abstract: 'This systematic review analyzes published studies to identify social and

  clinical factors in head and neck cancer treatment in low-income and

  lower-middle-income countries predominantly in South Asia.

  Importance The identification of the barriers to care for patients with

  head and neck cancer in low-income and lower-middle-income countries is

  a crucial first step toward the identification of targets for developing

  and implementing cost-effective programs to increase awareness,

  prevention, and treatment of head and neck cancer in this setting.

  Objective To identify the barriers to care for patients presenting with

  head and neck cancer in low-income and lower-middle-income countries.

  Evidence Review Nine databases were searched from their inception to

  December 21, 2017: Africa-Wide Information, the Cochrane Library,

  Embase, Global Health, LILACS, MEDLINE, BIOSIS Previews, and Web of

  Science. Search terms referred to head and neck cancer, barriers to

  care, and low- and lower-middle-income countries, and no temporal and

  linguistic restrictions were imposed. Articles were reviewed by 2

  independent investigators, and differences in inclusion were resolved by

  discussion. Bibliographies of all included articles were screened, and

  all relevant articles were reviewed using the same procedure.

  Quantitative articles were assessed using the Methodological Index for

  Non-Randomized Studies tool, and articles with qualitative data used the

  Critical Appraisal Skills Programme qualitative checklist. This

  systematic review was registered in PROSPERO (registration No.

  CRD42018092448) and followed the Preferred Reporting Items for

  Systematic Review and Meta-Analysis Protocols. Findings Of the 44

  articles selected for review, 18 (41\%) met the selection criteria. All

  articles reported quantitative results, and 3 (17\%) added some

  qualitative material to the study design. Most (11 {[}61\%]) of the

  studies originated from India. A total of 41 different barriers to care

  were identified, with low level of education (cited in 8 articles

  {[}44\%]), low socioeconomic status (in 4 articles {[}22\%]), and lack

  of knowledge about head and neck cancer (in 3 articles {[}17\%]) being

  statistically associated with a delayed presentation. Misunderstanding

  of signs and symptoms, use of alternative medicine, and inability to

  access health care were other barriers discussed in the qualitative

  articles. Conclusions and Relevance This systematic review highlighted

  the lack of both qualitative and quantitative information for patients

  with head and neck cancer in low-income and lower-middle-income

  countries. The findings suggest that integrating the barriers to care

  with information from patient lives may identify the clinical and social

  relevance of these barriers and guide future research.

  Question What are the barriers to care for patients presenting with head

  and neck cancer in low-income and lower-middle-income countries?

  Findings In this mixed-methods systematic review of 18 studies that

  originated from Asia and Africa, a low level of literacy was

  statistically associated with a delayed presentation in 8 articles

  (44\%), and lower socioeconomic status was statistically associated in 4

  articles (22\%). Qualitative articles identified misunderstanding of

  symptoms, use of alternative medicine, and inability to access health

  care as factors associated with a delayed presentation. Meaning Findings

  of this study may help identify the clinical and social validity of a

  given barrier to care in low-income and lower-middle-income countries

  and may guide future work in this understudied area.'
affiliation: 'Beaudoin, PL (Corresponding Author), Univ Montreal, OTL HNS, Otolaryngol
  Head \& Neck Surg, 1051 Rue Sanguinet, Montreal, PQ H2X 3E4, Canada.

  Beaudoin, Pier-Luc, McGill Univ, Dept Surg, Montreal, PQ, Canada.

  Beaudoin, Pier-Luc, Univ Montreal, PGY Otolaryngol Head \& Neck Surg 4, Montreal,
  PQ, Canada.

  Anchouche, Sonia; Gaffar, Rouan, McGill Univ, Dept Med, Montreal, PQ, Canada.

  Guadagno, Elena, McGill Univ, Ctr Hlth, Pediat Gen \& Thorac Surg, Montreal, PQ,
  Canada.

  Ayad, Tareck, Ctr Hosp Univ Montreal, Otolaryngol \& Head \& Neck Surg Dept, Montreal,
  PQ, Canada.

  Ayad, Tareck, Univ Montreal, Otolaryngol \& Head \& Neck Surg, Montreal, PQ, Canada.

  Poenaru, Dan, McGill Univ, Ctr Hlth, Dept Pediat Surg, Montreal, PQ, Canada.'
author: Beaudoin, Pier-Luc and Anchouche, Sonia and Gaffar, Rouan and Guadagno, Elena
  and Ayad, Tareck and Poenaru, Dan
author-email: pier-luc.beaudoin@mail.mcgill.ca
author_list:
- family: Beaudoin
  given: Pier-Luc
- family: Anchouche
  given: Sonia
- family: Gaffar
  given: Rouan
- family: Guadagno
  given: Elena
- family: Ayad
  given: Tareck
- family: Poenaru
  given: Dan
da: '2023-09-28'
doi: 10.1001/jamaoto.2019.4311
eissn: 2168-619X
files: []
issn: 2168-6181
journal: JAMA OTOLARYNGOLOGY-HEAD \& NECK SURGERY
keywords-plus: ORAL-CANCER; DELAY; CAVITY; HEALTH
language: English
month: MAR
number: '3'
number-of-cited-references: '35'
orcid-numbers: 'Poenaru, Dan/0000-0002-6267-6140

  Guadagno, Elena/0000-0002-4616-9990'
pages: 291-297
papis_id: ce7ac0b16d068209b4ba730e426f4079
ref: Beaudoin2020barriersaccess
researcherid-numbers: 'Poenaru, Dan/S-2562-2017

  '
tags:
- review
times-cited: '10'
title: Barriers in Access to Care for Patients With Head and Neck Cancer in Resource-Limited
  Settings A Systematic Review
type: Review
unique-id: WOS:000522034800014
usage-count-last-180-days: '0'
usage-count-since-2013: '5'
volume: '146'
web-of-science-categories: Otorhinolaryngology; Surgery
year: '2020'