Introduction: Cancer is a chronic debilitating disease that unnerves patients,
communities, and nations. At some point in cancer patient’s disease experience,
chemotherapy is used, and the patient is expected to adhere to treatment to
improve survival and quality of life. Methods: This multisite Cluster
Randomized Trial (CRT) evaluated the effectiveness of mobile phone Short
Message Service (SMS) support on the adherence to treatment schedules among
adult cancer patients in Kenya. Data was collected using questionnaires.
Ethical approvals were obtained from relevant Ethical Review Boards (ERBs). Results: The mean adherence was 83%. There was a significant difference between
treatment arms in relation to the adherence. The intervention arm had a higher
mean adherence difference, M = 3.913, 95% CI 2.632-5.193, t (402) = 6.006, p ≤0.001),
with Cohen’s d = 0.60. Although not significant, (χ2dd = 0.151, df = 1, p = 2.064), more women were
perfect adheres than males. Perfect adherers were satisfied with SMS support (χ2dd = 7.620, df = 1, p = 0.06),
were in the intervention arm (χ2dd
= 22.942, df = 1, p ≤0.001),
and had trust in the care provider (χ2dd
= 10.591 p ≤0.001).
SMS support was not significant in the multivariate analysis but had an
estimated effect size of 0.958 (z = 1.424, p = 0.154, CI = 0.242-3.781), indicating that mean adherence was slightly better in the presence of
the intervention. Conclusions:SMS-support
intervention has demonstrated superiority in influencing adherence. Further,
health system-related factors have a significant influence on the adherence to
chemotherapy treatment. Interventions to re-design health systems that
are responsive to unmet care needs of cancer patients must be explored.
References
[1]
Mohan, H. (2013) Textbook of Pathology. Jaypee Brothers Medical Publishers, New Delhi.
[2]
Wang, H., Naghavi, M., Allen, C., Barber, R. M., Bhutta, Z.A., Carter, A., Casey, D.C., Charlson, F.J., Chen, A.Z., Coates, M.M., Coggeshall, M., Dandona, L., Dicker, D.J., Erskine, H.E., Ferrari, A.J., Fitzmaurice, C., Foreman, K., Forouzanfar, M.H., Fraser, M.S., Murray, C.J.L., et al. (2016) Global, Regional, and National Life Expectancy, All-Cause Mortality, and Cause-Specific Mortality for 249 Causes of Death, 1980-2015: A Systematic Analysis for the Global Burden of Disease Study 2015. The Lancet, 388, 1459-1544. https://doi.org/10.1016/S0140-6736(16)31012-1
[3]
Bray, F., Ferlay, J., Soerjomataram, I., Siegel, R.L., Torre, L.A. and Jemal, A. (2018) Global Cancer Statistics 2018: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians, 68, 394-424. https://doi.org/10.3322/caac.21492
[4]
Bray, F. (2014) Transitions in Human Development and the Global Cancer Burden. World Cancer Report, 54-68.
[5]
Stewart, B.W. and Wild, C.P. (2014) World Cancer Report 2014. International Agency for Research on Cancer/World Health Organization, Lyon.
[6]
Sung, H., Ferlay, J., Siegel, R.L., Laversanne, M., Soerjomataram, I., Jemal, A. and Bray, F. (2021) Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians, 71, 209-249. https://doi.org/10.3322/caac.21660.
[7]
Ministry of Health (Kenya) (2013) National Palliative Care Guidelines. Nairobi.
[8]
Yarbro, C.H., Wujcik, D. and Gobel, B.H. (2014) Cancer Symptom Management. 4th Edition, Jones & Bartlett Learning, Burlington.
[9]
Xu, Z., Mohile, S.G., Tejani, M.A., Becerra, A.Z., Probst, C.P., Aquina, C.T., Hensley, B.J., Arsalanizadeh, R., Noyes, K. and Monson, J.R., et al. (2017) Poor Compliance with Adjuvant Chemotherapy Use Associated with Poorer Survival in Patients with Rectal Cancer: An NCDB Analysis. Cancer, 123, 52-61. https://doi.org/10.1002/cncr.30261
[10]
Abrams, R.A., Winter, K.A., Regine, W.F., Safran, H., Hoffman, J.P., Lustig, R., Konski, A.A., Benson, A.B., Macdonald, J.S., Rich, T.A. and Willett, C.G. (2012) Failure to Adhere to Protocol Specified Radiation Therapy Guidelines Was Associated with Decreased Survival in RTOG 9704—A Phase III Trial of Adjuvant Chemotherapy and Chemoradiotherapy for Patients with Resected Adenocarcinoma of the Pancreas. International Journal of Radiation Oncology, Biology, Physics, 82, 809-816. https://doi.org/10.1016/j.ijrobp.2010.11.039
[11]
Pathy, S., Roy, S., Malik, P.S., Mohanti, B.K. and Raina, V (2016) Treatment Compliance and Outcome in Geriatric Patients with Locally Advanced Non-Small Cell Lung Cancer: Experience from India. International Journal of Cancer Management, 9, Article e5481. https://doi.org/10.17795/ijcp-5481
[12]
Sabaté, E., Ed. (2003) Adherence to Long-Term Therapies: Evidence for Action. World Health Organization, Switzerland.
