Introduction
Female breast cancer has become the leading cause of cancer death in low and middle-income countries and, therefore, a challenge to their health systems [
1]. In Brazil, about 40% of the cases are diagnosed in stages III or IV, and only after the onset of symptoms [
2].
Prevention actions and timely access to resources of medium and high complexity for diagnosis and treatment of breast cancer are priorities of public health policy in Brazil [
2]. In addition, the Brazilian public health system plays important role in oncological care. Patients diagnosed with breast cancer through private health insurance often migrate to public health system for chemotherapy and radiotherapy, among other procedures [
3]. Therefore it is expected that there will be no inequality in access to diagnosis and treatment caused by economic or social disparities. However, breast cancer diagnosis, treatment, and mortality indicators are not equally distributed among the female population. Some characteristics, such as poverty, low schooling, and non-white ethnicity have been associated with late diagnosis, worse prognosis and lower 5-year survival [
4,
5].
Differentials in access to treatment for breast cancer according to individual attributes have been previously identified. In a Brazilian capital it was observed that non-white women with less than 8 years of schooling, when compared to white women with 12 years or more of schooling, had a greater probability of waiting > 60 days to start treatment after diagnosis, even when already registered at an oncology service. According to the authors, characteristics of social vulnerability are associated with the production of inequalities even after the access barriers have been overcome [
6]. Qualitative studies have contributed to the understanding of women’s behaviors and perceptions towards seeking preventive care [
7,
8]. The most frequently investigated population segment is one that presents characteristics of social vulnerability and does not fit into said care, either due to difficulties in scheduling appointments and examinations, or due to behavioral barriers (lack of information, fear, shame, etc.). Given this context, it is necessary to know how women from different social groups perceive their disease process and care trajectory to establish comparisons and investigate differences in the care received.
Through an interpretative analysis of the narratives of women with different sociodemographic profiles of breast cancer diagnosis and treatment in Belo Horizonte, Brazil, this study aimed to investigate differences in their care trajectory and to verify the mechanisms involved in producing these differences.
Methods
It is a hermeneutic study in which the meanings attributed to experience are explored according to the perspective of those who experienced it [
9,
10]. Hermeneutic or interpretive methodology has been used in the field of medical anthropology for the analysis of the cultural and symbolic dimensions of health, disease and care processes [
11].
The strategy used to know the experiences of women in breast cancer treatment was the analysis of narratives. In the narrative of lived experience, the sequence of events is established in a coherent way, according to the degree of importance and significance that the narrator attributes to each event [
10]. In this way, it is possible to access central aspects of the elaboration of the experience of illness according to specific social contexts [
12].
Subject selection was based on data from hospital records of four public and private oncology services in Belo Horizonte, Brazil, according to the following variables: age, schooling level and treatment cost source (income Proxy). The search met the following criteria: women undergoing breast cancer treatment diagnosed between 2011 and 2015, older than 18 years, living in the municipality and with valid information on the defined variables. Two hundred fifty records were selected. Based on these data three profiles were characterized: Profile 1 (N = 80), women aged 47 to 72 years, predominantly with ≥ 15 years of schooling and exclusively private treatment funding; Profile 2 (N = 78) women aged 40 to 71 years, with 11 years of schooling and predominantly public treatment funding; Profile 3 (N = 92) women aged 34 to 82 years, with ≤8 of schooling and exclusively public treatment funding. The recruitment of the participants was started from the women in profile 1 followed by profiles 2 and 3. It was finalized when the sufficient number of interviewees in each profile was reached. This number was defined through the technique of conceptual saturation. Of the 250 women initially selected, 57 were contacted by phone; after hearing the explanation of the study objectives, 35 agreed to be interviewed. Of these, seven (7) had characteristics of profile 1, thirteen (13) of profile 2 and fifteen (15) of profile 3.
In-depth interviews [
13] were conducted by ALLVC the between April and July, 2016. The following request was made to the women:
I would like you to tell me everything about this episode in your life [breast cancer]
, from the moment you think it started. In the narrative about the trajectory, some specific information interested us: habits and perceptions about preventive care; the moment of identification of signs or symptoms (suspected); perceptions about attention received.
Five pilot interviews tested the appropriateness of the guiding question. In addition to the conceptual saturation technique applied to the interviews with each of the profiles, to ensure the validity and reliability of results, we identified and assessed exceptions, compared women in the same profile and between different profiles and contacted some of the respondents by phone to confirm information, according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) [
14].
