ArticleBMJ open2026
Treatment adherence, survival outcomes and barriers to care of non-Hodgkin lymphoma in Northwest Ethiopia: a mixed-methods study.
Article in BMJ open, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
objectiveTo evaluate treatment adherence, survival and systemic patient and provider level factors associated with non-Hodgkin's lymphoma (NHL) management as reported by healthcare providers.
designExplanatory sequential mixed-methods study comprising a retrospective hospital-based cohort and a qualitative descriptive study.
settingFelege Hiwot Comprehensive Specialized Hospital in Bahir Dar, Ethiopia, and the University of Gondar Comprehensive Specialized Hospital in Gondar, Ethiopia.
participantsAdults (≥18 years) with histologically confirmed NHL who initiated systemic chemotherapy were eligible. We randomly selected 182 patients with NHL treated and diagnosed between 1 August 2019 and 31 July 2024, for retrospective chart review out of a total of 283 patients during the study period. 14 healthcare professionals with at least 1 year of oncology experience participated in in-depth interviews. PRIMARY AND SECONDARY OUTCOME: The primary outcome was overall survival, defined as the time from histological diagnosis to death from any cause. The secondary outcome was treatment adherence, defined as interruption between cycles or abandonment of prescribed chemotherapy.
resultsAt a median follow-up of 18 months, the estimated 3-year overall survival rate was 48.5% (95% CI 37.8% to 58.4%). Lower survival rate was independently associated with B-symptoms (adjusted HR (AHR) 2.7, 95% CI 1.6 to 4.4), high intermediate International Prognostic Index (IPI) (AHR 3.7, 95% CI 1.8 to 6.9) and high IPI (AHR 5.5, 95% CI 2.7 to 11.3). Treatment abandonment and interruption occurred in 22.5% and 20.5% of patients, respectively. Exposure to rituximab was more likely to abandon therapy (χ²=4.8, p=0.03). Patient residence in rural areas was associated with higher rates oftreatment interruption (χ² = 6.0, p = 0.01), whereas absence of healthinsurance was associated with treatment abandonment (χ² = 8.0, p =0.005).In the qualitative analysis, healthcare providers identified multilevel barriers to NHL care, including low patient awareness and late presentation, frequent misdiagnosis at the primary care level, weak referral systems, financial constraints, inconsistent drug availability and limited diagnostic capacity. These systemic and patient-level challenges are often associated with delayed diagnosis, treatment interruption and suboptimal survival outcomes.
conclusions3-year survival among adults with NHL in Northwest Ethiopia was substantially lower than reported in high-income settings. Mortality was higher among patients with B-symptoms and elevated IPI scores. High rates of treatment interruption and abandonment were observed. Patient-level and system-level factors are associated with reduced survival and treatment continuity. Strengthening early diagnosis, risk stratification and financial protection may support improved treatment adherence and survival outcomes.
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