[13]
Horne, R., Cooper, V., Wileman, V. and Chan, A. (2019) Supporting Adherence to Medicines for Long-Term Conditions: A Perceptions and Practicalities Approach Based on an Extended Common-Sense Model. European Psychologist, 24, 82-96. https://doi.org/10.1027/1016-9040/a000353
[14]
Tokdemir, G. and Kav, S. (2017) The Effect of Structured Education to Patients Receiving Oral Agents for Cancer Treatment on Medication Adherence and Self-Effi-cacy. Asia-Pacific Journal of Oncology Nursing, 4, 290-298. https://doi.org/10.4103/apjon.apjon_35_17
[15]
DiMatteo, M.R. (2004) Social Support and Patient Adherence to Medical Treatment: A Meta-Analysis. Health Psychology, 23, 207-218. https://doi.org/10.1037/0278-6133.23.2.207
[16]
DiMatteo, M.R., Giordani, P.J., Lepper, H.S. and Croghan, T.W. (2002) Patient Adherence and Medical Treatment Outcomes—A Meta-Analysis. Medical Care, 40, 794-811. https://doi.org/10.1097/00005650-200209000-00009
[17]
Lester, R.T., Ritvo, P., Mills, E.J., Kariri, A., Karanja, S., Chung, M.H., Jack, W., Habyarimana, J., Sadatsafavi, M., Najafzadeh, M., Marra, C.A., Estambale, B., Ngugi, E., Ball, T.B., Thabane, L., Gelmon, L.J., Kimani, J., Ackers, M. and Plummer, F.A. (2010) Effects of a Mobile Phone Short Message Service on Antiretroviral Treatment Adherence in Kenya (WelTel Kenya1): A Randomised Trial. The Lancet, 376, 1838-1845. https://doi.org/10.1016/S0140-6736(10)61997-6
[18]
Shrestha, R., Maviglia, F., Altice, F.L., DiDomizio, E., Khati, A., Mistler, C., Azwa, I., Kamarulzaman, A., Halim, M.A.A. and Wickersham, J.A. (2022) Mobile Health Technology Use and the Acceptability of an mHealth Platform for HIV Prevention among Men Who Have Sex with Men in Malaysia: Cross-Sectional Respondent-Driven Sampling Survey. Journal of Medical Internet Research, 24, Article e36917. https://doi.org/10.2196/36917
[19]
American Society of Clinical Oncology (2019) American Society of Clinical Oncology: ASCO. https://www.asco.org/
[20]
Andrade, S.E., Kahler, K.H., Frech, F. and Chan, K.A. (2006) Methods for Evaluation of Medication Adherence and Persistence Using Automated Databases. Pharmacoepidemiology and Drug Safety, 15, 565-574. https://doi.org/10.1002/pds.1230
[21]
Seal, B., Asche, C., Shermock, K., Anderson, S. and Cameron, J. (2013) Adherence rates for Intravenous Chemotherapy Regimens to Treat Colon Cancer. Value in Health, 16, A418. https://doi.org/10.1016/j.jval.2013.08.548
[22]
Seal, B.S., Anderson, S. and Shermock, K.M. (2016) Factors Associated with Adherence Rates for Oral and Intravenous Anticancer Therapy in Commercially Insured Patients with Metastatic Colon Cancer. Journal of Managed Care & Specialty Pharmacy, 22, 227-235. https://doi.org/10.18553/jmcp.2016.22.3.227
[23]
King, C.R. and Hinds, P.S., Eds. (2003) Quality of life: From Nursing and Patient Perspectives: Theory, Research, Practice. 2nd Edition, Jones and Bartlett Publishers, Burlington.
