Social and Institutional Support in Breast Cancer Management among Elderly Women in Nigeria

The focus of the study was on the social and institutional support available in Nigeria for the management of breast cancer among elderly women. It examined the occurrence and sociocultural factors implicated in breast cancer among elderly women in Nigeria. It discovered that there is increasing incidence of breast cancer among elderly women in Nigeria with an equally increasing mortality rate due largely to low awareness of this menace among women who are past childbearing age. In addition to a low level of awareness are other sociocultural factors such as age, income, education, and the belief systems of the people that the study identified as drivers of increasing menace of breast cancer among elderly women. The above are compounded by the scarcity and inaccessibility of cancer treatment and management facilities in Nigeria. Incidentally, counseling services from such professions as social work and clinical psychology are hardly in existence, leaving the burden of management and care entirely to the families of those affected by the ailment. This calls for a rethink of the sociocultural and support context of public health management in Nigeria. This paper examines the availability and adequacy of existing social and institutional support for breast cancer in Nigeria.


Introduction
The paper using information obtained through a survey examines the social and institutional support mechanisms in breast cancer management in Nigeria. Its main assumption is that despite what may be considered an alarming incidence of occurrence nowadays, breast cancer in management in Nigeria seems bedeviled by inadequate support. In other words, in spite of a significant incidence of breast cancer in Nigeria, the public health system has not responded commensurately, while social support has been affected by wrong notions of causes and stereotypes with severe implications for health of those affected and coping capacity of families [1]. In other words, the quality and access of women to reproductive health services are important in confronting these health problems. In spite of the above, women can only seek them out when the need arises if they are aware of their existence and where they can be received. In other words, awareness and access are critical in obtaining breast cancer services in Nigeria. Consequently, the extent to which members of the society hold the informed perception about the nature and care of breast cancer is crucial in accessing health provisions and services targeted at the disease.
Given that reproductive health-care provisioning has to do with the availability of health-care services to individuals in the society with regard to their reproductive well-being, societal perception of the causes, nature and management of breast cancer can be seen as making a major difference in whether aged women afflicted by breast cancer survive or not [2]. Among women, older women, i.e. those beyond childbearing age, may be seen as particularly disadvantaged. This is especially the case of Nigeria where the health needs of elderly women are not totally covered given the lack of a clearly conceptualized social policy on health care of elderly members of the Nigerian population [3]. Therefore, the survival and meaningful existence of women may not only depend on the health-care services available but also on the conviction of elderly their families and the larger society of the need to spend both time and money on the reproductive health needs of these women even as they have passed the stages of conception and childbearing. Breast cancer is without doubt largely a reproduction health problem much like cervical cancer. In this sense, both ailments can be addressed through reproductive health provisioning in the public health sector. Irrespective of the attitude of family members to the reproductive health of elderly women, there is also a crucial need for women as they age to become sensitive of the likelihood of reproductive health challenges they may encounter especially breast cancer and adopt right attitudes to such issues. Actually, a general consensus which appears true is that early detection makes a big difference in both the treatment and management of breast cancer. Conceding to this opinion, [4] asserted that the high mortality associated with the disease has been ascribed to late detection, lack of knowledge and inadequate medical response. In other words, knowledge and awareness by these women and the society at large are crucial. Hence, the poor attitude of society to women's health including breast cancer may be the product of misconception or lack of awareness of the reproductive health-care challenges women face as they age.
Even though it is contended that 85-90% of cancer incidence is attributable to lifestyle choices as diet and smoking and environmental factors, culture is however seen as the single most influential determinant of these life choices [5]. Culture in this sense refers to factors which exist in a given social environment that influence or inform health-seeking behaviors as well as support system. Thus, such things as perception of nature of illnesses, early access to and availability of health services, beliefs about one's susceptibility to a given illness, etc. are critical elements of one's cultural environment in this case. Therefore, the effort to nib the incidence of breast cancer in the bud must start from a good awareness and knowledge of the sociocultural factors that influence both cancer risk behaviors and attitudes to its prevention and control. Scholars of reproductive health diseases have suggested that there is what may be conceived as an emerging breast cancer epidemic in Africa and some scholars see the increase in breast cancer as ironically related to such things as increasing life expectancy in the general population, improved control of infectious diseases and changing life styles including diet and obstetric practices [1]. As Oluwatosin and Oladepo [4] and Adebamowo and Ajayi [6] observed, breast cancer has become the number one or commonest form of cancer among women with an increasing mortality rate; unfortunately, the mortality associated with the disease has been ascribed to late detection, lack of knowledge and inadequate medical response. In view of the above, the focus of a study on breast cancer among elderly women as a core reproductive health challenge in Nigeria can be seen as really imperative.
Actually it has been established that breast cancer mortality can be reduced by 30% for women aged 50-69 years with routine screening and mammography followed by appropriate treatment [7]. In other words, improved awareness of breast cancer and its appropriate perception and consequent behaviour modification are essential for prevention and control of the disease. Interestingly quite a good number of authors have identified socio-economic factors, adequacy or otherwise of the health-care system and cultural factors as the barriers to the utilization of such preventive practices as mammography, clinical breast examination and breast self-examination by women [8][9][10].
Perhaps, the challenges of the reproductive health care of the aged in Nigeria are underlined by the fact that nowadays, an increasing number of women are afflicted by diseases of the reproductive system long after ceasing childbearing. This problem is however not peculiar to Nigeria since there appears to be an observable steady increase in such diseases around the world [11]. But while a reproductive health disease like breast cancer may continue to affect elderly women, its early detection has often made a crucial difference between life and death.
This paper is therefore based on the study and findings from a study carried out in the Southeastern Nigeria which sought to reveal the dominant public perception and opinions regarding breast cancer among elderly women in Nigeria and how these affect social and institutional support in the management of the disease. The importance of the study is further enhanced by the fact that scholars are largely in agreement that breast cancer has been so far under-researched and dependence on small clinical and case studies has limited both social and medical responses to the disease [1].

