Introduction:

COVID-19-related disruptions around the globe severely impactedrnaccess to health services for noncommunicable diseases includingrncancer.1 This is true for both high-income countries HICs and to anrneven higher degree in low- and middle-income countries LMICs.1-7rnFrom the onset of the pandemic studies mostly in HICs have revealed increased COVID-19 morbidity and higher mortality in peoplernwith cancer8-10 who have poorer prognosis as a result of COVID-19rnand cancer comorbidity.58-10rnCancer is the third leading cause of mortality in Kenya an LMICrnwith 42 116 new cases and 27 092 deaths for the estimated population of 53.7 m.11 The next day after the first case was registered inrnKenya on March 12 202012 the country introduced strict pandemicrncontrol measures including public transport regulations and social distancing measures. On March 27 a nightly curfew was introducedrnnationwide restricting any movement at night. On April 6 all movement to and from the Nairobi metropolitan area was ceased for anrninitial period of 21 days.13 These restrictions have been lifted andrnre-introduced throughout 2020 and 202114-18 creating logisticalrnchallenges to triage patients in need of urgent care increasing thernimpact of existing barriers to care such as transportation and accessrnto medicines.rnTo date a number of COVID-19 and cancer surveys haverntargeted health care providers and health institutions globally1319rnand some have focused on surveying people with cancer that havernaccess and skills to complete online surveys4620 but to the best ofrnour knowledge no studies have focused on hard-to-reach patients inrnlow-resource settings with limited access to the internet or familiarityrnand adeptness with online surveys. To fill these gaps this articlernexamined the effects of COVID-19 disruptions on patients perceivedrnability to afford care delays in cancer care and access to pain reliefrnand other prescription medications.

Objectives:

Methodology:

Study designrnThis cross-sectional survey research study was conducted betweenrnDecember 2020 and February 2021 the survey tool is provided asrnthe Supporting Information. Data were collected using an anonymousrnsurvey of adult 18 cancer patients currently residing in Kenya.rn2.2 MeasuresrnThe survey questionnaire assessed community- and facility-levelrnbarriers to accessing cancer care that emerged or increased duernto the COVID-19 pandemic. The survey questionnaire wasrndesigned in English and translated into the Kiswahili languagernboth official languages of Kenya. Both versions of the surveyrnquestionnaire were reviewed by local sector experts and revisedrnin the light of their feedback. Additionally both versions werernalso pretested and revised accordingly. Tables 1 and 2 report outcome measures and covariates.rnTreatment delays were assessed through the question: Based onrnwhere you are in your cancer journey e.g. diagnosis treatment etc.rnhave you experienced any delays since the start of COVID-19rnResponse options included delays of a less than 1 monthrnb 1 month to 2 months c more than 2 months and d no delays.rnDuring the analysis responses were dichotomized as any delayrnoptions 1-3 vs no delay option 4.rnAccess to pain relief or other prescription medicines was assessedrnthrough the questions Since the start of COVID-19 pandemic havernyou had access to pain relief medicines and since the start ofrnCOVID-19 pandemic have you had access to other prescription medicines not pain relief like refills treatment for other symptomsrne.g. nausea vomiting Response options to both items were YesrnNo and Did not need. Did not need responses were excludedrnfrom the analyses.rnThe covariates used in our study were measured as follows. Thernsurvey asked participants: How in your opinion has COVID-19rnimpacted your cancer treatment and care journey The multi-answerrnresponses included I have limited access to hospitals e.g. hospitalsrnare seeing less patients changing appointments and my ability torntravel for treatment has been limited by curfews or county lockdowns. If a respondent checked the option it was coded as 1 otherwise 0 to create dichotomous variables.rnBesides demographics such as gender age education and treatment phase the county of patients residence was also assessed.rnGoogle Maps was used to estimate the travel time to Nairobi thernData collectionrnThe survey was administered using the following three methods: a arnself-administered online survey for respondents who could read andrnunderstand English and technologically felt comfortable completing anrnonline survey with recruitment from communication and socialrnnetworking platforms targeting cancer patients in Kenya b an enumerator assisted telephonic survey and c an enumerator-assistedrnin-person survey. For the last two methods participant recruitmentrnmaterials distributed by the Kenyatta National Hospital KNH andrnthe Kenyan Network of Cancer Organizations KENCO gave cancerrnpatients the option to contact trained survey enumerators who spokernboth English and Kiswahili languages to complete the survey viarnphone or in person.rn2.4 Statistical analysesrnStatistical analyses and data management were performed using IBMrnSPSS Statistics 24. Descriptive statistics were conducted. Stepwisernlogistic regression with forward selection was used to calculate oddsrnratios Nagelkerke R2rn P .05 cutoff with 95 confidence intervalsrnto determine which variables would go into the final model for thernthree outcomes. Multicollinearity was also examined all variancerninflation factors were 2 before making the final determination of thernvariables for the final models.

