Impact of sociocultural factors on appraisal and help-seeking behaviour among Ghanaian women ...

298 Pages·2017·5.4 MB·English

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Thesis: Seth Wiafe (2017) "Impact of sociocultural factors on appraisal and help-
seeking behaviour among Ghanaian women with breast cancer symptoms",

University of Southampton, Faculty of Health Sciences, PhD Thesis, pagination.

UNIVERSITY OF SOUTHAMPTON

FACULTY OF HEALTH SCIENCES

Centre for Innovation and Leadership in Health Sciences

Impact of sociocultural factors on appraisal and help-seeking
behaviour among Ghanaian women with breast cancer symptoms

By

Seth Agyei Wiafe

Thesis for the degree of Doctor of Philosophy

February 2017

UNIVERSITY OF SOUTHAMPTON
ABSTRACT
FACULTY OF HEALTH SCIENCES
Doctor of Philosophy
IMPACT OF SOCIOCULTURAL FACTORS ON APPRAISAL AND HELP-SEEKING
BEHAVIOUR AMONG GHANAIAN WOMEN WITH BREAST CANCER SYMPTOMS
by Seth Agyei Wiafe
Breast cancer is a disease that continues to rise across the world, and it is now
the leading cause of death among Ghanaian women. Currently, an estimated 85%
of new breast cancer patients are diagnosed at advanced stages, resulting from
delay in seeking modern medical help. Although it is generally acknowledged that
early detection and treatment of breast cancer improves survival, it is unclear why
the majority of Ghanaian women take longer to present symptoms than those in
Western world. The aims of this study are; to ascertain how specific sociocultural
issues influence Ghanaian women’s appraisal of breast cancer symptoms, the
meaning they ascribed to those symptoms, the significance of this experience on
their timing and choice of healthcare utilisation, and whether these factors are
different in Ghana from those identified in Western countries.
A qualitative design involving purposive sampling was used to recruit 35 patients
awaiting their first medical consultation at two healthcare facilities in Ghana, 27
members of the patients’ social networks, and eight healthcare professionals. The
interviews were face-to-face audio recorded, semi-structured, and participants
completed a demographic questionnaire. Additionally, field notes and a reflective
diary were kept as supportive data. Thematic analysis was conducted to identify
relevant themes. A computer software package was used for data management.
The study found four main influential factors that contributed to late presentation
within the sample; these are patients’ sociocultural backgrounds, specific
manifestation of breast cancer signs, patients’ emotional responses towards
those signs and symptoms, and existing healthcare system. The study has
deepened the understanding of appraisal and help-seeking behaviour of Ghanaian
women who discovered breast cancer symptoms. These insights would assist
healthcare professionals to implement interventions capable of encouraging early
symptom detection and presentation for modern medicine treatment.