Sociocultural factors in the management of breast cancer
According to Oluwatosin and Oladepo [4], Adebamowo and Ajayi [6], Okobia et al. [12] and Adotey and Jebbin [13], awareness and knowledge of breast cancer is critical to its early detection and management because its treatment and management are affected by social factors which according to Kagawa-Singer [5] and Levi [14] affect the treatment and management of breast cancer. These factors which the authors classified as lifestyle choices emanate from cultural beliefs, values and practices and may in fact be consistent with the fact that just like values and beliefs, awareness of the impact of breast cancer especially the likelihood of fatality differs among cultural and social groups globally.
While acknowledging the tremendous progress made in the understanding of cell biology and the genetic changes involved in oncogenesis, a few authors have pointed out the relative lag in sociocultural and behaviour studies of cancer which has undermined the expected impact of these advances on cancer control. As Kagawa-Singer (5:2) asserted, positive change in prevention and control of cancer means that "first, greater resources must be directed towards social and behavioural research, and second, better strategies must be developed to study the effects of cultural differences on health behaviour". This sentiment is related to the earlier contention of DeVita et al. [15] in that currently only about 5-10% of cancer globally is known to be due to inherited genetic abnormalities, while the remaining 90% is attributable to lifestyle factors like smoking, diet and environmental factors which are largely determined or influenced by sociocultural contexts. Interestingly the above authors in spite of their medical backgrounds see studies of the social and behavioral factors impacting on awareness and knowledge of cancer as critical to its control and prevention.