Findings:

Results:

ParticipantsrnOf the 314 survey participants 30 respondents did not meet inclusionrncriteria ie they did not complete the survey beyond demographicrnsection leaving 284 valid responses of adult cancer patients fromrn28 counties see Figure 1 for the breakdown of responses by county.rnSociodemographic characteristics of participants are shown inrnTable 1. Two-thirds 65 of the respondents were female. One-fifthrn21 of the participants were between 18 and 39 years of age nearlyrnhalf were between 40 and 59 years and 23 were 60 or older. Overrna third 36 of the survey participants had no education to completernprimary education 34 had some or complete secondary educationrnand 23 had some or complete higher education. Nearly half of thernsurvey participants 48 were in active cancer treatment 35 hadrncompleted the treatment and only 14 were in the diagnosis/rntreatment planning phase at the time of survey completion. A majorityrn84 of the participants had visited KNH in the course of their cancerrndiagnosis and/or treatment. The mean travel time to Nairobi from thernsurvey respondents county of residence was 2.47 2.73 hours. Thernmedian travel time was 2 hours with interquartile range of 4 hours.rn3.2 Economic impact of COVID-19 on peoplernwith cancerrnCOVID-19 has had devastating financial effects on people with cancerrnin Kenya as it significantly reduced household incomes and causedrnpatients to worry that they cannot afford the cancer treatments theyrnneed. Specifically 88 of the survey participants reported a decrease in their household income due to COVID-19. On top of this mostrnpatients reported the financial burden of treatment outside of thernclinical setting with 87 reporting that transportation to cancerrntreatment facility options became more expensive since the start ofrnCOVID-19 pandemic.rnThese results demonstrate the additional negative impact on people with cancer in low- and middle-income countries LMICs in comparison to high-income countries where survey results were alreadyrnalarming. For example in Australia 26 of respondents reported losing income and 29 indicated a worsening of financial concerns duernto COVID-19.21 In a US-based cancer patient survey 46 of respondents reported experiencing some loss of income and nearly 48rnwere worried about the potential loss of health insurance.6rnIn our study from Kenya the economic impact of COVID-19rnmanifested negatively in participants mental health. Overall 79 ofrnparticipants were worried that the financial impact of COVID-19 hadrnmade it harder for them to afford the cancer care they needed. Ofrnthose in the diagnosis or treatment planning phase 87 and of thosernin active treatment 89 reported being worried.rnA female in her 50s living with cancer summarized the financialrnimpact of COVID-19 in her response to an open-ended question:rnWe would sell tea for 35 Kenya shillings pre-COVID butrncurrently we sell at 6 shillings the same quantity. Thernmarket has been extremely disrupted by COVID 19. Thisrnloss of revenue has made it difficult to afford treatment.rnIn comparison a US-based study of cancer survivors found that onlyrn27 were worried the pandemic would make it harder to afford theirrncancer care.6 These data highlight the critical need to include vulnerable people with cancer and their caregivers in subsistence assistancernand subsidized insurance programs especially in LMICs.rn3.3 Delays in cancer carernAs shown in Table 2 42 of participants reported experiencing delaysrnin their cancer care journey since the start of COVID-19. As reportedrnin Table 3 longer travel time from Nairobi was associated with arnhigher likelihood of experiencing a delay in cancer care OR 1.20rn1.06-1.36. The importance of affordable and convenient transportation for access to care has been well established and reducing publicrntransportation options as pandemic control measures hurts patientsrnability to receive timely care.rnLack of access to hospitals due to lockdowns had a dramaticrneffect on the receipt of cancer treatment. Compared to those withrncontinued access to hospitals participants with limited access to hospitals had markedly higher odds of experiencing a delay in their cancerrncare OR 14.90 7.44-29.85. It is ever more important that the development of clear criteria for scheduling in-person cancer care and thernincreased use of innovative tools such as telemedicine22 during lockdowns along with the critical infrastructure should be prioritized inrnnational pandemic response strategies.rnCompared to those who had completed treatment the participants who were currently in the diagnosis or treatment planningrnphase had higher odds of experiencing delays in their cancer care OR 2.65 1.003-7.01. This is likely because patients in the diagnosisrnand