Exploring cancer care pathways and contextual influences on prospective guideline implementation in Nigeria

Implementing cancer survivorship guidelines in resource-limited settings poses unique challenges. While the National Comprehensive Cancer Network (NCCN) has developed harmonized survivorship guidelines for sub-Saharan Africa, little is known about the contextual factors that may affect their implementation in Nigeria, which bears the second-highest cancer burden in Africa. The objective of this study was to explore barriers and facilitators that may influence the implementation of NCCN harmonized survivorship guidelines based on perceptions, experiences, and attitudes of patients, caregivers, and healthcare providers at a major Nigerian cancer center using the Consolidated Framework for Implementation Research (CFIR). The study used qualitative methods and interviewed 22 key informants to explore experiences and perceptions. Data collection and analysis were guided by CFIR domains: inner setting, outer setting, intervention characteristics, and individual characteristics. Nine patients, nine healthcare providers, and four caregivers were interviewed via Zoom. The study highlighted several factors that may influence the implementation of guidelines. Healthcare workers perceived barriers to implementing the guidelines included human resource shortages, financial constraints, and limited awareness of the guidelines. However, strong communication practices and the existing infrastructure were seen as potential facilitators. Among patients and caregivers, social and religious influences emerged as factors that could either support or hinder implementation, while financial-related constraints remained the most prominent barrier. This study underscores the need for context specific guidelines. In this setting, such guidelines should more effectively address financial hardship, recognize and leverage the central role of caregivers, and consider the influence of faith and social networks in shaping patient experiences.

In 2005, the National Academies of Science, Engineering, and Medicine (NASEM) published From Cancer Patient to Cancer Survivor: Lost in Transition, a milestone report authored by oncology researchers and cancer survivors (1). The report highlighted the unique needs of individuals from diagnosis through post-treatment and outlined recommendations to improve cancer survivorship care. Beyond the four core cancer control strategies, screening, prevention, treatment, and palliative care, survivorship care emphasizes secondary prevention, surveillance, and coordination of care (2). While palliative care and survivorship care share complementary goals, they are conceptually and programmatically distinct: palliative care primarily addresses symptom management and end-of-life concerns, whereas survivorship care focuses on long-term health monitoring, psychosocial wellbeing, and reintegration into daily life following treatment (3). The focus on screening services and the late presentation of most cases in low- and middle-income settings has led to greater emphasis on palliative care services. A recent study reviewing survivorship-related strategies in National Cancer Control Plans in 21 countries in Sub-Saharan Africa found that 63% of the survivorship-related strategies were explicitly focused on palliative care, and less than half of these had measurable indicators (4).

To advance sustainable structures to support comprehensive cancer care that includes survivorship and palliative services in low- and middle-income countries, in February 2021, the National Comprehensive Cancer Network collaboratively developed resource-stratified harmonized cancer survivorship guidelines. The guidelines are intended as a starting point for implementing the full spectrum of survivorship services.

The guideline recommendations propose services for the general survivorship standard of care, services that are optional and may be considered when availability does not prevent general standard of care services, and services that are advanced that may be more costly and technically challenging and/ or have less of an impact on treatment outcomes (5). The guidelines are also to be followed as a supplement to the disease-specific treatment recommendations.

Federal Ministries of Health in several African countries have endorsed these guidelines and are gearing up to develop implementation strategies.

Previously, certain aspects of survivorship services were part of palliative care services under the Nigerian Cancer Control Plan, which expired in 2022. This plan has since been renewed, and following advocacy from stakeholders and emphasizing the need for survivorship programs, the new plan includes a dedicated pillar focused on cancer survivorship goals and objectives built on Nigeria-specific findings from the Garton et al. study (6). A key performance indicator for this objective is the development of culturally acceptable guidelines on supportive care.

While the NCCN harmonized survivorship guidelines provide valuable overarching recommendations for this group of countries, they may fail to account for contextual variations in national-level health systems, resource availability, and care priorities, and may limit their applicability across settings. The ongoing growth of cancer survivors, coupled with the gap between research and practice, calls for prioritization of implementation science models and frameworks. This will ensure seamless adaption of evidence-based interventions, scalability, and sustainability. The recent development of evidence-based resource-stratified cancer survivorship harmonized guidelines may encourage countries to adopt the recommendations and consider complementing implementation strategies to inform subsequent systematic uptake.

The goal of this study was:

To explore patient and caregiver experiences during the cancer care journey and identify factors that may influence implementation of the harmonized NCCN survivorship guidelines.

To assess healthcare workers' perceptions of the cancer care pathway and identify organizational, contextual, and individual-level factors that may affect implementation of the harmonized NCCN survivorship guidelines.

Findings of this study were used to develop actionable, context-specific recommendations mapped into the CFIR domains. This study aimed to inform context-specific strategies for effectively rolling out guidelines and may promote better patient outcomes in the study setting while also informing similar processes in similar settings.

Study design and theoretical framework

This study employed a descriptive qualitative design grounded in implementation science selected to explore how local contexts shape service delivery and to uncover nuanced factors that may affect the uptake of survivorship guidelines. Implementation science seeks to promote the adoption and integration of evidence-based interventions into practice to strengthen health outcomes, reduce program costs, and minimize health disparities (7).

