Understanding Cultural Barriers Improves Breast Cancer Navigation in Low-Resource Environments

Background: Patient culture creates a transparent yet substantial barrier to medical care: (1) Inadequate communication, poor public literacy, and language differences alter response to health messages; (2) Delays in accepting treatment suggestions, differing beliefs of disease/healing results from conflict between traditional medicine, cultural beliefs, and conventional medicine; and (3) Rejection of biomedical model due to failure in communication and understanding.

Introduction: Healthcare disparities studies rely on socioeconomic factors to explain physical barriers, such as the inability to pay for services or transportation. Few studies examine the patient belief systems or the lack of healthcare navigators, which results in an equally substantial barrier to breast cancer care.

Understanding the beliefs of patients through a culturally similar navigator/counselor may facilitate compliance.

Methods: The Helen Joseph Hospital Breast Care Clinic manages 500 to 700 patients monthly, with approximately 350 new diagnoses each year. Locally advanced disease accounts for the majority (62%) of breast cancer diagnoses. Navigators are breast cancer survivors with diverse cultural backgrounds, ages, and ethnicities who function as clinical coordinators/counselors ensuring compliance.

This system provides awareness of unseen barriers around patient care from failed clinician communication.

Results: Navigating the divide of breast healthcare

Phenomena that affect help-seeking behavior are ignorance of what the symptom means; fear of management strategies; and outcomes of the disease/treatment process. Conceptualizing 3 navigational barriers created a patient care model to ensure better outcomes.

1. Navigating the Neighborhood
   Patient navigators from the community highlighted reasons for failure and redirected information based on cultural belief systems, resulting in an increase in patient attendance. Problems such as the diversity of languages spoken, poor literacy, and suspicion of accepting advice from women of different cultural backgrounds were corrected through involvement of the navigator, who provided personalized information and training in understanding preconceptions/beliefs around the cause of cancer, which were resulting in women not accessing care.
2. Navigating Hospital Environments
   Insight into the perception of a “hostile hospital environment”: Accessing chemotherapy facilities, hospital admissions for breast cancer surgery, transportation, and monetary issues prevent patients from attending clinics. Receiving medication and collection of medication repeats in financially burdened patients affect compliance. Daily trips to clinics may result in the choice of mastectomy over breast conservation.
3. Navigating Medical Consultations
   Misinformation around treatments, or complications around clinical modalities of care may not be addressed by the treating physician. Some cultures do not have a model of patient autonomy, with disease perceived as a family issue. It is important to ascertain to whom news of diagnosis should be directed. Each patient is contacted monthly to determine concerns (logistically and medically) to facilitate compliance to treatment.

Concerns around the concept of a mastectomy is not a phenomenon unique to non-westernized cultures and is often managed insensitively by medical practitioners with the attitude of “life over limb.” Women may be unaware of advances such as breast conserving surgery and delay treatment due to fear of mastectomy.

Conclusion: The interplay between medicine, culture, and beliefs in breast cancer underlines the importance of patient navigators on the multidisciplinary team. Navigators should have diverse medical and cultural areas of expertise ensuring communication between physicians, patients/families, and communities.