Table 2

Study characteristics

Author	Country	Type/site	Title	Method	Outcome measure	Sample characteristics	Relevant findings
Dye et al26	Ethiopia	Breast	Complex care systems in developing countries: breast cancer patient navigation in Ethiopia	A mixed-methods study using semistructure interview to investigate the participant’s navigation through the health system before arriving at the tertiary health centre for treatment	Patient navigation through the healthcare system that culminated in the treatment of cancer	Participants: 55 patients with breast cancer plus 14 carers Mean age: 45.5 years Sex: 98% female	Initial presentation of symptoms was 53.7% to primary care, 16.4% to traditional healers, 16.4% to local/regional hospital, 9% to private hospital and 4.5% directly to the tertiary referral centre Definitive diagnoses were made at the tertiary health centre.
Jemebere27	Ethiopia	Breast	Barriers associated with presentation delay among breast cancer patients at Hawassa University Comprehensive and Specialised Hospital, Southern Ethiopia	Cross-sectional survey of women diagnosed with breast cancer at a specialised hospital	Route to diagnosis	Participants: 106 women Age range: 15–65 years Occupation: farmers (3%), labourer (9%), merchant (16%), professional 29%) and housewife (43%) Education: none (28%), elementary (29%), high school (24%) and college (≥19%) Family history of breast cancer (13%)	64% delayed presenting to the hospital due to initial use of complementary medicine, including herbal remedy, traditional healers and prayers Definitive diagnoses were made at the teaching hospital.
Ezeome19	Nigeria	Breast	Delays in presentation and treatment of breast cancer in Enugu, Nigeria	Cross-sectional survey of patiets with breast cancer at an oncology specialist unit (in a teaching hospital)	Patients first point of symptom(s) presentation Patients first point of conventional medical treatment	Participants: 164 patients (162 female and 2 male) Median (range) age: 45 (21–77) years Socioeconomic status: low (59%), middle (40%), high (1%) Education: none (15%), primary (24%), secondary (29%), degree (30%) Religion: 96% Christians	13.1% first used traditional healers. 4.4% first presented to a prayer house. 82.3% initially presented to healthcare facilities. First point of contact with medical facilities: 50% within primary (GP), 25% to consultant surgeon, 10.1% to patent medicine dealer, 7.5% to a gynaecologist, 5% to a nurse or allied health professional
Pruitt et al20	Nigeria	Breast	Social barriers to diagnosis and treatment of breast cancer in patients presenting at a teaching hospital in Ibadan, Nigeria	A qualitative study which used semistructured interview of patients with breast cancer in a teaching hospital	Help-seeking behaviour after noticing symptoms.	Participants: 31 women with breast cancer Median (range) age: 51 (28–≥80) years Education: none (n=7), primary/secondary (n=15), tertiary (n=9) Religion: Christians (83%) and Muslim (17%)	Most women rapidly sought orthodox medical care once they noticed symptoms, but few reported seeking herbal/spiritual help initially. Definitive diagnoses were made at the teaching hospital.
Adesunkanmi et al21	Nigeria	Breast	The severity, outcome and challenges of breast cancer in Nigeria	A retrospective study using 8 years records of patient with breast cancer diagnosis in a tertiary health centre.	To determine the challenges of breast cancer diagnosis at the centre	Participants: 212 patients Sex: 99.5% female Mean (SD) age: 48±12.3 years. Occupation: traders (52%), teachers (31.6%), nurses (5.5%), farmers (4%) and self-employed (1.4%) Education: primary (18%), secondary (14%) and tertiary (35%) Previous breast disease (25%), family history of breast cancer (7.2%)	92% of the tumour was self-detected. 4.2% was detected by physicians. 3.8% was detected by partners. Definitive diagnoses of all cases were made at the tertiary health centre.
Ahmed et al22	Nigeria	Breast	Management and outcomes of male breast cancer in Zaria, Nigeria	A retrospective study using 10 years of medical records of men with breast cancer in a specialist oncology centre (in a teaching hospital)	Route to diagnosis	Participants: 57 men Mean (SD) age: 59±2.3 years	Definitive diagnoses were made at the specialist centre. 21% initially consulted traditional healers before presenting to the specialist. 49% first presented symptoms to the specialist.