To guide the conceptualization, data collection, analysis, and interpretation, we used the Consolidated Framework for Implementation Research (CFIR). The CFIR, a determinant framework, was developed by consolidating previously published theory into a single framework to guide implementation research based on a review of implementation science literature (8). It offers a list of standardized implementation related constructs that help researchers assess contextual factors that may hinder or promote implementation (8). CFIR was selected for this study because of its comprehensive, multi-level approach to identifying contextual determinants of implementation across different domains. Its established track record in health systems research in LMICs and its flexibility in accommodating diverse stakeholder perspectives make it particularly well-suited for assessing survivorship guideline implementation readiness across various contexts. The framework is widely applied in studies examining system-level processes; however, recent reviews indicate that many researchers do not clearly describe how the CFIR is integrated into their methods or why particular constructs are selected (9). To address this gap, our study explicitly operationalized CFIR constructs throughout the research process, from tool development to analytic interpretation. For this study, data collection tools were informed by four CFIR domains central to the study aims: inner settings, outer settings, intervention characteristics, and individual characteristics. The inner settings reflect features of the institutions that would affect implementation, outer settings reflect features outside of the institutional setting that will influence implementation, intervention (innovation) characteristics reflect features of intervention that will influence implementation, and individual characteristics reflect features of the individuals who will be responsible for implementing the intervention that will influence the implementation (8). These constructs shaped both the development of our interview guides and the coding schema used during analysis. The research questions were as follows:

a. What are the lived experiences of patients and caregivers receiving cancer care in a satellite facility, considering local standards of care and community support systems?

b. What organizational factors within the inner setting may hinder or facilitate the implementation of new survivorship guidelines?

c. What external (outer setting) factors may hinder or facilitate guideline implementation?

d. What individual-level factors based on personal experiences, perceptions, and practices may influence guideline implementation?

Study setting and population

The study setting is a tertiary facility governed by a public-private partnership and known for providing a wide range of advanced medical services. Specifically, the study focused on patients and healthcare providers from the cancer care department. The institution is one of the largest in the country, offering comprehensive oncology services to a diverse patient population from multiple regions in the country. Patient-level participants were individuals who had completed their primary cancer treatment and were now in the post-treatment phase of their care. Healthcare providers included oncologists and nurses who provided direct care to cancer patients. This ensured that participants had adequate exposure to the department's systems, patient flows, and survivorship practices.

Data collection tools

Semi-structured interview guides were developed with guidance from the CFIR platform tailored to the context and the research questions. In addition to demographic and cancer care background information, healthcare provider interview guides had four sections based on four CFIR constructs: inner settings, outer settings, intervention characteristics, and characteristics of individuals. Patient and caregiver guides had outer settings questions.

Sampling

A purposeful, criterion-based, non-probabilistic sampling strategy was used. This approach enabled the intentional selection of information-rich cases capable of providing in-depth insights into cancer care experiences and implementation contexts. The oncology department served as the unit of analysis, consistent with the study's objective to understand factors shaping guideline implementation within a tertiary-level cancer program.

Sampling size and breakdown

Interviews were conducted with 22 participants from September to December 2024. This included five oncologists, three oncology nurses, one patient navigator, nine cancer patients, and four caregivers. The target sample size of 20–25 participants was informed by established qualitative research guidelines, which indicate that 15–30 participants are generally sufficient to achieve thematic saturation in studies exploring shared experiences among relatively homogeneous groups. Data collection continued until thematic saturation was achieved, defined as the point at which no substantively new themes or insights emerged from additional interviews. Saturation was assessed iteratively during concurrent data collection and analysis and was reached by the 20th interview; two additional interviews were conducted to confirm that no new themes emerged.

Recruitment

Local stakeholders facilitated the recruitment of healthcare workers based on the sampling criteria. The recruitment process proceeded as follows: (i) eligible healthcare providers were identified and approached by local stakeholders; (ii) those who expressed interest received a study background document and informed consent form electronically; (iii) upon returning signed consent, a Zoom interview was scheduled.

Similarly, patients and their caregivers were recruited based on specific criteria as they became available, with assistance from a facility patient navigator. The patient recruitment process involved (i) the patient navigator identified eligible patients based on predefined criteria; (ii) patients were contacted via telephone and provided with a brief study description; (iii) those who agreed to participate received the background document and consent form electronically; (iv) upon returning signed consent, a Zoom interview was scheduled. No in-person facility visit was required for study participation.

Data collection

Semi-structured interviews were the primary data source and were used to obtain specific information in line with the study's framework. Experience and behavior questions examined how interviewees typically behave and act in their day-to-day activities. Opinion and values questions assessed their thoughts on current practices and the potential new program. Feeling questions were asked to understand their feelings about implementing the new program and its processes.

Guides were minimally adapted after the first interview in each population to improve flow. The principal investigator (SS) interviewed healthcare workers (oncologists and head nurses), with the co-principal investigator introducing the sessions. The principal investigator similarly conducted patient interviews. All patients received 10,000 Naira ($7) as a token of appreciation.