[24]
Charlson, M.E., Pompei, P., Ales, K.L. and MacKenzie, C.R. (1987) A New Method of Classifying Prognostic Comorbidity in Longitudinal Studies: Development and Validation. Journal of Chronic Diseases, 40, 373-383. https://doi.org/10.1016/0021-9681(87)90171-8
[25]
McCorkle, R. and Young, K. (1978) Development of a Symptom Distress Scale. Cancer Nursing, 1, 373-378. https://doi.org/10.1097/00002820-197810000-00003
[26]
Eldridge, S. and Kerry, S. (2012) A Practical Guide to Cluster Randomised Trials in Health Services Research. John Wiley & Sons, Hoboken. https://doi.org/10.1002/9781119966241
[27]
Thompson, J.A., Leyrat, C., Fielding, K.L. and Hayes, R.J. (2022) Cluster Randomised Trials with a Binary Outcome and a Small Number of Clusters: Comparison of Individual and Cluster Level Analysis Method. BMC Medical Research Methodology, 22, Article No. 222. https://doi.org/10.1186/s12874-022-01699-2
[28]
Haberer, J.E., Bukusi, E.A., Mugo, N.R., Pyra, M., Kiptinness, C., Oware, K., Garrison, L.E., Thomas, K.K., Musinguzi, N., Morrison, S., Anderson, P.L., Ngure, K., Baeten, J.M., Haberer, J.E., Baeten, J.M., Bukusi, E.A., Mugo, N., Ngure, K., Barnabas, R., Morrison, S., et al. (2021) Effect of SMS Reminders on PrEP Adherence in Young Kenyan Women (MPYA Study): A Randomised Controlled Trial. The Lancet HIV, 8, E130-E137. https://doi.org/10.1016/S2352-3018(20)30307-6
[29]
Talisuna, A.O., Oburu, A., Githinji, S., Malinga, J., Amboko, B., Bejon, P., Jones, C., Snow, R.W. and Zurovac, D. (2017) Efficacy of Text-Message Reminders on Paediatric Malaria Treatment Adherence and Their Post-Treatment Return to Health Facilities in Kenya: A Randomized Controlled Trial. Malaria Journal, 16, Article No. 46. https://doi.org/10.1186/s12936-017-1702-6
[30]
Wanyoro, A.K. and Kabiru, E.W. (2017) Use of Mobile Phone Short Text Message Service to Enhance Cervical Cancer Screening at Thika Level 5 Hospital, Kiambu County, Kenya: A Randomised Controlled Trial. Research in Obstetrics and Gynecology, 5, 10-20.
[31]
Winkeljohn, D. (2010) Adherence to Oral Cancer Therapies: Nursing Interventions. Clinical Journal of Oncology Nursing, 14, 461-466. https://doi.org/10.1188/10.CJON.461-466
[32]
Kannisto, K.A., Koivunen, M.H. and Välimäki, M.A. (2014) Use of Mobile Phone Text Message Reminders in Health Care Services: A Narrative Literature Review. Journal of Medical Internet Research, 16, Article e222. https://doi.org/10.2196/jmir.3442
[33]
Pena-Robichaux, V., Kvedar, J.C. and Watson, A.J. (2010) Text Messages as a Reminder Aid and Educational Tool in Adults and Adolescents with Atopic Dermatitis: A Pilot Study. Dermatology Research and Practice, 2010, Article ID: 894258. https://doi.org/10.1155/2010/894258
[34]
Costas-Muniz, R., Leng, J., Aragones, A., Ramirez, J., Roberts, N., Mujawar, M.I. and Gany, F. (2016) Association of Socioeconomic and Practical Unmet Needs with Self-Reported Nonadherence to Cancer Treatment Appointments in Low-Income Latino and Black Cancer Patients. Ethnicity & Health, 21, 118-128. https://doi.org/10.1080/13557858.2015.1034658
[35]
Gunasekaran, G.H., Hassali, M.A.B.A., Sabri, W.M.A.B.W. and Rahman, M.T.B. (2020) Impact of Chemotherapy Schedule Modification on Breast Cancer Patients: A Single-Centre Retrospective Study. International Journal of Clinical Pharmacy, 42, 642-651. https://doi.org/10.1007/s11096-020-01011-6
