemotherapy 5. Health system factors: Has 8 items
and radiotherapy services. The sampling interval (K) was obtained by
dividing 6354 by 329, and it was (K = 19.3) so that every 20th adult
cancer patient coming to receive the routine service was recruited to 2.7 | Data processing and management
the study.
The collected data were coded and checked for consistency and com-
pleteness up to the end of each data collection period. Before the
2.4 | Data collection instrument and process analysis, the whole data were cleaned, and 20% of the data were
double-entered randomly to check for data entry errors, and Epi Info
A pretested structured interviewer-administered questionnaire was Version 7.2.3.1 software (Center for Disease Control and
used to collect the data. The questionnaire was derived from different Prevention, 2019) was used for data entry.
works of literature (Canadian Hospice Palliative Care
Association, 2013; Lakew et al., 2015; Reid et al., 2018; Sung
et al., 2021; Worku et al., 2017) and contains important variables, 2.8 | Data analysis
which were organised according to the objective of the study (See the
supplementary file). The interviewer-administered questionnaire was The entered data were exported to Statistical Package for the Social
prepared in English, then translated into the local language (Amharic) Sciences (SPSS) Version 25.0 for windows. Descriptive statistics were
and re-translated back to English by language experts to maintain its presented in medians with an interquartile range for numerical vari-
consistency. ables, and categorical variables were presented using frequency and
The responses were scored on a 5-point Likert scale, which was percentages. The chi-square test and logistic regression were com-
1 (strongly disagree), 2 (disagree), 3 (neutral), 4 (agree) and 5 (strongly puted to assess the statistical association.
agree). An equal number of positively and negatively worded ques- The bivariate analysis was done to check the existence of crude
tions were formulated; to determine the proportion of adult cancer association, and to select candidate variables, those variables that are
patients who utilised palliative care services, the five Likert scales clinically important and have P < 0.25 were included in the final model
were adjusted into a 0–100 scale by utilising a Likert transformation (David & Stanley, 2000). Confounding was checked, and the
4 of 10 TEKLEMARIAM ET AL.

T A B L E 1 Socio-demographic characteristics of adult cancer patients receiving palliative care service in Tikur Anbessa Specialized Hospital,
Ethiopia, 2019 (n = 304)

Patient profile Frequency Percent

Age, median (interquartile range), years 56 (44.5–62)
Age (years) <35 57 18.8
≥35 247 81.2
Gender Female 181 59.5
Male 123 40.5
Religion Orthodox 192 63.2
Muslim 80 26.3
Protestant 31 10.2
a
Others 1 0.3
Residence Rural 173 56.9
Urban 131 43.1
Educational status No formal schooling 147 48.4
Primary completed 39 12.8
Secondary completed 69 22.7
College/university completed 49 16.1
Ethnicity Amhara 110 36.2
Oromo 102 33.6
Tigray 29 9.5
Sidama 47 15.5
Wolayta 14 4.6
b
Others 2 0.6
Marital status Single 58 19.1
Married 191 62.8
Divorced 15 4.9
Widowed 40 13.2
Occupational status Housewife 86 28.3
Farmer 69 22.7
Self-employed/NGO 64 21.1
Government employee 44 14.5
Student 28 9.2
c
Others 13 4.2
Average family monthly income (in US dollar)d <17.45 18 5.9
17.45–52.35 78 25.7
52.35–87.25 94 30.9
>87.25 114 37.5
Family size 1–2 30 9.9
3–4 105 34.5
≥5 169 55.6

Abbreviation: NGO, non-governmental organisation.