The interviews were transcribed verbatim by ALLVC and four research assistants. The narrative of each subject was identified with the letter P (profile) followed by the profile number (1,2,3) and the respondent’s number (N) of order within the profile. In the next stage of the analysis we aim to identify the elements that, according to Good [
10], characterize the construction of the illness narratives, namely: the construction of the plot, which indicates the sequential organization of events and the relation between them; the meanings attributed to illness and the facts and events highlighted in the construction of the narrative; the experience of illness in the interviewee life context . After repeated tapping and reading of the recorded and transcribed material, the researcher proceeded to identify of themes common to the three groups. The product of this work was the construction of an interpretive synthesis of narratives of each profile, structured around the themes identified.
This study is part of the research project “Mulheres com câncer de mama em Belo Horizonte: perfil, trajetória e representações sobre o cuidado” [Women with breast cancer in Belo Horizonte: profile, trajectory and representations about care], approved by the Research Ethics Committee of the Universidade Federal de Minas Gerais (UFMG), process 48,120,614.3.0000.5149. All ethical precepts were respected. The subjects read and signed the Informed Consent Form before the interview began and had their identity preserved in result presentation.
Discussion
This study compared the breast cancer care trajectories, in a Brazilian capital city, of three different women profiles, defined by age, level of schooling and treatment funding (income proxy).
The main results suggested that the differences found in breast cancer care among the participants may be related to social inequalities, i.e. those that, when associated with individual characteristics such as schooling, income, ethnicity and others, put certain groups at a disadvantage compared to others [
15].
Directly or indirectly, these inequalities apparently result in lower-quality care to women of greater vulnerability: asymmetrical relationships with healthcare professionals and services, resulting in negligent and discriminatory service; priority in providing services to private health insurance users to the detriment of public health system users in health units accredited by the public health network and that serve these two groups; difficulties in the course of treatment, such as long and uncomfortable trips in public transport, no companions and no proper meals on chemotherapy days; precarious employment conditions, which hinder the search for preventive care and create lack of confidence due to the risk of unemployment after treatment.
Regarding the preventive care behavior, the narratives of each profile confirmed the findings from the literature: women of higher income and schooling were more likely to perform routine exams than women of lower income and schooling [
16]; adherence to screening mammography decreased as age increased (> 69 years) [
17,
18]; among younger women, not considering the possibility of having the disease was a factor - attributable to both patients and physicians, which might have contributed to late diagnosis of the disease [
19].
Women in profiles 1 and 2, in search of a plausible explanation for the disease, maintained constant vigilance over their own body. Preventive care recommendations from physicians, government guidelines or the media, seem to remit to the individual the responsibility for a possible occurrence of the disease. After treatment, the risk of recurrence exacerbated this self-vigilance in such a way that daily activities were re-evaluated considering the following question: “will this favor cancer or not”? [
20].
Castiel [
21] drew attention to the “
blaming the victim” mechanism created by coercive forms of controlling health-related behaviors, based on the autonomy argument. This perspective does not take into account the unpredictability of some health issues, nor the difficulties experienced by people seeking care [
22].
Among women in Profile 3, recommendations about preventive exams and how to get them were not ignored. Differently from women in profiles 1 and 2, such practices were not top priorities in their life contexts. According to the literature, low-income working women and those who are the heads of the households tend to use health services less than those living in male-headed households [
22]. Moreover, activities lacking social protection, such as informal work (odd jobs) or work performed by day laborers, hamper the regular use of health services [
23]. The opening hours of primary care units, which coincide with women’s work hours, are another obstacle. In this context, the search for medical care will take place imperatively, in borderline situations, − pain or any sign of abnormality - which would increase, in theory, the probability of a late diagnosis.
The reasonable waiting time for consultations and examinations among women with private health insurance contrasts with the difficulties faced by users who exclusively used the public system. Fragilities of the public system at the primary and specialty levels encouraged the search for alternatives in the private system. The public-private mix, narrated by women in Profile 2, was an artifice used to overcome the delay in scheduling appointments and examinations. In these cases, vulnerable groups are the most penalized, because with all the obstacles of the public system and without private health insurance, they resorted to out-of-pocket payment to expedite the diagnosis [
24]. Facilitating access through personal relationships with healthcare workers was another strategy present in the narratives and previously identified by other authors [
25]. It is important to emphasize that the use of parallel and informal systems make it difficult for the patient to link with the team and for the coordination of care which are fundamental roles of primary care [
26].
From the perspective of critical medical anthropology, one of the characteristics of the hegemonic biomedical model is to exclude from the “care sphere patients themselves, their biography, their local world and also their social conditions and existence materials” [
11]. The disease rather than the patient is the priority of medicine. This model implies an asymmetry in the relationship between physicians and patients, where the former, unilaterally and without prior negotiation, define the rules of treatment [
27].
