title: A framework for improving early detection of breast cancer in sub-Saharan Africa: A qualitative study of help-seeking behaviors among Malawian women.
abstract: Many women in Africa are diagnosed with advanced breast cancer. We explored Malawian breast cancer patients' perspectives about their diagnosis and ability to access care to identify help-seeking behaviors and to describe factors influencing delay.
  
  
  
  We purposively sampled 20 Malawian breast cancer patients to conduct in-depth interviews. Transcripts were double coded to identify major themes of breast cancer help-seeking behaviors and what delayed or facilitated access to care.
  
  
  
  We outlined a breast cancer help-seeking pathway describing decisions, behaviors, and interactions from symptom presentation to receipt of cancer care. Patients were largely unaware of breast cancer and did not immediately notice or interpret symptoms. As symptoms progressed, women inferred illness and sought help from social networks, traditional remedies, and medical care. Economic hardship, distance to the facility, provider knowledge, health system factors, and social norms often delayed reaching the facility, referrals, diagnosis, and receipt of care.
  
  
  
  Social-contextual factors at the individual, interpersonal, health system, and societal levels delay decisions, behaviors, and access to breast cancer detection and appropriate care.
  
  
  
  A comprehensive approach to improving breast cancer early detection must address public awareness and misconceptions, provider knowledge and communication, and cancer care delivery.
authors.affiliation: Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA; UNC Project-Malawi, Lilongwe, Malawi. Electronic address: rkohler@email.unc.edu.
authors.forename: Racquel E
authors.initials: RE
authors.lastname: Kohler
authors.affiliation: UNC Project-Malawi, Lilongwe, Malawi; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, USA.
authors.forename: Satish
authors.initials: S
authors.lastname: Gopal
authors.affiliation: Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA.
authors.forename: Anna R
authors.initials: AR
authors.lastname: Miller
authors.affiliation: Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, USA.
authors.forename: Clara N
authors.initials: CN
authors.lastname: Lee
authors.affiliation: Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, USA.
authors.forename: Bryce B
authors.initials: BB
authors.lastname: Reeve
authors.affiliation: Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, USA.
authors.forename: Bryan J
authors.initials: BJ
authors.lastname: Weiner
authors.affiliation: Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, USA.
authors.forename: Stephanie B
authors.initials: SB
authors.lastname: Wheeler
mesh_terms: D001943:Breast Neoplasms / Q000175:diagnosis* / Q000208:ethnology; D057210:Delayed Diagnosis / Q000523:psychology*; D055088:Early Detection of Cancer; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D000066505:Help-Seeking Behavior; D006801:Humans; D007407:Interviews as Topic; D008295:Malawi; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000208:ethnology / Q000523:psychology*; D036301:Qualitative Research; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012923:Social Class; D012959:Socioeconomic Factors; D061665:Time-to-Treatment
keywords: Breast cancer; Breast symptoms; Delay; Early detection; Help-seeking behavior; Malawi; Sub-Saharan Africa