a
Others = Catholic.
b
Others = Gurage and Afar.
c
Others = Daily labourer and pensioned.
d
According to the National Bank of Ethiopia, on average, one US dollar was exchanged as 28.6572 Ethiopian birrs during the data collection period from 1
January to 31 March 2019.
TEKLEMARIAM ET AL. 5 of 10

percentage change in the regression coefficients (β) less than 20% containing 5, 8, 6, and 4 Likert items, respectively, with the overall
reveals an absence of confounder. Interaction for the main effect Cronbach's alpha level of 0.75, indicating a very good internal consis-
model was also checked, and the partial likelihood ratio test result tency of the items. Concerning the financial factors, 235 (77.3%) of
with P-value > 0.05 and the variance inflation factor less than 10 indi- patients strongly agreed that patients are facing difficulty in obtaining
cated the non-existence of multicollinearity among the independent transportation when they travel to the hospital to receive palliative
variables. care services.
The multivariable binary logistic regression model was used to The total mean score of financial barrier items was 22.51, which
identify the independent factors associated with palliative care service ranges from 4.2 to 4.8, and a standard deviation of 0.49–0.92 as
utilisation. The summary measures of estimated crude (COR) and shown below (Table 2). Concerning the health system factors,
adjusted odds ratios (AOR) with a 95% confidence interval were pre- 174 (57.2%) of patients strongly agree that there is a delay during the
sented, and P-value less than 0.05 was used to declare statistical sig- transfer of patient data from the medical record room to the service
nificance, and the goodness of fit of the model was assessed by using provider room, and 214 (70.4%) of patients are forced to buy pre-
Hosmer and Lemeshow goodness-of-fit test. scribed medications outside due to stock-outs. A significant number
of patients agree that patients should be provided with recreation
facilities within the hospital premises while they are receiving pallia-
3 | RESULTS tive care services, and the total mean score of health system barrier
items was 29.16 as shown below (Table 3).
3.1 | Socio-demographic characteristics of patients Concerning knowledge factors that hinder patients not to utilise
palliative care services revealed that 97 (31.9%) of patients believe that
There were 304 adult cancer patients who participated in the study, palliative care should be started when medical and surgical methods of
with a response rate of 92.4%. The median age of the patients was treatment are ineffective. One hundred sixty-six patients (54.6%) of
56 years, with an interquartile range of 44.3–62 years. One hundred patients were not informed about their diagnosis and prognosis by
eighty-one (59.5%) of the patients were females, and 173 (56.9%) of their respective service providers. The total mean score of the items in
the patients were rural residents. Concerning the patient's family size, the knowledge factors was 15.1 as shown below (Table 4).
169 (55.6%) of them had more than five families, followed by those Concerning the communication factors that patients face, while
who had three to four family members, 105 (34.54%) (Table 1). they receive palliative care service, 142 (46.7%) of patients were not
provided clear appointments for their next visit. One hundred fifteen
(37.8%) patients or their respective caregiver does not receive clear
3.2 | Barriers to palliative care service utilisation and honest information about their condition and prognosis. The total
mean score of the items was 2.7 as shown below (Table 5). Palliative
In the Likert-scale data analysis, there were four domains (financial, care service was not utilised by 174 (57.2%) adult cancer patients, and
health system, knowledge and communication factors), each 130 (42.8%) of the patients utilised palliative care service.

T A B L E 2 Financial barriers faced by adult cancer patients receiving palliative care service in Tikur Anbessa Specialized Hospital, Ethiopia,
2019 (n = 304)

Strongly disagree Disagree Neutral Agree Strongly agree Mean/standard

Items Frequency (%) Frequency (%) Frequency (%) Frequency (%) Frequency (%) deviation
Patients are facing a financial 2(0.65) 2(0.65) 9(3) 93(30.6) 198(65.1) 4.6(0.65)
shortage for hospitalisation fee
Patients are facing a financial 1(0.3) 2(0.65) 2(0.65) 79(26) 220(72.4) 4.7(0.55)
loss for buying the prescribed
medications (opioid analgesics)
While travelling to the hospital 1(0.3) 1(0.3) 0(0) 67(22.1) 235(77.3) 4.8(0.49)
patients are having difficulty
obtaining transportation
Patients are forced to stop 20(6.6) 16(5.3) 1(0.3) 97(31.9) 170(55.9) 4.3(1.14)
palliative care services due to
the lack of family support
Families are forced to stop 134(44.1) 132(43.4) 12(3.9) 22(7.3) 4(1.3) 4.2(0.92)
palliative care services due to
the lack of financial support
from charities
Total mean score 22.51
6 of 10 TEKLEMARIAM ET AL.