All interviews were conducted via Zoom in English, and each session lasted about 45 min. All patients received the Zoom link via WhatsApp and clicked it to join the call. All participants gave additional verbal consent to record the session at the beginning of each interview.

Data management

Interviews were recorded on audio and via Zoom, and each session was immediately transcribed verbatim from the Zoom recorded transcripts. Files were then cleaned and anonymized by renaming and deleting any identifying information within the transcript. For example, a patient interview will be named by type of interviewee, cancer type, gender, and date. Data was stored in password-protected computer files and on a cloud website accessible only to the principal investigator. Data was uploaded to NVivo 15 (Lumivero, Denver, Colorado, United States) to support and facilitate coding and categorization.

Analysis

Data were collected and analyzed simultaneously, allowing refinement or reformulation of the questions as necessary (10). Analysis began with deductive coding based on a priori theoretical constructs, followed by inductive coding to capture emerging insights not captured by the initial constructs. Data analysis commenced with the first interview, with ongoing reflection on the conversations through the lens of the research questions and philosophical underpinnings. The process was conducted in phases adopted from various literature (10–12) and involved four non-linear phases: immersion in data, initial coding, developing coding structure with definitions, and finalizing and applying code structure. Initial coding was performed by the principal investigator (SS), with a second coder (OB) independently reviewing a subset of transcripts (approximately 30%) to ensure intercoder reliability. Discrepancies in coding were resolved through iterative discussion between the two coders and consultation with the larger team until consensus was reached. The finalized codebook, aligned with the four CFIR domains, was then systematically applied to all remaining transcripts by SS.

The results present findings from 22 key informant interviews organized by CFIR domains. We begin with a brief overview of participants' entry into the cancer care pathway to contextualize their perspectives, followed by inner setting factors (knowledge gaps, structural characteristics, and implementation climate including communication practices), intervention characteristics (healthcare providers' perceptions of the NCCN survivorship guideline recommendations), outer setting factors (financial burden, stigma, sociocultural influences, and faith and community support), and individual characteristics (information-seeking behavior and patient needs) that may influence guideline implementation. Table 1 presents the demographic characteristics of study participants.

Cancer detection, diagnosis, and treatment pathway

Participants' entry into the cancer care pathway was characterized by several common features that provide essential context for understanding survivorship needs. All patients stated they were unaware of any screening initiatives and were either self-diagnosed, having noticed symptoms such as a breast lump, or were experiencing other symptoms that led them to seek medical attention. Most patients initially sought care at lower-level facilities (family clinics or private hospitals) before being referred to the tertiary center, with some experiencing diagnostic delays due to misdiagnosis at these initial points of contact. The communication of a cancer diagnosis varied considerably: while some patients were informed in person, others received results via email or had to actively collect them, highlighting inconsistencies in diagnostic communication practices that warrant attention within survivorship frameworks. Upon reaching the tertiary facility, patients navigated a structured but resource-intensive process involving documentation, financial payments, and multiple clinical assessments before treatment initiation.

Implementation facilitators and barriers

Providers' interviews explored the extent to which participants were familiar with the new NCCN harmonized guidelines for cancer survivorship, their perceived relevance of the guidelines to improve patients' experience, and potential facilitators and barriers based on current practices and realities that may impact the implementation of the guidelines. The results are presented based on their corresponding CFIR constructs.

Inner setting factors

Knowledge on intervention

Most healthcare workers awareness of the NCCN harmonized cancer survivorship guidelines for sub-Saharan Africa was notably limited, with all but one reporting no prior knowledge of these guidelines, which poses a potential barrier to implementation. As communicated by one provider,

I haven't heard of that survivorship. I won't lie to you there is almost zero structure for it. HCW_Oncologist

Structural characteristics

One recurring inner setting theme that can be a potential barrier for the recommendations in the guidelines is the limitation of time among healthcare providers, with most providers stating having insufficient time to attend to the large volume of patients, resulting in minimal contact time with each patient. As a result, healthcare providers are forced to prioritize immediate clinical needs. One provider described this in the following quote:

We don't..also don't have the manpower to take care of that as well so, we are sometimes burdened with everything, and of course, you would imagine that we're not able to meet up all the demands because we already have the clinical demand and then to now add counseling and mental health assessment, we're not the right professionals to do that. HCW_Oncologist

Another related barrier is the lack of human resources as illustrated in this quote from another provider:

Manpower is going to be one of the major issues And that's manpower within the oncology space. If we are open to bringing people outside the oncology space and training them to perform specific roles in these guidelines, that will help. that will limit the amount of work that the oncologist has to do in the survivorship team. so but if all of most of the responsibilities put on the oncologist, it may now not be sustainable because they're already overburdened. HCW_ Oncologist

The gaps in human resources and time were compounded by highlighted disruptions or delays related to machine breakdowns or maintenance.

Institutional barriers are also there, bottlenecks in machine failure or machine breakdown you know so, those could cause some barriers. HCW_ Oncologists

All services at this facility require out-of-pocket payments before services can be rendered. All study participants identified treatment costs as a primary challenge in accessing cancer care services.