Social and institutional support
When confronted with challenges, having people to turn to or share problems with usually gives some sort of solace or succor to those affected. These sources of succor can come in form of social or institutional pillars aimed at giving readily available shoulders to lean on in times of distress. In the case of breast cancer, social support comes from interactions with people be they family, friends, co-workers or even the church community. Though it has not been established scientifically, this kind of support has been revealed to increase the quality of life and help promote recovery and patients who have some sort of social support have quicker recovery and better survival [16]. In another study on the importance of social support in the management of breast cancer, it was revealed that such support had a significant effect on emotional adjustment of the patients after surgery as this often comes in form of family and friends who talk to and help the patients with personal problems [17]. This can be explained by the fact that these patients from such relationships and interactions develop resilience against the diseases while nurturing the feeling that they are not alone in the fight.
Institutional support on the other hand can be described as the kind of support patients and their families receive from official bodies be it governmental or religious bodies. This institutional support more often than not comes from the church and herbal homes due to the belief that breast cancer is more spiritual than medical. In this kind of situation, the disease is viewed as caused by evil arrows from enemies and as such demands more for spiritual healing more than medical [17]. Unfortunately, when confronted with breast cancer, most women in Nigeria usually seek help from religious institutions more than medical attention, leading to late detection and a high mortality rate. According to Ololade et al. [18], they seek advice from an imam or a pastor, requesting for prayers for healing but do not seek anything else not just because of their faith in prayers but because they may not be able to afford treatment, thereby resigning to fate and hoping for the best.
In some cases, individuals receive institutional support for the treatment of breast cancer through their work places, and this makes it easier for both the patients and their families to maintain some level of emotional stability during the course of the treatment knowing that they do not have to bother about the financial implications of the disease. In a recent study by Mitchelle and Lorenz [19], it was revealed that those who have their employers paying for their medical bills are more likely to present early and seek orthodox treatment instead of running to churches and traditional healers. Therefore, whether social or institutional, there is no gainsaying the fact that cancer patients and their families (just like any other category of people in distress) cope better with their challenges when they receive some form of support be it from close relations or from formal institutions.

Findings
The findings of this study are discussed here under the following subheadings:

Sociocultural factors in the management of breast cancer
In line with the literature, it was discovered in the study that a number of factors influenced awareness and treatment of breast cancer in Nigeria. These factors ranges from sex, education, age to income, and social factors affect women's awareness of the disease and their use and access to breast cancer services. The results of the study showed that 17.3% of the respondents in the study stated the major factors that affect women's awareness and use and access to breast cancerrelated services in the state as financial constraints. This is because even if the services are made available on women's doorsteps, using them would still be a problem as these women sometimes find it difficult to feed not to talk of being able to afford cancer treatments, which are usually very exorbitant. On the other hand, 9.8 and 18.7% argued that the factors that affect them the most are lack of awareness and illiteracy, respectively, because when one is either unaware of the availability of some services or completely uneducated, one's use of these services will be limited if not non-existent entirely.
Therefore income was observed as having a direct relationship with awareness of breast cancer occurrence among elderly women. Hence, while only 31% of the respondents who earn low monthly income were aware of the occurrence of breast cancer among elderly women, 61.6 and 72.9% of those who earn middle and high incomes, respectively, were aware of breast cancer among elderly women. This is not surprising since improved income is a product of improved social status which places the individual in a position to access relevant health information. In agreement with the preceding statement, one of the respondents in the IDI stated that: "there is a relationship between income and awareness of breast cancer occurrence among elderly women because most rich people nowadays usually go for routine medical check-ups both within the country and abroad and this creates a lot of awareness on diseases such as breast cancer" [20] The above gained credibility from the opinion of Ashing-Giwa [21] that financial constraints can serve as a barrier to the use of breast cancer preventive and control measures like mammography as women who are living at or below the poverty level have to struggle with competing issues such as food, shelter, safety and employment that take precedence over their own health and well-being. Therefore, given that improved income often results from higher education, this impacts on one's awareness and knowledge generally.
From the foregoing therefore, it was not surprising when it was observed that the respondents with high education were more aware of the occurrence of breast cancer among elderly women than the others because the results showed that the higher the educational qualification, the higher the number of respondents who were aware of breast cancer occurrence among elderly women. Consequently, 71.7% of those with high educational qualification (from university first degree and above) were aware of the occurrence of breast cancer among elderly women, while only 22.6% of the respondents with low educational qualifications were aware of the occurrence of the disease among elderly women.
In the words of Adebamowo and Ajayi [6] and Ohanaka [22], the elderly in Nigeria who are illiterate and reside in the rural communities are usually not reached during public health campaigns, hence, the lack of awareness of breast cancer among those who are uneducated. Ohanaka goes on to contend that though screening and mammography remain the most effective means of detecting breast cancer in elderly women, the facility is not readily available in Nigeria therefore leaving health education on the use of BSE as the only option. The above is unsurprising since some of the respondents encountered in the interviews especially in Nsukka LGA were still totally uneducated with regard to breast cancer and as such had no ideas concerning its treatment and where they may be received. They were still confusing it with "mastitis" which is a disease of the mammary gland which inhibits the perfect flow of breast milk after child birth which in Nsukka dialect is referred to as "eshi era". In the words of a middle-aged woman in the area, she requested that the interviewers describe the nature of the disease to her as she understood breast cancer to be a new name for "eshi era".

