Multi-level determinants of comprehensive palliative care delivery for breast and cervical cancer patients in Ethiopia: using the socio-ecological model as an analytical framework

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INTRODUCTION: Comprehensive palliative care is essential for improving the quality of life of women with breast and cervical cancer in Ethiopia, yet services remain poorly organized, largely inaccessible, and concentrated in the capital. While existing studies have quantified service gaps, the multi-level determinants enabling or hindering comprehensive care remain under-explored, particularly how these factors differ between urban and rural settings. OBJECTIVE: To explore the multi-level determinants of implementing comprehensive palliative care for women with breast and cervical cancer in Ethiopia. METHODS: An exploratory qualitative study was conducted from January to March 2025 in urban Addis Ababa and Sidama. Using purposive sampling with maximum variation, ninety-three participants including 37 women with breast or cervical cancer, 20 caregivers, and 36 key informants were recruited. Data were collected through open ended interview guides, transcribed verbatim, and analyzed using framework analysis guided by the Socio-Ecological Model. The analysis focused on identifying determinants at individual, interpersonal, community, organizational, and policy levels. ATLAS. ti V.09 was used to analyze the data. FINDINGS: Determinants of comprehensive palliative care access and quality emerged across five socio-ecological levels, with urban-rural variations. At the individual level, determinants included personal health literacy, assets, and financial resources. Patient resilience and health literacy enabled care, but outweighed by catastrophic out-of-pocket costs and misconceptions of cancer as a curse more pronounced in Sidama. At the interpersonal level, social support and family dynamics were critical. Supportive families enabled care, while family stigma and partner abandonment were major barriers with stigma more intense in Sidama. At the community level, social capital, community networks, and traditional structures served as determinants. Survivor-led groups, edirs, and religious leaders enabled support, yet their impact was constrained by resource deficits. Sidama relied on informal support. Cervical cancer patients experienced stigma rooted in sexually transmitted infection leading to social exclusion, whereas breast cancer patients' stigma was linked to fears of contagion and visible disfigurement. At the organizational level, access to healthcare services, resource allocation, and organizational culture were dominant determinants. Specialized cancer centers and community based health insurance enabled access, but systemic undervaluation of comprehensive palliative care, opioid shortages, lack of trained staff, and broken referral systems were barriers, worse in Sidama. At the policy level, governance, regulations, and health system financing were the overarching determinants. A national guideline exists but lacks rural implementation guidance, and is undermined by restrictive opioid regulations and absence of palliative care in professional curricula. CONCLUSION: Determinants of comprehensive palliative care exist across all levels but are systematically undermined by organizational and policy barriers. Community-based organizations and traditional structures show promise but require sustainable funding. Policy reform, opioid access liberalization, curriculum integration, and decentralized community-based service models are needed to ensure equitable, and comprehensive palliative care.

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