Among the study subjects, these assumptions were shown in the reports of treatment protocols being applied without any dialogue, which creates anxiety and fear. However, women in profile 1, and some in profile 2, exercised their right to information about the treatment processes and the choice to receive them or not. This appropriation of the treatment process is enabled by an active interaction with physicians and other healthcare professionals, which seemed to contribute to decrease the impact of the treatment phase [
28].
There is evidence in the literature that good doctor-patient communication positively influences emotional health, functional status, and pain control, but for improved communication to occur there needs to be a “shift in the balance of power between physician and patient” [
29].
In the light of these observations, the narratives of women in profile 3 about ironic or disrespectful behaviors of healthcare professionals along the way, especially physicians, may suggest differences in the relationships with different patient profiles. It may be assumed that, in some cases, the greater the difference in social position between physicians and patients, the more distant and less empathic the relationship between them. And the opposite is also true: relationships between physicians and women of similar levels of schooling and income entails more balanced power relations, since both sides have attributes - or symbolic capital - that give them prominent social positions [
27].
Studies with healthcare professionals demonstrated the existence of unintentional discriminatory approaches, rooted in negative cultural stereotypes that fall on certain social groups and result in poorer quality of care [
28]. Thus, a study conducted in a large Brazilian metropolitan area, women and the poor were more likely to report experiencing discrimination in the search for health care [
30]. Moreover, in the South region of the country, low socioeconomic status and ethnicity were associated with perceived discrimination in health care services [
31].
Farmer [
32] uses the term
structural violence, originally coined by Galtung [
33], to describe attacks on human dignity, reproduced by social structures and their practices predominantly based on historically determined inequalities. According to the author,
“Social inequalities based on race or ethnicity, gender, beliefs and, above all, social class, are the driving force behind most human rights violations. In other words, violence against individuals is generally embedded in a deep-rooted structural violence” [
32].
The perspective of structural violence allows us to think about discrimination in health care not only as a result of individual prejudice, but also as a product of fundamentally unequal social and economic structures that not only allow, but also naturalize behaviors, such as those observed in this study.
The perception of some women about the differentiated care provided to public patients in private units contracted by the public system which, in face of limited resources, prioritize the provision of services to health insurance patients is evidence of an institutionalized discriminatory practice. A study about the public-private mix in Brazil draws attention to inequities resulting from “inequalities in the supply, access and use of services and the behavior of professionals” between insured and uninsured patients in private units contracted by the Brazilian public health system [
34]. In the present study, it is noteworthy that none of the participants with treatment funded by the public system mentioned these disparities in care. Studies on how to measure discrimination stated that, since discriminatory acts are increasingly veiled (whether by law enforcement or social surveillance over politically incorrect behaviors), discrimination is often overlooked by the target [
35]. On the other hand, this denial can be a self-protection mechanism of people for whom “recognizing discrimination is like experiencing again the degrading experience” [
27].
Adding to this logic, and based on the tolerance seen in women in profile 3 regarding the adversities experienced in their care trajectory, one may suppose that, at the start of treatment, after feeling threatened with being deprived of their right to care, they are grateful as if they were in the receiving end of a huge favor. This effect seems to be fed by and, at the same time, feed the perception of “beneficence” that some professionals have of their work, and which ends up clouding the patient’s awareness of their right to health care [
27].
Other dimensions of inequality in health care go beyond the limits of health services and affect the quality of life of women, with devastating consequences. This is the case of mutilating surgeries, as well as omission or denial of the right to breast reconstruction, and other consequences of professional negligence and institutional ineptitude, to which the concept of structural violence can and should be applied to bring such practices to light as a first step towards overcoming them and achieving social justice.
Some limitations of this study require consideration. The respondents in this study do not represent the totality of women on treatment for breast cancer in the city. Information on the itineraries and clinical details of the treatment - except for cancer staging upon diagnosis - were obtained from the participants’ narratives. Therefore, biases are expected and considered important, since they show how respondents perceived the reality they lived in.
Conclusion
The analysis of the narratives provided clues in pointing out situations that resulted in the loss of quality of attention to women of greater vulnerability and could be understood as discriminatory acts, such as negligent and disrespectful behaviors of health professionals in dealing with the patient.
Other important problems related to the breast cancer care have been identified: precarious labor ties that make it difficult to seek preventive care, suffering during treatment caused by material and immaterial deprivation, lack of basic social support in post-treatment, among others.
Taken together, the findings of this study refer to a citizenship problem that, for vulnerable groups, appears to be a distant and abstract concept. These are issues that should be addressed in future studies to support the formulation of policies and strategies that meet the needs of care of women from different social groups, from prevention to post-treatment of breast cancer, so that social inequalities do not result in inequalities of attention.
Finally, we hope that this study contributes to the qualification of breast cancer care in Brazil. The results presented here reflect the reality of a country that ages - and falls ill - without having solved its main challenge: social inequalities.
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