Public health institutions and breast cancer management in Nigeria
Recent studies have revealed that the public health institutions played an insignificant role in the management and care of breast cancer among elderly women in Nigeria [20]. According to the study also, 26.1% of the respondents used in the study were of the opinion that most people affected by breast cancer in the state make use of the public health institutions in the state, while 73.9% were of a contrary opinion. According to some of the IDI respondents, depending on the public health institutions when afflicted by breast cancer can be equated to suicide. In the words of one respondent: "How can someone afflicted with a disease as serious as breast cancer depend on the government hospitals for treatment and survival? Most times, if the doctors are not on strike, the nurses and other members of staff are on their own strike and worse still, sometimes, you are told that some of the drugs or equipment are either out of use or completely spoilt" [20] These sentiments capture the extent of distrust people have in the public health institutions in the state when it comes to such diseases as cancer treatment, and this distrust of the public health institutions to assist elderly women suffering from breast cancer is not peculiar to Nigeria since it has been reported that some doctors in public health institutions are reluctant to consider surgery and resort to "tamoxifen" (an effective anticancer drug) because it is easier to administer, but several studies have proven that the cancer will eventually grow and spread if a tumor is not first removed surgically, even if the patient continues to take the drug [23]. In their study, a group of scholars in their study of elderly Swiss women with breast cancer stated that the under treatment of elderly women with breast cancer is usually often based on the belief that they do not tolerate treatment and that among the Swiss many elderly women with breast cancer died because they did not receive full or appropriate treatment for their diseases; consequently, breast cancer patients over age 80 who did not receive adequate treatment had a much higher death rate from their cancer than women who did receive proper treatment [24].
According to Mitchelle and Lorenz [19] and Anugwom [25], it was also revealed that the respondents who said that public health institutions should not be trusted further stated that when afflicted by the disease, the best places to be visit would be private hospitals and chemists/pharmacists giving 27.2 and 25.2% of the respondents, respectively. This in some way underlines a gross lack of faith and trust of people in government hospitals as one of the IDI respondents supported these opinions saying: "When you go to these big teaching hospitals, it takes you days, even weeks to see a doctor except you know someone who works there and sometimes before you get the chance to see a doctor, the patient in question either dies or his/her conditions gets out of hand. This is unlike the private hospitals where both the doctors and DOI: http://dx.doi.org/10.5772/intechopen.88748 the nurses are usually friendly and treat their patients with utmost care in order to retain their patients and the reputations of their hospitals as their continued stay in the business and daily bread depend on these. Therefore, even though private hospitals are usually more expensive, people still prefer to use them for their treatments or where the patient comes from a wealthy family, she is flown out of the country to such countries as India, Germany and the US for treatment" [20] Interestingly also, another 47.6% of the respondents stated that people afflicted by breast cancer go to spiritual houses and herbalists, and this was buttressed by the fact that even key persons in the interview who were mostly doctors, public health officers and nurses were also of the opinion that sometimes, these diseases manifest as a result of charms and spells cast on people through evil means and given that God is omnipotent and can cure all sorts of diseases, He can also destroy the evil effects of the spell and heal the patients of their ailments.

Social workers and breast cancer care and management in Nigeria
Though social work and social workers through counseling and advocacy go a long way in helping patients and their families cope with ill health in developed countries, patients afflicted with cancer and their families in the southeastern parts of Nigeria do not experience this solace as social work faces the challenge of popularity and professionalization in the country as a whole [2].
While trying to ascertain how much assistance and which services social workers rendered to individuals afflicted with breast cancer, the respondents were asked about their knowledge of professional counseling services or intervention by professionals especially social workers in the case of breast cancer, and their responses were disheartening as they revealed a low level of knowledge of such services in the area. Most of the respondents did not even know what social work meant let alone knowing what social workers do, while those who claimed to know stated categorically that there were no social work services with regard to cancer detection, management, and treatment. It was just a few respondents in the high urban areas like Enugu North who stated that they knew of such services, and this also underlines the fact that those women in the rural or semiurban areas of the state are neglected not just by the government but also by individual bodies that rise up to the challenges of such deadly diseases as breast cancer.
In clearer terms, the results from the study showed that though 37.9% of the respondents used in the study argued social work services are available in the state to assist those affected by breast cancer, 62.1% of the respondents stated categorically that there are no such services in the state, and this shows that those who believed that there are no such help for women suffering from breast cancer are more in number than those who said there are such services, thereby confirming the opinions of one of two key persons in the in-depth interview, a senior nursing officer in a popular teaching hospital in Enugu and a public health officer, respectively; they opined that: "though there are services going on in the state to help women detect cancer early enough to make treatment easier and more effective, these services are usually provided by some other groups or associations but there is none known to be organized and delivered by social workers"; "social workers though not totally new in the country any more, are yet to gain the same level of recognition they have in the western societies both from the Nigerian government and the individuals who need their services" [2,20] Overcoming Perennial Afflictions -Understanding and Mitigating Public Health Challenges... This revelation challenges social workers in the state and Nigeria as a whole to get more involved and work towards meaningful intervention strategies in relation to public health and breast cancer in particular given that both cancer victims and their families need a lot of social support and counseling for their coping with cancer. This involvement of social workers can come in the form of creating more awareness on both the occurrence of breast cancer and ways of managing and treating it when it does occur. This opinion gains more substance by the results from the study where 76.4% of the respondents stated that people's awareness of breast cancer and its prevention, care and management can be improved by social workers in the state through rural-based workshops/seminars, while 12.5 and 11.1% stated that the awareness needed can be created through regular counseling for women with breast cancer and in-service training for medical practitioners respectively; this can be explained by the fact that people are usually more responsive to things they are familiar with and, obviously, a lot of people are familiar with workshops/seminars [20,25].

Methodology
The area of the study is Enugu State, a state that goes by such nicknames as "Wawa State", "Coal" and "Ọrānke Amaichekù" which is a mainland state in southeastern Nigeria, and the study focused on three LGAs drawn from the state. Hence, the study was carried out in Nsukka, Udi and Enugu north local government areas [26]. These areas are within the same axis and made for easier data collection. Furthermore, these areas have similarities in their traditions and attitudes towards diseases because traditionally they believe that certain serious diseases occur in individuals' lives as a result of evil deeds by the individuals or evil manipulations by the individuals' enemies.
Enugu State has a population of 3, 267, and 837, and it was this population that formed the population of the study. The study sample was therefore drawn from the members of this population who are 18 years and above. Thirty respondents were selected for the in-depth interview (IDI) using the purposive sampling method, i.e. 10 respondents from each of the LGAs. The selection was guided by gender equity, age variation and different educational levels of the respondents in a bid to cover as much diversity as possible in the sample. In this case, the researcher used judgmental criteria in selecting respondents considered both knowledgeable in the subject of the study and also representative of the population. Thus, such factors as sex, age, and the need to spread respondents throughout the various quarters in each LGA were used in ensuring gender and socio-economic diversity or spread in the selection of the respondents for the IDIs.
The in-depth interview guide/schedule addressed such issues as reproductive health of elderly women; awareness of breast cancer; dominant perception of the public health system and the management of breast cancer among elderly women; sociocultural factors impacting on perception of breast cancer among elderly women; societal perception of factors associated with breast cancer; services and agencies of breast cancer management, etc. They also provided probing questions aimed at generating more in-depth views or opinions and aided the researcher in maintaining focus during the interviews and in garnering deeper insights into people's perceptions of the concerns of the study. In addition, the non-verbal gestures and communications of the interviewees were also noted. These IDIs were conducted by the researcher with the help of a research assistant who acted as a recorder and note taker. The interviews were conducted in locations and at times chosen by the respondents, and the interviews were also recorded in order to explicitly capture both verbal and non-verbal responses. Finally, the analysis of the IDIs focused on identifying common themes in the study and used them as a basis for comparing and contrasting opinions of respondents and how these are consistent or otherwise.