treatment planning phase needed to visit health facilities morernfrequently but due to access challenges and lockdowns they mightrnhave been prohibited from doing so. Likewise those who had completed treatment require fewer visits to the hospital than those inrnactive treatment thus the impact of the delays may be less clinically significant. Age and gender were not associated with experiencingrndelays in cancer care in our participant population.rnCompared to those who had a college degree or better participants without college degree or lower had lower odds of experiencing delays in their cancer care OR 0.22 0.10-0.46. While thisrnfinding seems counter intuitive discussions with in-country partnersrnrevealed that patients with college or higher education were likelyrnmore empowered knowledgeable about infection risk and mayrnhave chosen to delay cancer care due to fear of being infected withrnCOVID-19.rnThis perspective is supported by a recent study in Ethiopia thatrnfound a significant association between education level and COVID19 risk perception.23rn3.4 Challenges in accessing pain relief andrnprescription medicinesrnAs shown in Table 2 52 of respondents reported not having accessrnto pain relief medicine and 50 reported not having access to otherrnprescription medicines such as refills and treatment for other symptoms eg nausea vomiting since the start of the COVID-19 pandemic. Compared to older participants aged 60 years and abovernyounger participants aged between 40 and 59 had lower odds ofrnhaving access to pain relief medicine OR 0.35 0.15-0.83 and accessrnto other prescription medicines OR 0.42 0.18-0.94. More research isrnneeded to identify the associations between age and access to medicines among people with cancer in Kenya.rnSimilar to the delays in care reduced ability to travel due to lockdowns and curfews also had a negative effect on access to pain reliefrnmedicine. Compared to those with the reduced ability to travel participants without such restrictions had twice the odds of having accessrnto pain relief medicine OR 2.01 1.09-3.69 and access to other prescription medicines OR 2.19 1.19-4.02. The importance of transportation has been well documented as an important determinant ofrnaccess to care.124 Lockdowns curfews or other movement restrictions should account for the needs of people with cancer in activerntreatment to adhere to their treatment plan in a timely manner and tornaccess medicines and pain relief both often necessary during thernactive cancer treatment phase.rnCompared to those who had already completed treatment participants who were currently in the active treatment had higher odds ofrnhaving access to pain relief medicine OR 2.14 1.11-4.13. Genderrnand travel time to Nairobi were not associated with access to painrnrelief and other prescription medicine which may suggest more localrnavailability of medicines without the need to travel to the cancerrntreatment center.rn3.5 LimitationsrnDespite the strengths of our study such as reaching patients whornmay be less likely to respond to an electronic-only survey and utilizingrnbilingual survey deployment our study had notable limitations including a cross-sectional design self-reported information and surveyrnitems not previously validated. The use of multiple modalities likelyrnintroduced biases such as social desirability of responses especiallyrnfor the in-person channel.rnWithout having access to exact participant addresses travel timesrnbased on the county center provided estimates that may be too conservative since not all patients live in county centers and are likely tornrequire even more time to get to the center before embarking onrntravel to Nairobi.rnGiven these limitations our results are not generalizable to otherrnpopulations but they provide a better understanding of the challengesrnfaced by hard to reach and not well-understood cancer patients

Conclusion:

Our results highlight that people with cancer in Kenya an LMICrnin East Africa are facing disproportionately strong downward pressure of the economic burden and logistical challenges accessing vitalrncancer care. The pandemic mitigation policies such as cash assistancerninter-county travel permits and so forth will be very helpful forrnpatients with cancer in these times.rnMore research is needed to examine the financial impact ofrnCOVID-19 on people with cancer and health care delivery institutionsrnand the importance of creative approaches to facilitating transportation for cancer patients.

Author(s):

Focus County(s):

Taita Taveta County

Programme Area(s):

Non-Communicable Diseases

Research Priority Area(s):

cancer (Breast, cervix, prostrate, throat, stomach, ovaries and skin)

Disease Domain(s):

COVID 19

Publication Date: 10.Dec.2021

Conference Title:

Venue: