Diagnostic delay as health system navigation: a mixed-methods study of childhood cancer in Burkina Faso

BACKGROUND: Diagnostic delay is a major contributor to childhood cancer mortality in low- and middle-income countries (LMICs). Existing studies identify determinants of delay but provide limited insight into how delays accumulate across care pathways. This study examined diagnostic delay among children with cancer in Burkina Faso using a health system navigation perspective and an explanatory mixed-methods design. METHODS: We conducted a sequential explanatory mixed-methods study at the two national paediatric oncology units in Ouagadougou, Burkina Faso. Quantitative analyses of children with a first cancer diagnosis (n = 30) examined associations between total diagnostic delay, number of provider encounters, and entry-point provider type, using minimal multivariable regression models. Analyses were exploratory and intended to identify associations rather than establish causal relationships. Qualitative interviews with caregivers (n = 20) explored diagnostic trajectories and mechanisms of delay accumulation. Findings were integrated through a health system navigation framework. RESULTS: The median total diagnostic delay was 103.5 days (IQR 58-196), with referral delay representing the longest component. A greater number of provider encounters was associated with longer total diagnostic delay (β = 0.22, 95% CI 0.02-0.41; p = 0.03). Qualitative analyses identified two dominant mechanisms of delay accumulation: fragmented looping across multiple providers and system-induced diagnostic bottlenecks within higher-level biomedical facilities. Structural and social vulnerabilities further shaped families' ability to navigate referral pathways. Integrated analyses suggested that provider encounters reflected cumulative navigation complexity rather than simply repeated consultations. CONCLUSIONS: Diagnostic delay among children with cancer in Burkina Faso emerged as a cumulative process of health system navigation across a fragmented healthcare system. A health system navigation perspective may help inform strategies to reduce diagnostic delay by improving referral coordination, patient navigation, and diagnostic capacity in LMIC settings.