Discussions and conclusion
The goal of the study was to find out the dominant public perception of breast cancer among elderly women and the sociocultural factors that influence awareness, treatment and management of breast cancer using Enugu State which portends both urban and rural characteristics. Due to low socio-economic status, a good number of the women in this category are in this day and time still struggling to understand what the disease is all about and what exactly causes it. Low level of education/illiteracy served as a very strong negative influence in the awareness of the disease in the state, and in some cases, they argued based on their convictions that it is "mastitis" which is locally referred to as "eshi era" in areas like Nsukka as this only affects nursing mothers and implies a collection of breast milk even though it does not flow and inflict a lot of pain on the nursing mother. This however is handled by the intake of some local herbs and the bathing of the breasts with some concoctions to make the milk start flowing. In the case of breast cancer, the worry is that it affects everyone especially those who had exceeded the childbearing ages. It was also not surprising that they did not go for the regular medically advocated screening for breast cancer given that they do not even know what it means and what it is meant for.
Disheartening also was the discovery that most women died of breast cancers even after they had been detected because of their lack of access and use of the necessary health care needed for its treatment and management as a result of lack of funds and distance as they are often very far away from the places where these facilities can be accessed. Unfortunately, most public health centres that are easily accessible do not provide these women with the usual breast cancer screening and other related services needed for early detection. Even when they are eventually detected which are usually very late, financial constraints do not allow them to receive the necessary treatment to relieve their pains as the treatment is not subsidized by the government. Consequently, some of them refer to it as the big man's disease stating that when a poor person is affected by the disease, it simply means that her days are numbered. For a good number of the women, all they know about the disease is that it is a disease that affects the breasts and which can only be treated through surgery (i.e. the removal of the affected breasts). As a result of this poor knowledge about the disease, it was not surprising therefore that such terms as mammography, screening and staging were totally novel to them underlining the level of unawareness of breast cancer among women especially those from lower socio-economic status.
Social workers are, therefore, encouraged to help in the fight against breast cancer by creating awareness through seminars and workshops for women and the general public taking into consideration the educational level of the target audience. Consequently, posters, pictures and PowerPoint presentations should be used in getting the clear nature and symptoms of the disease across women as well as showing them the correct ways of carrying out the BSE, what mammography is all about and when to start seeking such services. Since there is an established distrust of public hospitals, government should also organize seminars focusing not only on women or the general public but also on the medical personnel especially those of them working in rural and semiurban-based public health centres in order to sensitize them to the kind of commitment needed in dealing with both cancer patients and their families bearing in mind that the disease poses a very serious challenge not only to the affected persons but to their entire family. These seminars should also aim at educating the people on the right ways to live to prevent cancers and the right ways to live and manage them when they do occur. They should also be aimed at purging their minds of any misconceptions or stigmas they may have attached to the disease and those who are affected by it.
Finally, with regard to the theoretical framework, the study showed that the basic assumptions of the theories are true judging by the fact that those who believed they would be susceptible to breast cancer tried to live out a particular life pattern going in line with the Health Belief Model (HBM), while those who had little or no knowledge about the disease attributed it to charms or spells cast on individuals by other evil people in the society and had no idea how to deal with the disease or where to get help when affected by the disease going in line with the assertions of the Health Communication Theory (HCT).

Author details
Kenechukwu N. Anugwom Department of Social Work, Faculty of the Social Sciences, University of Nigeria, Nsukka, Enugu State, Nigeria *Address all correspondence to: keneeder@yahoo.com © 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.