Aziato and Clegg-Lamptey29	Ghana	Breast	Breast cancer diagnosis and factors influencing treatment decisions in Ghana	A qualitative study using face-to-face interviews of patients with breast cancer patients from a surgical unit and breast cancer support group	Route to diagnosis	Participants: 12 women Age range: 31–60 years Religion: all were Christians.	Women self-identified breast lesion or accidentally during medical examination for other problems. Participants with self-identified breast lesion presented directly to the tertiary health centre where definitive diagnoses were made.
Agbokey et al30	Ghana	Breast	Knowledge and health seeking behaviour of breast cancer patients in Ghana	A qualitative study using in-depth interviews to examine help-seeking behaviour of female breast cancer patients at a teaching hospital	Patient help-seeking behaviour after noticing female breast cancer symptoms	Participants: 20 women Median (range) age: 52.5 (29–80) years Occupation: traders (n=11), teachers (n=3), farmers (n=5) and nurse (n=1). Education: none (n=4), primary (n=12), secondary (n=1) and tertiary (n=3) Religion: 95% were Christians.	12/20 first sought unorthodox care (herbalist, drug stores, home remedies and prayer camps) after noticing symptoms. Some patients went through a cycle of hospital-to-herbalist and back to hospital care before diagnosis. In all of the cases, however, definitive diagnoses were made at the tertiary health centre.
Mlange et al34	Tanzania	Cervical	Patient and disease characteristics associated with late tumour stage at presentation of cervical cancer in north-western Tanzania	A cross-sectional survey of women with histologically confirmed cervical cancer at a tertiary health centre	Route to diagnosis	Participants: 202 women with cervical cancers Mean (SD) age: 50±11 years Education: none (57%), primary (39%), secondary (2.4%) and college (1.4%). Occupation: farmers (84%), trader (9.9%), employed (2.4%), business (0.9%) and unemployed (2.4%)	95 (47%) initially presented to a traditional health practitioner. Presenting to a traditional health practitioner was strongly associated with late-stage diagnosis (OR=2.3, 95% CI 1.2 to 4.2, p=0.011) Definitive diagnosis was made at the tertiary health centre.
Begoihn et al28	Ethiopia	Cervical	Cervical cancer in Ethiopia: predictors of advanced stage and prolonged time to diagnosis	A retrospective cohort study of patients diagnosed with primary cervical cancer at a tertiary health centre	Route to diagnosis of cervical cancer	Participants: 1575 women with cervical cancers Mean (SD) age: 48.9±11.5 years	All of the 1575 women presented with cervical cancer symptoms to the tertiary health centre.
Eze et al23	Nigeria	Cervical	A six-year study of the clinical presentation of cervical cancer and the management challenges encountered at a state teaching hospital in Southeast Nigeria	A retrospective cohort study of patients diagnosed with primary cervical cancer at a tertiary health centre	Route to diagnosis of cervical	Participants: 61 women with primary cervical cancers. Mean (SD) age: 54±12.7 years Education: none (36.1%), primary (39.3%), secondary (23%) and college (1.6%) Occupation: farmers (60%), trader (37.7%), dependent (36.1%), business (0.9%) and retired (6.6%)	All of the 61 women presented with cervical cancer symptoms to the tertiary health centre.
Alatise et al24	Nigeria	Colorectal	Health-seeking behaviour and barriers to care in patients with rectal bleeding in Nigeria	A prospective survey of patients with rectal bleeding in the general population.	Attitude about seeking expert opinion among patients with rectal bleeding Initial help-seeking after the onset of rectal bleeding	Participants: 82 patients with rectal bleeding Median (range) age: 45 (18–85) years Sex: 78% were men Education: primary (28%), secondary (33%), tertiary (30%) Religion: Christians (66%) and Muslims (33%)	39% of the participants consulted a physician with rectal bleeding. 38% suggested that herbs should be used before seeing a physician. Patients who scored high on knowledge of rectal bleeding were more likely to consult the physician (OR: 3.82; 95% CI, 55 to 10.2).