[36]
Hadji, P., Blettner, M., Harbeck, N., Jackisch, C., Lück, H.-J., Windemuth-Kieselbach, C., Zaun, S. and Kreienberg, R. (2013) The Patient’s Anastrozole Compliance to Therapy (PACT) Program: A Randomized, In-Practice Study on the Impact of a Standardized Information Program on Persistence and Compliance to Adjuvant Endocrine Therapy in Postmenopausal Women with Early Breast Cancer. Annals of Oncology, 24, 1505-1512. https://doi.org/10.1093/annonc/mds653
[37]
Haskard-Zolnierek, K.B., Miller, T.A. and DiMatteo, M.R. (2017) Promoting Treatment Adherence. In: Kissane, D.W., Bultz, B.D., et al, Eds., Oxford Textbook of Communication in Oncology and Palliative Care, 2 Edition, Oxford University Press, Oxford, 239-243. https://doi.org/10.1093/med/9780198736134.003.0037
[38]
Adisa, A., Lawal, O. and Adesunkanmi, A. (2008) Evaluation of Patients\’ Adherence to Chemotherapy for Breast Cancer. African Journal of Health Sciences, 15, 22-27. https://doi.org/10.4314/ajhs.v15i1.30869
[39]
Beypinar, I. (2020) Intravenous Chemotherapy Adherence of Cancer Patients in Time of Covid-19 Crisis. International Journal of Hematology and Oncology, 30, 133-138. https://doi.org/10.4999/uhod.204528
[40]
Nkenu, N.G., Nsoh, M., Nkondjock, A. and Paul, A.J. (2022) Characterizing Factors Influencing Adherence to Surgery and Chemotherapy amongst Women Suffering from Breast Cancer in Mbingo Baptist Hospital Cameroon. Pan African Medical Journal, 43, Article 102. https://doi.org/10.11604/pamj.2022.43.102.28672
[41]
Wells, J.S., Strickland, O.L., Dalton, J.A. and Freeman, S. (2015) Adherence to Intravenous Chemotherapy in African American and White Women with Early-Stage Breast Cancer. Cancer Nursing, 38, 89-98. https://doi.org/10.1097/NCC.0000000000000139
[42]
The Economist (2014) Worse than AIDS: The Burden of Cancer Is Falling Increasingly Heavily on the Poor.
[43]
Luger, T.M. (2013) Health Beliefs/Health Belief Model. In: Gellman, M.D. and Turner, J.R., Eds., Encyclopedia of Behavioral Medicine, Springer, New York, 907-908. https://doi.org/10.1007/978-1-4419-1005-9_1227
[44]
Muiyuro, M. (2020) Adherence to Highly Active Antiretroviral Therapy and Associated Factors among HIV Positive Adolescents in Muranga County Hospital, Kenya. Master’s Thesis, Jomo Kenyatta University of Agriculture and Technology, Juja.
[45]
Wakibi, S.N., Ng’ang’a, Z.W. and Mbugua, G.G. (2011) Factors Associated with Non-Adherence to Highly Active Antiretroviral Therapy in Nairobi, Kenya. AIDS Research and Therapy, 8, Article No. 43. https://doi.org/10.1186/1742-6405-8-43
[46]
Ministry of Health (Kenya) (2021) National Tuberculosis, Leprosy and Lung Disease Program. Nairobi.
[47]
Ministry of Health (Kenya) (2023) The National Cancer Control Strategy (2023-2027). Nairobi.
[48]
DiMatteo, M.R., Haskard-Zolnierek, K.B. and Martin, L.R. (2012) Improving Patient Adherence: A Three-Factor Model to Guide Practice. Health Psychology Review, 6, 74-91. https://doi.org/10.1080/17437199.2010.537592
[49]
Hansen, L.A. (2015) Impact of Nonadherence to Cancer Therapy. Oncology Pharmacist. https://theoncologypharmacist.com/web-exclusives/14873:top-14873
[50]
Hoskin, P., Neal, A.J. and Hoskin, P.J. (2009) Clinical Oncology: Basic Principles and Practice. 4th Edition, CRC Press, London.
