The impact of socioeconomic disparities nutrition and mental health on cervical cancer outcomes in patients undergoing chemotherapy in Africa

Abstract Cervical cancer still remains a significant public health concern globally and a leading cause of premature death among women in low and middle income countries. Although many African counties have made a substantial progress in improving cervical cancer treatment outcomes, the burden still remains disproportionately high. Approximately 87% of death of cervical cancer are reported in lower and middle income countries with sub-Saharan Africa contributing to 22.5 per 100,000 women death [2]. This narrative explores how socioeconomic disparities, nutrition and mental health influence cervical cancer treatment outcomes in patients undergoing chemotherapy in Africa. Through an extensive literature search several challenges were identified under four subthemes; community level and cultural barriers, health system barriers, governance challenges and geographical accessibility barriers. The review emphasized critical areas that require attention including decentralization of cervical cancer healthcare services, integration of cervical cancer prevention and management services with other health services, strengthening partnership and collaboration across sectors, adoption of telecommunication innovations such as e-health and tele-oncology, improving community awareness and health education, community involvement in cervical cancer projects, women autonomy and decision making, capacity building of community health teams were identified as critical strategies. Strengthening policy frameworks and institution support in African countries emerged as key priorities. Improving cervical cancer treatment outcomes requires coordinated interventions that extend beyond medical treatment to address socioeconomic disparities, nutrition and mental health of cervical cancer patients. Prioritizing these interventions is essential for improving survival rates and enhancing the overall quality of life among cervical cancer patients undergoing chemotherapy in Africa. Key words: Impact, Socioeconomic disparities, Nutrition, Mental health, Cervical cancer, Outcome, Chemotherapy, Africa. Background Cervical cancer is fourth most common cancer in the world and a leading cause of premature death among women in low and middle income countries, posing a significant concern to efforts directed at increasing life expectancy worldwide [1]. Globally, approximately 266,000 women die of cervical cancer annually, and an estimated 87% of these deaths are happening in lower income countries of the world such as the African region [2]. 34.8 new cases of cervical cancer are diagnosed per 100,000 women per year and with an estimated 22.5 per 100,000 women death from cervical cancer in sub – Saharan Africa [2]. These figures compare with 6.6 and 2.5 per 100000 women respectively in North America. Though several African countries have made a substantial progress in improvement of cervical cancer treatment outcomes, the burden still remain disproportionately high. Cervical cancer treatment outcomes are influenced by various factors such as presence of treatment modalities e.g. tertiary care facilities, chemotherapies, stage of diagnosis of cervical cancer, individual related factors such as socioeconomic status, nutrition status and mental health support [3,4,5]. Socioeconomic disparities play a crucial role in influencing the outcomes of cancer globally, particularly in low income countries like Africa [6]. Socioeconomic status (SES) such as income, education, occupation and social class directly affects access and utilization of the healthcare services [7,8], including early detection, diagnosis and treatment adherence [9]. Cancer patients from low socioeconomic status often face multiple barriers, including limited financial costs to afford chemotherapy, transport expenses to treatment centers, lack of follow-up and competing priorities at home like work, children care [9,6,2]. In many African countries, healthcare infrastructures are under resourced, with almost all cervical cancer treatment centers centered in urban areas, making rural population hard to timely access cervical cancer management [10,11]. This result in late stage diagnosis of cervical cancer when chemotherapy efficacy is reduced, thus impacts the cervical cancer outcomes [10]. Lack of health insurance coverage or out of pocket payments for chemotherapy drugs by a large population in Africa impose financial burden to cancer patients and their families, this causes interruption in treatment thus poor adherence to chemotherapy [12,13,14]. Studies show that low socioeconomic status is significantly associated with poor survival rates in cervical cancer patients undergoing chemotherapy due to the multiple barriers [9,15]. Nutrition is a critical component in cancer treatment outcomes but mostly overlooked. Malnutrition is highly prevalent among patients with chronic illness like cancer patients [16,17] in African countries due to food insecurity, patients with comorbidities such as HIV/AIDS, tuberculosis and cancer related metabolic changes [18,19]. Patients undergoing chemotherapy for cervical cancer, requires adequate nutrition to maintain immune function, reduce drug induced toxicity and enable tolerance to cytotoxic chemotherapies [20,21]. Chemotherapy further exacerbates nutritional deficits in cervical cancer patients by causing side effects such nausea, loss of appetite, nausea and vomiting which in turn reduces oral food intake [22]. Additionally, high prevalence of comorbidities such as HIV/AIDS, TB complicates the nutrition status of patients receiving cervical cancer chemotherapy, by affecting the pharmacokinetics of the drugs, and increasing chemotherapies side effect [23]. Nutritional program needs to address nutrition through counseling, supplementation, and food security intervention to improve treatment adherence and quality of life among cervical patients receiving chemotherapy [24]. The psychological burden of cervical cancer diagnosis, added on side effects of chemotherapies, often causes a serious mental health challenges such as depression, anxiety, and post-traumatic stress disorders to cervical cancer patients [25,26,27]. Mental health conditions affects patient’s chemotherapies regimens adherence, patient’s capacity to cope up with symptoms and overall impacts the quality of life [28]. In Africa mental health care services are poorly developed and stigmatized, resulting in limited psychosocial support services to cervical cancer patients [29]. This decreases motivation to continue chemotherapy, affecting treatment adherence and worsen the clinical outcomes of cervical cancer [30]. Studies highlights integrated mental health intervention such as counseling and peer groups improve patient’s mental wellbeing and chemotherapy adherence [30]. However, the scarcity of trained mental health professional in cancer treating center across Africa limits the implementations of such interventions. The interplay among socioeconomic disparities, nutritional status and mental health support makes a complex framework that influence cervical cancer outcomes among low income countries specifically Africa patients undergoing chemotherapy. Patients from a low/ poor background are more likely to experience food insecurity leading to malnutrition, which in turn can affect the psychological distress [31]. Unmanaged mental health conditions can impair nutritional intake and also affects the ability to manage financial and logistics of chemotherapies [32]. Fig 1; interplay among socioeconomic disparities, nutrition and mental health in patients undergoing chemotherapy, a modified ecological framework [187]. Addressing cervical cancer outcomes in patients undergoing chemotherapy in Africa requires a multidisciplinary approach that extends beyond chemotherapy to include social support, nutritional and mental health care support intervention. Through the integrated healthcare approaches, policy reforms and community engagement, these interventions are essential to improve survival and quality of life among African cervical cancer patients undergoing chemotherapy. Socioeconomic disparities and cervical cancer treatment outcomes in patients undergoing chemotherapy Socioeconomic disparities significantly influence treatment outcomes for cervical cancer women undergoing chemotherapy particularly in low income countries worldwide. The socioeconomic disparities manifest through unequitable access to preventive measures, late stage presentation, inadequate treatment centers availability and poor drug adherence. Globally, cervical cancer remains among the most inequitable diseases worldwide with biggest percentage about 90% of cervical cancer mortality occurring in low and middle income countries [33]. The burden of cervical cancer is highest among women with lower socioeconomic status living in low income and middle countries, facing structural barriers that hinder treatment effectiveness and overall outcomes [9]. Socioeconomic disparities contribute to delayed cervical cancer diagnosis in women. Women from low income households in Africa and other low income countries mostly presents at a late stage of cervical cancer [33] due to low awareness, lack of screening services and financial constraints in seeking early timely treatments [34,33]. Late stage diagnosis reduces the effectiveness of chemotherapy and leads to poor treatment outcomes [35]. Studies from low income regions like sub-Saharan Africa show more than 70% of women starts cervical cancer treatments at an advanced stage [36] a proportion higher than in higher income countries such as Europe, America [37]. The late diagnosis results into poor prognosis, decreased survival rates and poor quality of life during treatment. Socioeconomic status influences treatment accessibility and continuity among cervical cancer patients. In many sub-Saharan African countries, the availability of chemotherapies is