Illness Experiences, Collective Decisions, and the Therapeutic Encounter in Indian Oncology

Improving Access and Health Outcomes in Palliative Care through Cultural Competence: An exploration of opportunities and challenges in India

People who belong to ethnic, racial and cultural minorities often have less access to healthcare and have poorer health outcomes when compared to the majority population. In the COVID pandemic, too, health disparities have been observed. Similar disparities have been noted in patients with advanced disease and suffering from pain, with minority patients having less access to or making less use of palliative care. In the US, a range of solutions has been proposed to address the issue of inequality in access to healthcare, with cultural competence figuring prominently among them. This study explores whether and how cultural competence may be applied to palliative care in India to improve access and health outcomes. In the literature, it is argued that, in diverse societies, cultural competence is an essential part of the solution towards equitable healthcare systems. Solutions to problems of healthcare disparities must go beyond an increase in financial resources as more financial resources will not necessarily make the healthcare system more equitable. A culturally competent system recognises and integrates at all levels the culture as a significant component of care, which is particularly relevant at the end of life. If efficiently implemented, cultural competence will lead to higher patient satisfaction, better follow-up and patient compliance and an improved reputation of palliative care among minorities. This may help to reduce inequalities in access and health outcomes in palliative care.

'I don't talk about my distress to others; I feel that I have to suffer my problems...' Voices of Indian women with breast cancer: a qualitative interview study

Background

Breast cancer is the commonest form of cancer among women globally, including in India. The rising incidence in the developing world is thought to be due to increased life expectancy, urbanisation, and adoption of western lifestyles. A recent systematic review found that Indian women living in India or as immigrants in Canada experienced a range of psychological distresses both ameliorated and exacerbated by cultural issues personally, within the family, within their community, and in the context of faith, and only two of the five qualitative studies explored the experience of women with breast cancer living in India. Distress may also affect treatment compliance.

Aim

The aim of the study was to explore the psychological distresses experienced by Indian women with breast cancer living in Kerala, South India, during and after treatment and to understand better what helped to relieve or increase these distresses.

Methods

In-depth interviews were conducted with 20 consenting women undergoing treatment for breast cancer. Purposive sampling was used to obtain maximum variation in sociodemographic and clinical characteristics. Interviews were verbatim transcribed, translated into English, and back-translated to Malayalam to ensure that the meaning had not been lost. English data were analysed using thematic frame work analysis and synthesised to provide a deeper understanding of the individuals’ experience.

Results

Three major themes emerged from the data. The first major theme was ‘far-reaching psychological distress’. This included anxiety, guilt, anger, and depression in response to the disease and physical side effects of treatment and issues relating to body image, especially hair loss and sexuality. The second major theme was ‘getting on with life’. Women tried to make sense of the disease, by actively seeking information, the role of medical professionals, and their practical adaptations. Many found a new future and a new way to live normal. The third major theme was the ‘support system’ strongly based on family, friends, faith, and the community which affect them positively as well as negatively.

Conclusion

Psychological concerns related to disease and treatment are common in Indian women with particular emphasis on body image issues associated with hair loss. Family and faith were key support systems for almost all the women, although it could also be the causes of distress.

Electronic supplementary material

The online version of this article (10.1007/s00520-020-05756-8) contains supplementary material, which is available to authorized users.

Indian patient use of cancer euphemisms: Association with psychological outcomes and health behaviours

OBJECTIVE

Euphemisms may be used to reduce the threat associated with the word "cancer." Cancer may be particularly threatening in Indian culture due to the myths surrounding its cause and prognosis. This study explored the prevalence of euphemism use by Indian patients and the relationship among euphemism use and illness cognitions, affect, health behaviour, and spontaneous self-affirmation (a behaviour associated with dealing with threat).

METHODS

In total, 350 cancer patients in India were recruited to take part in a study exploring patients' experiences of, and thoughts about, having an illness. They responded to a questionnaire measuring illness perceptions, coping strategies, anxiety, depression, health behaviours, and spontaneous self-affirmation. Patients were asked what words they used to describe their illness; euphemism users were those who used a euphemism (ie, non-medical term) as a first word.

RESULTS

About 51% of patients used a euphemism as a first word. Those with less education, unskilled employment, a lower income, and more children were more likely to be euphemism users. Euphemism users reported (a) weaker illness perceptions (less personal control, greater reporting of symptoms, and less understanding of their condition), (b) less use of 3 of 14 coping strategies, (c) less likelihood of spontaneously self-affirming, and (d) fewer healthy eating days.

CONCLUSIONS

Euphemism use in patients was not related to distress but was related to negative illness perceptions and use of fewer coping strategies, suggesting that we need further study about the extent to which euphemisms signal issues in psychological adaptation to cancer diagnosis.

Analysis of Social Science Research Into Cancer Care in Low- and Middle-Income Countries: Improving Global Cancer Control Through Greater Interdisciplinary Research

This analysis lays a framework for greater collaboration between the cancer community and social scientists in both research and policy. We argue that the growing cancer burden that low- and middle-income countries face is raising social, political, and economic challenges of global cancer that require interdisciplinary research beyond the traditional biomedical-clinical nexus. First, we briefly review some of the most important existing social science studies that have addressed cancer in low- and middle-income countries, including the main methods, approaches, and findings of this research. Second, we give an overview of recent interdisciplinary collaborations between social scientists and oncologists and demonstrate how qualitative research can help us to understand the distinct challenges of cancer care in low- and middle-income settings. Finally, we identify key areas for future collaboration and suggest possible paths forward for cancer research and policy that involve social science.