[51]
Yee, M.K., Sereika, S.M., Bender, C.M., Brufsky, A.M., Connolly, M.C. and Rosenzweig, M.Q. (2017) Symptom Incidence, Distress, Cancer-Related Distress, and Adherence to Chemotherapy among African American Women with Breast Cancer. Cancer, 123, 2061-2069. https://doi.org/10.1002/cncr.30575
[52]
Kahn, K.L., Schneider, E.C., Malin, J.L., Adams, J.L. and Epstein, A.M. (2007) Patient Centered Experiences in Breast Cancer: Predicting Long-Term Adherence to Tamoxifen Use. Medical Care, 45, 431-439. https://doi.org/10.1097/01.mlr.0000257193.10760.7f
[53]
Lash, T.L., Fox, M.P., Westrup, J.L., Fink, A.K. and Silliman, R.A. (2006) Adherence to Tamoxifen over the Five-Year Course. Breast Cancer Research and Treatment, 99, 215-220. https://doi.org/10.1007/s10549-006-9193-0
[54]
Nieuwlaat, R., Wilczynski, N., Navarro, T., Hobson, N., Jeffery, R., Keepanasseril, A., Agoritsas, T., Mistry, N., Iorio, A., Jack, S., Sivaramalingam, B., Iserman, E., Mustafa, R.A., Jedraszewski, D., Cotoi, C. and Haynes, R.B. (2014) Interventions for Enhancing Medication Adherence. Cochrane Database of Systematic Reviews, No. 11, Article No. CD000011. https://doi.org/10.1002/14651858.CD000011.pub4
[55]
Kini, V. and Ho, P.M. (2018) Interventions to Improve Medication Adherence: A Review. JAMA, 320, 2461-2473. https://doi.org/10.1001/jama.2018.19271
[56]
Tan, E.H., Wong, A.L.A., Tan, C.C., Wong, P., Tan, S.H., Ang, L.E.Y., Lim, S.E., Chong, W.Q., Ho, J., Lee, S.C. and Tai, B.C. (2020) Improving Medication Adherence with Adjuvant Aromatase Inhibitor in Women with Breast Cancer: A Randomised Controlled Trial to Evaluate the Effect of Short Message Service (SMS) Reminder. The Breast, 53, 77-84. https://doi.org/10.1016/j.breast.2020.06.012
[57]
Singleton, A.C., Raeside, R., Partridge, S.R., Hyun, K.K., Tat-Ko, J., Sum, S.C.M., Hayes, M., Chow, C.K., Thiagalingam, A., Maka, K., Sherman, K.A., Elder, E. and Redfern, J. (2022) Supporting Women’s Health Outcomes after Breast Cancer Treatment Comparing a Text Message Intervention to Usual Care: The EMPOWER-SMS Randomised Clinical Trial. Journal of Cancer Survivorship, 17, 1533-1545. https://doi.org/10.1007/s11764-022-01209-9
[58]
Wijeratne, D.T., Bowman, M., Sharpe, I., Srivastava, S., Jalink, M. and Gyawali, B. (2021) Text Messaging in Cancer-Supportive Care: A Systematic Review. Cancers, 13, Article 3542. https://doi.org/10.3390/cancers13143542
[59]
Timmers, L., Boons, C.C.L.M., Verbrugghe, M., Van Den Bemt, B.J.F., Van Hecke, A. and Hugtenburg, J.G. (2017) Supporting Adherence to Oral Anticancer Agents: Clinical Practice and Clues to Improve Care Provided by Physicians, Nurse Practitioners, Nurses and Pharmacists. BMC Cancer, 17, Article No. 122. https://doi.org/10.1186/s12885-017-3110-2
[60]
Griffin, D.A., Penprase, B. and Klamerus, J.F. (2012) Relative Dose Intensity—Improving Treatment and Outcomes in Early-Stage Breast Cancer: A Retrospective Study. Oncology Nursing Forum, 39, E459-E467. https://doi.org/10.1188/12.ONF.E459-E467
[61]
Denduluri, N., Lyman, G.H., Wang, Y., Morrow, P.K., Barron, R., Patt, D., Bhowmik, D., Li, X., Bhor, M., Fox, P., Dhanda, R., Saravanan, S., Jiao, X., Garcia, J. and Crawford, J. (2018) Chemotherapy Dose Intensity and Overall Survival among Patients with Advanced Breast or Ovarian Cancer. Clinical Breast Cancer, 18, 380-386. https://doi.org/10.1016/j.clbc.2018.02.003
[62]
Ruddy, K., Mayer, E. and Partridge, A. (2009) Patient Adherence and Persistence with Oral Anticancer Treatment. CA: A Cancer Journal for Clinicians, 59, 56-66. https://doi.org/10.3322/caac.20004
[63]
Sarfati, D., Koczwara, B. and Jackson, C. (2016) The Impact of Comorbidity on Cancer and Its Treatment: Cancer and Comorbidity. CA: A Cancer Journal for Clinicians, 66, 337-350. https://doi.org/10.3322/caac.21342
[64]