T A B L E 3 Health system barriers faced by adult cancer patients receiving palliative care service in Tikur Anbessa Specialized Hospital,
Ethiopia, 2019 (n = 304)

Strongly disagree Disagree Neutral Agree Strongly agree Mean/standard

Items Frequency (%) Frequency (%) Frequency (%) Frequency (%) Frequency (%) deviation
The hospital has bureaucratic 3(1) 28(9.2) 11(3.6) 139(45.7) 123(40.5) 4.15 (0.94)
procedures for receiving care
Patients are forced to buy 6(2) 8(2.6) 4(1.3) 214(70.4) 72(23.7) 4.11 (0.72)
prescribed medications outside
due to stock-outs
Patients should be provided with 3(1) 11(3.6) 46(15.1) 216(71.1) 28(9.2) 3.84 (0.67)
recreation facilities within the
hospital premises
The service providers provide 1(0.3) 55(18.1) 51(16.8) 133(43.8) 64(21) 3.67 (1.01)
support for the patients/
caregivers during the visit
Palliative care can be delivered 3(1) 57(18.8) 50(16.4) 124(40.8) 70(23) 3.76 (1.06)
concurrently with curative
cancer treatments
Palliative care represents a 67(22) 94(30.9) 61(20.1) 78(25.7) 4(1.3) 2.53 (1.13)
distinct phase in cancer
treatment
The service providers give 22(7.2) 139(45.7) 31(10.2) 82(27) 30(9.9) 2.87 (1.18)
enough time and attention to
their patients
There is a delay during the 6(2) 28(9.2) 2(0.7) 94(30.9) 174(57.2) 4.32 (1.01)
transfer of patient data from
the medical record room to the
service provider room
Total mean score 29.16

T A B L E 4 Knowledge barriers faced by adult cancer patients receiving palliative care service in Tikur Anbessa Specialized Hospital, Ethiopia,
2019 (n = 304)

Strongly disagree Disagree Neutral Agree Strongly agree Mean/standard

Items Frequency (%) Frequency (%) Frequency (%) Frequency (%) Frequency (%) deviation
Palliative care is essentially the 61(20.1) 84(27.6) 31(10.2) 126(41.4) 2(0.7) 2.75 (1.2)
care for terminally ill patients
Palliative care is all about pain 43(14.1) 49(16.1) 16(5.3) 184(60.5) 12(4) 3.24 (1.2)
management
Palliative care is a service only 59(19.4) 83(27.3) 24(7.9) 130(42.8) 8(2.6) 2.88 (1.7)
for patients with cancer
Palliative care should be started 63(20.7) 89(29.3) 53(17.4) 97(31.9) 2(0.7) 2.63 (1.2)
when medical and surgical
methods of treatment are
ineffective
Physicians routinely inform 112(36.8) 166(54.6) 6(2) 11(3.6) 9(3) 1.81(0.9)
patients about their diagnosis
and prognosis
Physicians discuss end-of-life 0 (0) 11(3.6) 13(4.3) 164(53.9) 116(38.2) 1.73(0.7)
issues with their patients
Total mean score 15.1
TEKLEMARIAM ET AL. 7 of 10

T A B L E 5 Communication barriers faced by adult cancer patients receiving palliative care service in Tikur Anbessa Specialized Hospital,
Ethiopia, 2019 (n = 304)