The biggest challenge I had was finance. Finance, because it is expensive to go through cancer treatment. Very, very expensive. Very expensive. The major challenge I had was finance. Patient FBC

Implementation climate

Communication practices

Despite the noted barriers, all patients reported encouraging communication and interaction between themselves and their attending healthcare providers. Most highlighted their comfortability in always asking questions and receiving either answers or solutions to their challenges. As highlighted in the following quote from a female breast cancer patient,

God gave me the woman that's the woman I call my consultant. She's always there for me. Whenever I call her. Even if I cannot make it to the clinic, if I send message to her she will answer me. Even the doctors under her, I have two of them. If I send message to them they will also answer me. That gives me hope cause there are some things that might need urgent attention that you might not really, you might be feeling weak, or it might be a weekend that you cannot go to that hospital because they are not open. But if you call them or send message to them immediately, they will send reply and tell you go to so and so place buy this and use it. And once you buy it and use it, you are good to go. FBC_Patient

Another factor that can serve as an implementation facilitator for the guidelines is the access to new information, which typically arises from attending conferences and webinars, and the dissemination of this information among co-workers. One provider remarked,

Someone goes for a conference or training, and they come back to feed us with what they have learned from your training and your conference. Then we see what is feasible, what is applicable, and how that can be implemented to affect or improve our training. HCW_Oncologist

Similarly, the communication styles and leadership dynamics described were participatory and collaborative. Difficulties are addressed in an escalating manner while also allowing for bidirectional learning, and more advanced challenges are discussed in team settings. Additionally, new information, which typically arises from attending conferences and webinars, is more easily disseminated due to the fluidity of communication and the collaborative environment highlighted. Most providers highlighted this culture as described in the quotes below,

Okay, okay, so the culture here is. And I'm not saying it because I work here. But it's beautiful. It's really beautiful. So there's always that whole. What do you think we should do here? I worked with Dr. X today And it's been all, what do you think? what do you think? Well, it's not actually she doesn't know what. She just bounced it off you, just in case you have a superior idea; it could happen. HCW_Oncologist

Structurally, the institution demonstrated strong administrative and infrastructural support due to its public-private partnership model, which provided access to advanced diagnostic and therapeutic facilities.

Intervention characteristics

Healthcare providers were presented with the recommendations from the new NCCN guidelines and were asked to evaluate them. They were prompted to discuss the strengths of the recommendations in addressing current needs and how well they align with existing practices.

Perception of recommendations

Most healthcare workers found the recommendations comprehensive; however, a few noted a disconnect with their realities. This barrier was noted as an incompatibility with regard to the requirement in managing patients' long term treatment effects. The following statements from two providers highlight this,

So this number four, prevention and detection of these effects of cancer and therapy, cause it's not everybody that can be followed up long enough to follow up to even detect late effects of treatment or the disease. So especially if it's too debilitating, we just leave them, we just lose them to follow up, they just stop attending sometimes, not every time. HCW_ Oncologist

Monitoring long-term effects of cancer, that monitoring is just for patients that can afford to come, and you keep monitoring. HCW_ Nurse Oncologist

Perception of recommendations

However, most of the healthcare workers reported that they recognized the interconnected nature of survivorship care recommendations and that they already provide some of the services, albeit not calling them survivorship services. One provider explained the need to implement all the recommendations due to their interconnectedness in the following quote:

Well, to me, they are all important. You cannot do without the others. For example, if you say you don't want planning for ongoing survivorship, that one is important. To me, they are all very important, because as much as you want to assist them to understand their diagnosis, planning for their survival is also very important. So they are all important. HCW_Nurse Onc

Outer settings

Participants were prompted to discuss the realities and experiences within their communities as they relate to the cancer care pathway. This included sharing about their most prominent challenges and the support systems that were most helpful throughout the process.

Patients level challenges

Financial burden

Financial constraints emerged as a dominant outer setting barrier that may affect patients' ability to access healthcare service. All participants identified treatment costs as huge challenge. Patients further shared the implications of this, including sacrifices they had to make, the measures they took to afford care, and how their lives were affected by the financial strain encountered during the process. Reflecting on the financial challenges, one female breast cancer patient shared,

This thing turned me to beggar. When you want to do treatment, you tell them, ah, I need hundreds I need 50. I need this, even if they will not give you. If you are ashamed, you go to another person. It got to a point for me like that that even you know everything was down. There was a time I did not take my tamoxifen for three good months, three good three good months. Patient_FBC

Another patient spoke of the challenge and its consequences,

So the major problem is still, and that is what some of, some of the patients going through this treatment are still facing. Finance is a major problem. That's why some people don't want to go to the hospital when they hear they have cancer. Patient_ FBC.