Chu et al31	South Africa	Kaposi’s sarcoma	AIDS-associated Kaposi’s sarcoma is linked to advanced disease and high mortality in a primary care HIV programme in South Africa	Analysis of data from a cohort study of patients with AIDS-associated Kaposi’s sarcoma in primary care	Patient pathway to diagnosis of Kaposi’s sarcoma	Participants: 215 patients with Kaposi’s sarcoma Median age: 34 (IQR 29–41) years Sex: 41% women	189/6292 patients enrolled at the HIV clinic were diagnosed with AIDS-associated Kaposi’s sarcoma during routine examination.
Freeman et al36	Kenya Uganda Malawi Nigeria Cameroon	Kaposi’s sarcoma	Pitfalls of practicing cancer epidemiology in resource-limited settings: the case of survival and loss to follow-up after a diagnosis of Kaposi’s sarcoma in five countries across sub-Saharan Africa	Analysis of HIV-infected patients’ in primary care records across five countries	Route to diagnosis of Kaposi’s sarcoma	Participants: 1328 patients with Kaposi’s sarcoma Median age: 35 (IQR 30–41) years Sex: 40% women	During routine examination for AIDS-related infections at the HIV clinic, 1328 patients were diagnosed with Kaposi’s sarcoma across the five countries between 2009 and 2012.
Afungchwi et al33	Cameroon	Burkitt lymphoma	The role of traditional healers in the diagnosis and management of Burkitt lymphoma in Cameroon: understanding the challenges and moving forward	A survey of parents and carers of children diagnosed with Burtkitt lymphoma in three large hospitals	Route to diagnosis Burkitt lymphoma	Participants: 384 completed the questionnaire. Median age: 8 (range 1–15) years Sex: male (57.4%) and female (42.4%) Religion: Christians (68.9%) and Muslims (30%)	Overall, 55% of parents used traditional healers before hospital admission. 41.8% first consulted traditional healers before reporting at the local health centre.
Antel et al32	South Africa	Lymphoma	The determinants and impact of diagnostic delay in lymphoma in a TB and HIV endemic setting	A retrospective cohort study of patients diagnosed with lymphomas Data sources included hospital records, telephone and face-to-face interviews.	Route to diagnosis of Hodgkin and non-Hodgkin's lymphoma	Participants: 163 HIV patients Median age: 48 (range 15–86) years Sex: 58% male Socioeconomic status: 70% on social grant or <251 monthly income	All 163 HIV patients were diagnosed with Hodgkin (41) and non-Hodgkin (122) lymphoma. They were referred to the tertiary health centre by healthcare practitioners.
Brown et al25	Nigeria	Childhood	A Prospective Study on the Causes of Delayed Diagnosis of Childhood Cancer in Ibadan, Nigeria	A survey of parents and carers of children diagnosed with malignant tumour in a tertiary healthcare settings	Factors influencing pre-diagnostic intervals among parent/carers of patient with childhood cancers	Participants: 91 children with cancer Median (range) age: 4 years (1 month −15 years). Sex: 50.5% male	69% of parents initially sought medical help for their children within a health facility 19% self-medicated. 4% used an herbalist. 3% consulted a patent medicine dealer. 2% presented to a nurse/health worker and 1% visited a church. Health facilities used comprised 69% public hospital, 31% private
Njuguna et al35	Kenya	Childhood	Factors influencing time to diagnosis and treatment among paediatric oncology patients in Kenya	A cross-sectional survey of parent and carers of 99 children diagnosed with a malignancy.	Help-seeking after the onset of symptoms.	Participants: 99 children with cancer Median age: children: 5.7 years, mother: 31 (19–56) years Sex: 67% male Religion: 99% of mothers were Christians. Employment: farmers (29%), regular jobs (24%), casual labourers (6%) and unemployed (6%)	58 (59%) of parents initially sought alternative treatment for their children, including praying ceremonies (41%), visiting herbalist (36%), special food intake (11%) and attending traditional healer (3%) First contact with conventional healthcare facilities included 60% in primary care, 38% in secondary and 2% in tertiary healthcare.

GP, general practitioner.