Strongly disagree Disagree Neutral Agree Strongly agree Mean/standard

Items Frequency (%) Frequency (%) Frequency (%) Frequency (%) Frequency (%) deviation
The service providers give clear 67(22) 142(46.72) 29(9.54) 60(19.74) 6(2) 2.33(1.1)
appointments on the next visit
There are agreements between 3(1) 56(18.4) 40(13.2) 142(46.7) 63(20.7) 2.32(1.1)
patients and service providers
when discussing their patient
needs
Patients/respective caregivers 53(17.4) 48(15.8) 13(4.3) 115(37.8) 75(24.7) 3.37(1.4)
receive clear and honest
information about their
condition and prognosis
There are language factors 45(14.8) 94(30.9) 84(27.6) 75(24.7) 6(2) 2.68(1.1)
between service providers and
patients/caregivers
Total mean score 2.7

T A B L E 6 Bivariate and multivariable binary logistic regression model for determining factors associated with palliative care service utilisation
among adult cancer patients in Tikur Anbessa Specialized Hospital, Ethiopia, 2019 (n = 304)

Palliative care service utilisation

Characteristics Yes (n = 130) No (n = 174) COR P-value AOR (95% CI) P-value
Age (years) <35 30(9.9) 27(8.9) Reference group
≥35 100(32.9) 147(48.3) 1.63 0.10 0.87(0.37,2.10) 0.76
Gender Female 78(25.7) 103(33.9) Reference group
Male 52(17) 71(23.4) 1.03 0.89
Residence Rural 75(24.7) 98(32.2) Reference group
Urban 55(18.1) 76(25) 1.10 0.81
Educational status No formal schooling 52(17) 95(31.3) Reference group
Formal schooling 78(25.7) 79(26) 0.55 0.01 0.51(0.23,0.94) 0.03*
Marital status Single 34(11.2) 24(7.9) Reference group
Married 96(31.6) 150(49.3) 2.21 0.01 2.14(0.88,5.23) 0.10
Occupational status Non-government 26(8.6) 18(5.9) Reference group
Government employed 104(34.2) 156(51.3) 0.46 0.02 0.42(0.20,0.87) 0.02*
Family size ≤2 18(5.9) 12(4) Reference group
≥3 112(36.8) 162(53.3) 2.17 0.05 2.28(1.02,5.13) 0.04*
Monthly income (in US dollars) <52.35 50(16.4) 46(15.1) Reference group
≥52.35 80(26.3) 128(42.2) 1.74 0.03 2.36(1.37,4.06) 0.002*

Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio; Reference group (those least to utilise palliative care service were
considered as a reference group).
*Variables were significant at P < 0.05.

3.3 | Factors associated with palliative care service counterparts who earn a monthly income of fewer than $ 52.35
utilisation (AOR = 2.36, 95% CI 1.37,4.06).
Similarly, those patients who had more than two family members
According to the final multivariable binary logistic regression model, were 2.28 times more likely to utilise palliative care services
patients who earn more than $ 52.35 monthly income were 2.36 as compared to their counterparts who had less than or equal to two
times more likely to utilise palliative care services as compared to their family members (AOR = 2.28, 95% CI 1.02, 5.13). The chance
8 of 10 TEKLEMARIAM ET AL.