Another patient echoed similar sentiments,

I can't sew clothes, the money that I'm using for the fabric business, the capital is gone. So, I'm also back to square one. Going to the health uh to the health hospital the bills are much. Consultation fee they will tell you 20,000 before you can see your consultant Talk less of the drugs you are going to buy. Is much. The money they are collecting from cancer patients is too much. is too much. We do not plant money. Patient_FBC

This concern was also mentioned by all providers, with many emphasizing that the high costs of treatment, along with immediate expenses like accommodation and transportation, significantly affect not only patients but also their families and the larger community that surrounds them. One provider remarked,

These drugs are expensive to pay out of pocket. It's usually very draining to the immediate family, and to some extent, you discover that even payment for such person might involve the larger family where meetings are called you know to see how to contribute money for the person's payment. So that's the number one difficulty that we experience. HCW_Oncologist

The effect of the financial challenges on extended family was described by a caregiver in the following quote:

So those are part of the challenges one goes through, when it comes when you are not financially bouyant, you are depending on the goodwill of people, kindness, generosity of one or 2 persons, so that challenges psychologically you may be frustrated, if you are not careful you may be depressed because the money is not coming as expected. Caregiver (CG)

Patients level challenges

Stigma, fear, and sociocultural influences

Another outer setting barrier to accessing care and adhering to treatment was the impact of fear, stigma, religious and sociocultural influences. Fear was primarily driven by concerns about side effects, either experienced personally or shared by other patients. Healthcare providers often cited faith as a reason for treatment delays and interruptions. Additionally, family members played a significant role in influencing patients' decisions. Most HCWs acknowledged these realities along with their associated effects. Some providers noted the influence of religion on adherence and the decision to seek care. For instance, two providers expressed,

I mean, you can easily question why do these patients present late to the hospital because someone hasn't intercepted their treatment presentation, so its usually a religious leader, the Islamic cleric or, the pastor, or the local traditionalist who intercepts them and tells them to use herbs. HCW _Oncologist

The second barrier is the treatment barrier. Now, because of the patients in our local environment, there's a social-religious cultural hold on those patients. They usually go to religious leaders. First, that is what I said, the treatment barrier, so these religious leaders usually intercept treatment except for those who are enlightened. A lot of them exploit the patients, taking them into prayer houses and prayer programs and all of that; they pay for such services, and at this time, the disease is progressing, the disease is advancing so that is the other barrier. HCW_Oncologist

Another provider shared about fear and its influence on the same,

So, yeah so they are always scared to come and take the next one. They are scared of it, because they just finished one side effect and that as I'm aware of entirely, and coming to take another one, they would not want to. So I will tell them. Oh, just do your blood test. Let's see what your blood test is. Okay. If it's okay, I'll just encourage them just come and take it. You'll be fine. Some is not about money, some is about money, some is about the side effects they are feeling on other moments. HCW_Patient Nav

Closer connections also played an influential role in decision making. One patient shared an instance,

Some people they say, okay, you are going for mastectomy that is what you need. Due to this from, their husband would say if you try it if you try it, do not come back to the house. That is a problem for the woman and some people from there, they will not do it. Before you know it, everything escalates, and they are gone. FBC_Patient

A provider had similar sentiments,

The influence of people around them, you know, because a lot of time give you a prescription or you counsel them on a course of treatment or give them something with regards to their treatment, and then you go outside and hear and see the direct opposite and for some reason 80 to 90% of the time they follow that other person outside. HCW_oncologist

Stigma was also mentioned by some providers and patients. One patient spoke about the feelings of stigma associated with cancer treatment,

I'll go to church sometimes I used clothes I fold it and put pin so now I can't wear a bra just to make it look like there a breast there that's how I would go to church sometimes. FBC_Patient

Characteristics of individuals (patients)

Information seeking behavior and mindset

In addition to these barriers, many patients shared strategies and behaviors that they found effective in promoting a better quality of life. Most patients reported the common approach of maintaining a positive mindset and engaging in uplifting activities, such as listening to motivational videos or gospel music, for encouragement. As shared by two patients in the following quotes:

It's with prayers and support from your family and you, telling yourself that you can make it telling yourself you can make it and that you can push through. No matter how it comes, you'll be able to pass through that. FBC_Patient

What helped me is that if I find myself in that mood. I play some Christian music or I read my Bible, or my family is there. FBC_Patient

Additionally, most patients frequently reported at least one encounter of accessing the internet to seek additional information. One patient shared,

But even at that, I was using my Google to check some things. Why am I feeling like this? Why am I feeling like this? Or when you take this type of chemo, look at what issue is expected. Patient_FBC

Patient needs resulting from disease and treatment effects

An important justification for implementing cancer survivorship programs is the need to address the non-clinical needs of cancer patients. As patients shared their experiences, all highlighted both the physical and psychological effects of the disease and its treatment. These assertions are highlighted in some quotes below,

You know, the whole body system has really changed. So one, I'm always conscious around you know my breasts because I did mastectomy. FBC_Patient

I won't lie to you. Sometimes you feel depressed sometimes you will not be happy seeing what you are passing through or going to the mirror to look at yourself all your hair gone. You don't know what you now look like * sigh, you just you might feel that. FBC_Patient

External support and policies

Government commitment and initiatives on cancer care

At the government leadership level, there was concern about the perceived lack of accountability and ownership from the government in ensuring the sustainability and widespread implementation of new programs, as noted by a majority of the providers. Providers pointed out a disconnect between their needs and the support offered, which was often hindered by a top-down approach where recommendations were frequently shared without clear strategies for follow-through. Despite these challenges, many providers conveyed a sense of optimism and renewed momentum, believing in the potential that comes with new leadership and their extensive experience. As shared in the following quotes from providers,