Theofilou, P. and Panagiotaki, H. (2012) A Literature Review to Investigate the Link between Psychosocial Characteristics and Treatment Adherence in Cancer Patients. Oncology Reviews, 6, Article e5. https://doi.org/10.4081/oncol.2012.e5
[65]
Butow, P., Palmer, S., Pai, A., Goodenough, B., Luckett, T. and King, M. (2010) Review of Adherence-Related Issues in Adolescents and Young Adults with Cancer. Journal of Clinical Oncology, 28, 4800-4809. https://doi.org/10.1200/JCO.2009.22.2802
[66]
Marshall, K.H., Wakefield, C.E., Robertson, E.G. and Sansom-Daly, U.M. (2015) Strategies to Improve Adherence to Treatment in Adolescents and Young Adults with Cancer: A Systematic Review. Clinical Oncology in Adolescents and Young Adults, 5, 35-49. https://doi.org/10.2147/COAYA.S85988
[67]
Thomas, D.M., Albritton, K.H. and Ferrari, A. (2010) Adolescent and Young Adult Oncology: An Emerging Field. Journal of Clinical Oncology, 28, 4781-4782. https://doi.org/10.1200/JCO.2010.30.5128
[68]
Nebert, M.K., Agina, B.M.O. and Andre, Y. (2017) Health Behaviour among Nurses Working in Public Hospitals in Kakamega County, Kenya. Nursing Research and Practice, 2017, Article ID: 4683189. https://doi.org/10.1155/2017/4683189
[69]
Lee, M. and Khan, M.M. (2016) Gender Differences in Cost-Related Medication Non-Adherence among Cancer Survivors. Journal of Cancer Survivorship, 10, 384-393. https://doi.org/10.1007/s11764-015-0484-5
[70]
International Agency for Research on Cancer (2020) Globocan 2020: Kenya Fact Sheet. https://gco.iarc.fr/today/data/factsheets/populations/404-kenya-fact-sheets.pdf
[71]
Syse, A. and Lyngstad, T.H. (2017) In Sickness and in Health: The Role of Marital Partners in Cancer Survival. SSM-Population Health, 3, 99-110. https://doi.org/10.1016/j.ssmph.2016.12.007
[72]
Abiodun, P., Makanjuola, S., Anthonia, S., Adaeze, I., Oludara, M., Nasir, I. and Foluso, O. (2015) Level of Adherence to Cytotoxic Drugs by Breast Cancer Patients’ in Lagos State University Teaching Hospital. Journal of Cancer Therapy, 6, 383-389. https://doi.org/10.4236/jct.2015.64041
[73]
Zafar, S.Y., Peppercorn, J.M., Schrag, D., Taylor, D.H., Goetzinger, A.M., Zhong, X. and Abernethy, A.P. (2013) The Financial Toxicity of Cancer Treatment: A Pilot Study Assessing Out-of-Pocket Expenses and the Insured Cancer Patient’s Experience. The Oncologist, 18, 381-390. https://doi.org/10.1634/theoncologist.2012-0279
[74]
Atieno, O.M., Opanga, S., Martin, A., Kurdi, A. and Godman, B. (2018) Pilot Study Assessing the Direct Medical Cost of Treating Patients with Cancer in Kenya; Findings and Implications for the Future. Journal of Medical Economics, 21, 878-887. https://doi.org/10.1080/13696998.2018.1484372
[75]
Ingwu, J.-A., Idoko, C., Israel, C.-E., Maduakolam, I. and Madu, O. (2019) Factors Influencing Non-Adherence to Chemotherapy: Perspective of Nigerian Breast Cancer Survivors. Nursing Practice Today, 6, 41-48. https://doi.org/10.18502/npt.v6i1.392
[76]
Jahangir, E., Irazola, V. and Rubinstein, A. (2012) Need, Enabling, Predisposing, and Behavioral Determinants of Access to Preventative Care in Argentina: Analysis of the National Survey of Risk Factors. PLOS ONE, 7, e45053. https://doi.org/10.1371/journal.pone.0045053
[77]
Sandman, L. and Hofmann, B. (2019) Why We Don’t Need “Unmet Needs”! On the Concepts of Unmet Need and Severity in Health-Care Priority Setting. Health Care Analysis, 27, 26-44. https://doi.org/10.1007/s10728-018-0361-2
[78]
World Health Organization (2011) Sexual and Reproductive Health: Core Competencies in Primary Care: Attitudes, Knowledge, Ethics, Human Rights, Leadership, Management, Teamwork, Community Work, Education, Counselling, Clinical Settings, Service, Provision. https://iris.who.int/bitstream/handle/10665/44507/9789241501002_eng.pdf?sequence=1