of utilising palliative care services among government employers was that married patients were found to utilise more than single patients.
58% less likely than their counterpart non-government employers In contrast to these studies, a study conducted in Addis Ababa found
(AOR = 0.42, 95% CI 0.20, 0.87). The odds of utilising palliative that single patients were more likely to utilise palliative care services
care services among individuals who had formal schooling were (Lakew et al., 2015). This can be explained by single patients who
49% less likely than their counterparts who had no formal schooling want to be relatively healthy for the next marriage and want to live a
(AOR = 0.51, 95% CI 0.23,0.94) (Table 6). quality life as compared to those who are already married.
Adult cancer patients who have more than three family members
are almost three times more likely to utilise palliative care services as
4 | DISCUSSIONS compared to those who have less than three family members. In
agreement with our study, a study conducted in Addis Ababa (Lakew
Palliative care is a poorly addressed public health problem with scarce et al., 2015) found that adult cancer patients who have more family
data on the factors associated with service utilisation. This study tried members were almost two times more likely to utilise palliative care
to assess the perception about palliative care and factors influencing services as compared to those who do not have any family support or
the likelihood of palliative care service utilisation among adult cancer social services. This could be due to the involvement of the family
patients receiving palliative care services in Tikur Anbessa Specialized members in the provision of social, economic and moral support given
Hospital and found that 42.8% of adult cancer patients utilised pallia- to their family members.
tive care services. Among those who utilised palliative care services, In contrast to our study, a study conducted in Australia found that
the majority of them have more than three family members and earn those living alone are more likely to receive palliative care services
more than $52.35 monthly income. (Aoun et al., 2007). This can be explained by the complete allocation
In contrast to this, a study conducted in the same study area of their income for palliative care services since they do not have any
found that only 26% (Worku et al., 2017) adult cancer patients extra expenses to be used by other family members. Adult cancer
received the service; this could be due to the improvement of pallia- patients who earn more than $52.35 monthly income were almost
tive care service over time. Palliative care service utilisation in the three times more likely to utilise palliative care services as compared
United States is more than 90% (Walker et al., 2017), whereas in to their counterparts who earn a monthly income of fewer than
Europe it ranges from 50% to 65% of adult cancer patients receiving $52.35.
palliative care services from their general practitioners, whereas 29%– In line with our study, a study conducted in Canada (Wales
47% of patients received specialist palliative care services (Pivodic et al., 2018) and Texas (Taylor et al., 2019) found that higher socio-
et al., 2013). This could be due to the differences in the accessibility, economic status was associated with a higher likelihood of palliative
affordability and socio-economic status of the countries. care service utilisation; this helps the patient to have better health
A survey of hospice and palliative care services conducted in and healthcare understanding, a higher capacity for advocacy, a more
Africa found that only 9% (African Palliative Care Association, 2019) stable home environment and more caregiver support. Similarly, a
of cancer patients were receiving the necessary palliative care service; study conducted in Addis Abba found that almost 30% (Worku
this shows that there is a significant unmet palliative care need. In our et al., 2017) patients face a higher cost of palliative care service, and
study, older cancer patients were 13% less likely to utilise palliative around half of the patients were not able to access the service. Simi-
care services as compared to younger cancer patients, but this was larly, a study conducted in Addis Ababa and Jimma found that opioid
not statistically significant. Even though male cancer patients are more analgesics were non-prescribed for 24% of patients and 64% of the
likely to utilise palliative care services as compared to female patients, patients reported having sold their homes and other significant
this was not found to be a statistically significant difference. sources of wealth to pay for medical care (Reid et al., 2018).
In contrast, a study conducted in Denmark found that female can-
cer patients were almost three times more likely to utilise palliative
care services as compared to male cancer patients (Benthien 4.1 | Strength and limitations of the study
et al., 2016). This can be explained by differences in the socio-
economic status of patients and sample size. Despite being statisti- This is the first study in Ethiopia that tried to address the financial,
cally non-significant, urban residents were 45% more likely to utilise health system, knowledge and communication factors that are associ-
palliative care services than their counterpart rural residents. Those ated with palliative care service utilisation from the patient side using
adult cancer patients who have formal schooling were 49% less likely a standard method of data collection and standard models of identify-
to utilise palliative care services as compared to those who have no ing factors for palliative care service.
formal schooling. This might be due to the difference in the propor- The study is not without limitations. First, the study does not
tion of the patients; the majority of them had formal schooling. measure service utilisation, and it was measured by considering the
Those married adult cancer patients were two times more likely perception of the respondents on the factors related to the financial,
to utilise palliative care services as compared to those who are single, health system, knowledge and communication so that the outcome is
even though it was not a statistically significant difference. In line with simply a proxy indicator for use of palliative care, not actual service
our study, a study conducted in Sudan (Awadalla et al., 2007) found use. Second, it would have been better if it includes supplementary
TEKLEMARIAM ET AL. 9 of 10

qualitative aspects from the service provider side so that the factors Southeast Asia: Results from a longitudinal study in eight countries.
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