What we have seen time and again is that we have a lot of paperwork, but there's no push by the government to implement it and make sure that it's reflected. HCW_Oncologist

There are policies are coming up now. To promote the use. And I said a lot a lot of interest, a lot of interest that's now gone into cancer care. So policies around care, you know, are being developed, but those are still in their infancy. HCW_Oncologist

Caregivers

Caregivers play a crucial role in cancer care, as highlighted by the most interviewed participants. They provide essential physical, emotional, and financial support to patients. They help with daily tasks and decision-making as they navigate care. As such, caregivers were asked to share some of their needs and experiences. All shared the emotions and associated anxieties associated with caring for a loved one. This quote from a spouse highlights this,

This question you ask ehhh I want even my worst enemy to go through the experience I went through is not a good feeling It's not something one wish somebody to undergo It's not easy as humor, even as I'm talking, if not because am a man, I'm just constraining my pain and my tears there is nobody that will go through such experience that is very painful that you see all over yourself you can't sleep the psychological and the emotional trauma, the stress. Caregiver

Most caregivers spoke of their responsibility to ensure that patients have the funds to access and continue care, often involving exploring all available means to solicit financial support. Some discussed how they became ostracized due to the negative reputations they gained from frequently seeking financial assistance from members of the community. One caregiver shared,

there are other challenges we know majorly treatment it has to do with financial challenges when you have your attention on how to look for attend to each treatment and the challenge is that even when you are search for funds people will reject you, irritate you some will not accept you some would think you are lying, you are scummer, some who think you are trying to trick on it, while some will believe on you. Some will even begin to think you are a liability to them when you begin to, because of the consistent test, you know…. Caregiver

Local attitudes

Faith, familial and community support

Family and community were continuously spoken of as essential pillars in the lives of patients as they navigated the challenges of cancer diagnosis and treatment. All patients highlighted the support from family in their involvement, including spouses and the wider community who offered emotional and practical support throughout their treatment, One female breast cancer patient remarked,

I was fortunate to be around the people that really loves me and care about me.

So I think if one is going through such, And if you have people that really loves you around, you know, they pamper you, make you feel that you don't have that much problem… FBC_Patient

Another said,

…. and the children coming around encouraging you, asking your question, praying with you. FBC_Patient.

Alongside this support, faith served as a crucial source of strength and hope for all patients. Every patient credited their support systems and treatment outcomes to God, with some going further to attribute the wisdom of their healthcare in managing their care to God's guidance: A male breast cancer patient mentioned,

What got me going was my faith. That God was going to heal me. Apart from what both our. I always tell people that even that where you believe in God for God to heal you have to follow your doctor instruction, because I, on my own understanding. I believe that it's God that gives the doctor the wisdom. MBC_Patient

The findings identified barriers, including inadequate human resources, limited infrastructure, and knowledge gaps, while also highlighting opportunities that can be leveraged in outer settings, such as the exisiting hospital infrastructure, community support, and communication practices.

To the best of the researcher's knowledge, this is one of the first studies in West Africa to examine the cancer care pathway from a qualitative perspective to identify factors that may inform the implementation of cancer survivorship guidelines. The study comes at a critical time as the country has made significant strides in survivorship care, including incorporating survivorship into the latest national cancer control plan. Some of the barriers identified in the study are not unique to cancer care, specifically human resource constraints and the financial burden of accessing care. This overlap emphasizes the importance of strengthening comprehensive health systems that would not only benefit the cancer survivorship component of care or cancer patients but also improve broader health services delivery.

Cancer survivorship care model

Several cancer survivorship models have been developed, and selecting the most appropriate model requires careful consideration of contextual factors, including available resources and institutional practices. Based on the findings of this study, two models are particularly relevant for the settings: the General Survivorship Care model and the Transition to Primary Care model (13). The General Survivorship Care Model focuses on providing continuous care through specialist providers within a survivorship clinic, with referrals made for additional services (13). The Transition to Primary Care Model involves transferring care to primary care providers after completion of initial treatment (13). Given the structural and human resource limitations at the institution, both models aim to alleviate pressure on existing providers. The General Survivorship Care Model provides an opportunity for additional support through specialized clinics and finessing of the interventions at a tertiary facility, while the Transition to Primary Care Model could help distribute care to lower-level facilities, thus building capacity and ensuring sustainable care. Strengthening services at the primary healthcare level offers a sustainable solution to addressing human resource constraints while also reducing financial barriers by bringing services closer to the community.

Bridging knowledge gaps

The significant knowledge gaps among healthcare workers, many of whom were unfamiliar with the NCCN harmonized cancer survivorship guidelines for sub-Saharan Africa, represent the first significant barrier that stands to limit the integration of recommendations into routine care at the facility. While the inclusion of survivorship care services is relatively new, some recommended services are already being implemented as communicated by a provider, “ For monitoring the long-term effects, we do virtual consultation for the patients to ask them how they are coping with the chemotherapy. We also give them appointments to come to the center for follow-up visits.” However, these services not be formally recognized as part of survivorship care due to differences in terminology, and furthermore, they may also lack structured and standardized implementation. This highlights the need for systematic assessments at healthcare facilities to identify and document services that align with the guideline recommendations, with the goal of formalizing these services within a structured survivorship program. Additionally, appointing departmental leads, who already exist in this setting, to oversee the program implementation and ensure programmatic oversight will be critical for the successful integration and sustained delivery of cancer survivorship services.