Table of Contents
Table of Contents ............................................................................................................................. i
List of Tables ................................................................................................................................. vii
List of Figures .................................................................................................................................. ix
Declaration of Authorship ............................................................................................................ xi
Acknowledgements .................................................................................................................... xiii
Definition of Abbreviations ........................................................................................................ xv
Chapter 1: Introduction and Background ........................................................................ 1
1.1 Introduction .....................................................................................1
1.2 Background ......................................................................................2
1.2.1 Information about Ghana..........................................................3
1.2.2 Breast cancer incidence and mortality ........................................ 10
1.2.3 Delayed presentation of symptoms ........................................... 12
1.2.4 Breast cancer control and prevention strategies ........................... 15
1.2.5 Sociocultural impact of delayed presentation ............................... 17
1.3 Justification for this research .............................................................. 18
1.4 Contribution of this study to understanding delayed presentation ................ 20
1.5 Structure of the thesis ....................................................................... 21
Chapter 2: Literature review .......................................................................................... 23
2.1 Strategy ........................................................................................ 23
2.1.1 Search for literature .............................................................. 23
2.1.2 Selection of papers................................................................ 24
2.1.3 Synthesis of themes and critical appraisal .................................... 27
2.2 Presentation of results ...................................................................... 28
2.2.1 Study location ...................................................................... 28
2.2.2 Methodology ....................................................................... 29
2.2.3 Theoretical framework ........................................................... 31
2.2.4 Stage at presentation ............................................................. 32
2.2.5 Major reasons for delay .......................................................... 34
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2.3 Rationale for conducting the research .................................................. 50
2.4 Research question, aims, and objectives ................................................ 51
2.5 Literature review post 2014 ............................................................... 52
2.6 Chapter summary ............................................................................ 54
Chapter 3: Methodology and methods ......................................................................... 57
3.1 Research design .............................................................................. 57
3.1.1 Research paradigm ............................................................... 58
3.1.2 Using a qualitative approach ................................................... 59
3.1.3 Data collection strategy ......................................................... 63
3.2 Ethics ........................................................................................... 66
3.2.1 Ethical approval ................................................................... 66
3.2.2 Informed consent ................................................................. 67
3.2.3 Anonymity and confidentiality ................................................. 67
3.2.4 Data protection ................................................................... 68
3.3 Selection and location of participants ................................................... 68
3.3.1 Selection of study sites .......................................................... 68
3.3.2 Participants and sample ......................................................... 69
3.3.3 Access to participants ............................................................ 70
3.3.4 Identification and recruitment of patients ................................... 71
3.3.5 Identification and recruitment of members of patients’ social
networks ........................................................................... 75
3.3.6 Identification of healthcare professionals ................................... 75
3.4 Data collection ............................................................................... 76
3.4.1 Completing the interviews ...................................................... 77
3.4.2 Completing the demographic questionnaire ................................ 78
3.4.3 Support for participants ......................................................... 79
3.4.4 Support for the researcher ..................................................... 79
3.4.5 Data collection summary ........................................................ 80
3.5 Data analysis .................................................................................. 80
3.5.1 Preparing the data for analysis ................................................. 80
ii
3.5.2 Methods of analysing qualitative data ........................................ 84
3.5.3 Thematic analysis ................................................................. 84
3.5.4 Data analysis procedure for all participants.................................. 87
3.6 Quality of the research ...................................................................... 95
3.6.1 Credibility ........................................................................... 95
3.6.2 Dependability and confirmability .............................................. 97
3.6.3 Transferability...................................................................... 98
3.7 Chapter summary ............................................................................ 99
Chapter 4: Findings ........................................................................................................ 101
4.1 Findings from interviews with patients ................................................ 101
4.1.1 Characteristics of the patients ................................................ 101
4.1.2 Themes and sub-themes for patients ....................................... 107
4.1.3 Theme 1: Cultural beliefs and practices ..................................... 107
4.1.4 Theme 2: Trust in the modern healthcare system ........................ 114
4.1.5 Theme 3: Emotional reactions to symptoms ............................... 120
4.1.6 Theme 4: Eliciting lay advice .................................................. 125
4.2 Findings from the patients’ social networks .......................................... 131
4.2.1 Characteristics of patients’ friends and family members ................ 132
4.2.2 Themes and sub-themes from friends and family members ........... 135
4.2.3 Theme 1: Superstitious beliefs about cancer .............................. 135
4.2.4 Theme 2: Protecting family from societal ridicule ........................ 136
4.2.5 Theme 3: Inadequate social support ........................................ 138
4.3 Findings from interviews with healthcare professionals............................ 143
4.3.1 Characteristics of the healthcare professionals ........................... 144
4.3.2 Themes and sub-themes from the healthcare professionals ........... 144
4.3.3 Theme 1: Cultural beliefs and practices ..................................... 145
4.3.4 Theme 2: Trust in modern healthcare systems ............................ 149
4.3.5 Theme 3: Societal perception of breast cancer............................ 153
4.3.6 Theme 4: Knowledge and experience of cancer........................... 155
4.4 Integration of findings ..................................................................... 159
iii
4.5 Facilitators for prompt help-seeking ................................................... 167
4.6 Chapter summary .......................................................................... 167
Chapter 5: Discussion .................................................................................................... 169
5.1 Introduction ................................................................................ 169
5.2 The patients’ pathways to modern medicine ........................................ 170
5.3 Contributing factors of symptom appraisal and help-seeking .................... 172
5.3.1 Patients’ sociocultural background ......................................... 173
5.3.2 Patients’ emotional responses to symptoms .............................. 174
5.3.3 Symptom manifestation ....................................................... 174
5.3.4 The healthcare system ......................................................... 175
5.4 The symptom appraisal interval ........................................................ 177
5.4.1 Detection of breast changes .................................................. 178
5.4.2 Interpretation of symptoms .................................................. 180
5.5 Help-seeking interval ...................................................................... 185
5.5.1 Motives for help-seeking ...................................................... 186
5.5.2 Final re-appraisal and decision to change help-seeking ................. 199
5.6 A conceptual framework of sociocultural determinants of delay in help-seeking
for breast cancer symptoms ............................................................. 201
5.6.1 Concepts and definitions ...................................................... 203
5.6.2 Perceived threat ................................................................ 204
5.6.3 Sociocultural representations of breast symptoms ...................... 205
5.6.4 Intentions for help-seeking ................................................... 207
5.6.5 Switching coping behaviour .................................................. 208
5.7 Chapter summary .......................................................................... 210
Chapter 6: Conclusions and recommendations ........................................................ 211
6.1 Overview of the study .................................................................... 211
6.2 The study’s unique contribution to knowledge ...................................... 212
6.3 Strengths of the study .................................................................... 214
6.4 Limitations of the study .................................................................. 215
6.5 Suggestions for future research ......................................................... 216
iv