The strong communication infrastructure presents an opportunity for adopting successful models of guideline implementation, where education through peer-to-peer learning has been shown to be an effective dissemination strategy (14). There is growing evidence that traditional training methods alone are ineffective in changing behavior (15). Therefore, training for survivorship care provision should be customized to align with the learning culture, available tools, and resources that are contextually appropriate. It should also consider the use of adult learning methodologies and theories. Furthermore, it is crucial to design training with evaluation measures for both immediate learning outcomes and impact, such as improvement in patient outcomes.

The established communication networks within the healthcare facility can be leveraged to promote collaborative decision-making and disseminate knowledge on new recommendations and practices. Numerous studies in low-income populations show limited dissemination of clinical guidelines (16), emphasizing the importance of clear and structured implementation strategies. These may include training on new services alongside other behavioral change catalysts, such as clear communication about implementation opportunities, cues, and motivation to facilitate the process.

Addressing financial constraints

Financial constraints emerged as another significant and pervasive barrier impacting all aspects of cancer care, including cancer survivorship care. Patients' reliance on personal funds to cover treatment costs not only restricted access to various aspects of treatment but also exacerbated the financial strain on their families. This, in turn, led to disruptions in education and employment while also negatively affecting the psychological wellbeing of both patients and their caregivers. Financial impact and its implications for access to care in LMICs have been extensively documented in literature (17–19). A heartbreaking patient narrative, “ This thing turned me to beggar ” underscores the harsh realities faced by cancer patients. The broader effects on family wellbeing were particularly noteworthy, with another patient noting, “ I can't sew clothes, the money that I am using for fabric business, the capital is gone.” Addressing this challenge necessitates comprehensive systematic reforms engaging key partners.

Cancer survivorship recommendations should include opportunities to inform patients about available financial assistance programs. This may involve formalizing partnerships with local charity organizations, which were mentioned in the study in a few interviews. While this support may not cover treatment costs, small contributions toward food or accommodation during treatment would make a significant difference. As one caregiver shared, “ I tell you. As we as we speak, if we have somebody that will give us. I wouldn't know your value of currency in Nigeria if as little as 5,000 naira. If you see somebody that's having this issue, you say take. I'm telling you. It's a great relief. Even just to buy water.”

Considering the severe financial burden that cancer care and treatment impose, it is essential to integrate strategies for alleviating this burden into the core implementation plans of each recommendation. Such measures must be prioritized to ensure the successful and sustainable adoption of the recommendations.

Acknowledging the limited resources available for budgetary allocation, it is essential to explore alternative funding mechanisms to finance cancer care in LMICs. These include forming partnerships, establishing universal, affordable health insurance programs that can negotiate treatment costs, and ensuring access as well as other potential cost-sharing mechanisms (20). Additionally, numerous countries implement mandatory pension systems that gather contributions from workers to ensure their financial security in retirement. These funds may also be directed toward cancer research and treatment, offering crucial financial support. (20). Notably, these were also suggested recommendations from the study participants, “ Well, my own idea is I think the government needs to do a lot about this, you know. If there is a way they can have a special, you know, tax fund for those who are passing through this type of disease. And you know they can involve, they can involve organizations, you know. Helping people out.”

Leveraging faith, social and family support

Support from family and the broader community proved crucial in offering financial, physical, and emotional support to patients. In this context, spouses significantly contributed to caregiving and decision-making, which illustrates the communal approach to care in this society. This underscores the need for culturally tailored survivorship interventions that recognize and utilize these vital relationships. Social support significantly influences emotional adaptation to a cancer diagnosis, better quality of life, and prognosis (21–23). In this context, faith served as a strong pillar of hope and support. Patients relied on their belief in God to address the gaps in their cancer care experience. Many viewed God's presence as central to their journey, believing that even family support or care received at the hospital was ultimately a blessing from God. As such, faith-based organizations and other community support groups were similarly recognized as valuable resources offering psychosocial support and, at times, financial assistance. Failing to fully utilize these resources, even in generic recommendations, is a missed opportunity for holistic cancer care. A key consideration may involve decentralizing some services, such as services to address psychological distress or stigma, by training and equipping community-level groups and faith-based organizations to deliver these services locally. Deep faith also shaped their perspective on challenges. For instance, despite experiencing shortfalls in accessing healthcare services, many patients felt reluctant to complain. Given the blessings they had already received, they believed it would be selfish to focus on the negatives. One patient noted, “ Unfortunately, at that time. I was out of job. I see things were very, very rough. Tough, in fact, * inaudible, but by the grace of God. I say, Christian, the Bible, says everything, give thanks. I say, Okay, if that is how it is, that is how it is.” A caregiver also said, “ There was a time when she was under chemo, she couldn't walk, she have to pee on the vessel, I would be the one to go and throw it away I don't feel like talking is pathetic, but I just thank God for his grace, I thank God for His grace.” Given the role of faith as a source of emotional and social support, incorporating faith into survivorship care can serve as an effective strategy to address distress, raise awareness, and provide holistic support. Acknowledging faith in care may foster a culturally responsive environment that may enhance adherence to treatment but also ultimately have a positive effect on patients' quality of life.

Caregivers similarly play a central role in a patient's journey, often spending most of the time with them and, in many cases, making decisions on their behalf. The significant responsibilities placed on caregivers have been widely documented, with evidence showing that this process may have negative effects on their wellbeing, which may, in turn, affect the patient's care and possibly their prognosis. Therefore, survivorship recommendations should include strategies to support and protect caregivers, offering opportunities for them to enhance their health literacy and learn coping strategies to address their unique challenges.

Addressing stigma

The stigma surrounding mastectomy and the consequences of chemotherapy create additional barriers to care. Patients' reluctance to have surgery, shaped by cultural views on body image, can mirror broader societal beliefs about femininity. These observations align with other studies in comparable contexts, highlighting the harmful effect of stigma on not only accessing care but also on treatment adherence (24, 25). To address such barriers, interventions need to look at various possibilities of normalizing cancer treatment such as engaging supportive survivorship networks and education to challenge prevalent misconceptions (24). The demonstrated strengths in provider-patient communication, along with the collaborative culture, present an opportunity to educate and dispel misconceptions.

Advancing health literacy

Patients' proactive information-seeking behavior, particularly through internet resources, highlights an opportunity for patient education initiatives focused on cancer survivorship recommendations. Utilizing digital platforms to disseminate accurate and evidence-based cancer information and mitigate misinformation. Digital health literacy aligns with global trends and has been shown to improve patient education and self-management (26). Nevertheless, research warns against unguided use of digital resources, as it may subject patients to misinformation, particularly in settings with varying literacy levels. Effective digital health initiatives have utilized structured strategies to address these challenges, which incorporate pairing online resources with personalized support (26).

Although the NCCN harmonized cancer survivorship guidelines offer evidence-based recommendations, their practical implementation in Nigerian healthcare requires thoughtful attention to local financing mechanisms, workforce capabilities, and cultural relevance. Our research indicates that effective strategies must address both upstream factors, such as health policy and financing, and downstream components, including provider training and patient engagement. It is also crucial to recognize the essential role of family support systems and religious organizations in promoting positive health outcomes and to incorporate some of these aspects into the recommendations.

The study highlighted factors that align with the CFIR implementation science framework, reinforcing the importance of inner and outer settings as well as intervention characteristics as key factors influencing the implementation of evidence-based interventions. However, the study suggests extending the individual characteristics construct to encompass factors in the outer setting environment rather than limiting it solely to the implementers of an intervention in the inner setting. This was evident in the attributes of intervention recipients that may play a significant role in supporting the implementation of evidence-based recommendations, especially in the context of cancer survivorship. To substantiate this, future research should collect quantitative data to test the hypothesis that the characteristics of patients or recipients of interventions influence the implementation of evidence-based interventions.

Recommendations

Based on the findings of this study and guided by the CFIR framework, we propose the following actionable recommendations organized by implementation priority.

To prioritize the recommendations, the first step would be to address the knowledge gaps using effective dissemination methods. In addition, upstream stakeholders should consider adding appropriate national implementation strategies informed by subsequent in-depth analyses across diverse cancer types and treatment settings.

Similar efforts should be made on the community level to equip social support groups to better support cancer patients in addressing the psychosocial challenges of late and long-term effects of cancer. In addition, such efforts should consider the position of faith and how it can be integrated as a component of holistic care. Support could include disseminating tools, resources, and accurate information to address misinformation, all of which can be shared through social channels.

At the patient's level, the existing coping strategies, such as positive mindsets, can be shared with other patients through digital platforms in addition to other information pertaining to cancer care, tools and resources to better support them through the process (Table 2).

Study limitations

This study's findings are not without limitations and should thus be interpreted within the context of the study site. The study was conducted at a single cancer care site in Lagos, Nigeria, and as such, the findings might not be generalizable to other sites or populations. Furthermore, the recruitment strategy used may have introduced selection bias, possibly missing patients who have been lost to follow-up or who do not own telephones and underrepresenting other significant barriers. This is particularly important given the heterogeneity of the disease and its treatments. Despite efforts to achieve a diverse representation of study participants, the study's sample included a limited representation of male patients, caregivers, providers from other lower-level facilities, and patients diagnosed with other cancer types, potentially not being able to capture the unique experiences and challenges of these populations. Notably, the majority of patient participants had breast cancer (8 of 9), which limits the transferability of findings to patients with other cancer types. All key informant interviews took place on Zoom, potentially limiting the assessment of non-verbal communication. Despite these limitations, the study allowed for an in-depth exploration of implementation factors to be considered when preparing for the broad rollout of the harmonized cancer survivorship guidelines in Sub-Saharan Africa.