Utilization of Cancer Information System for Breast Cancer Control in Lagos, Nigeria

Introduction There is a substantial increase in the incidence of breast cancer in Nigeria usually with the late stage presentations and subsequent poor rates of survival attributed mainly to a low level of cancer awareness and ignorance amongst patients. Cancer information system (CIS) is now assuming an emerging role in this respect. Methods This was a descriptive study carried out over a one year period using a health communications program comprising of 3 breast help lines. An initial period of public awareness was carried out over a 3 months period after which members of the public were encouraged to call the help lines. Breast cancer information was provided and the socio-demographic characteristics and other relevant data of the callers were recorded by the information specialists. Results A total of 294 people were reached during the study period. Majority of the callers (82%) sought information for themselves while the remaining 18% called on behalf of a loved one or friend. Majority [248 (84.3%)] of callers had no breast abnormality, 38 (13%) called to report breast abnormalities and required information on what to do and 8 (2.7%) were breast cancer patients who required information on how to live and cope as breast cancer survivors. Conclusion The rapid growth of mobile phone use in the Nigeria has presented a unique opportunity and promise to improve cancer care. There is evidence to suggest that mHealth can be used to deliver increased health care services to the increasing population of cancer patients in Nigeria.


Introduction
In 2012, breast cancer accounted for 27,304 new cases and 13,960 deaths [1]. There is a substantial increase in the incidence of breast cancer in Nigeria [2] with a persistence of late stage presentations to the hospitals as seen in various hospital based series [3]. Late stage presentations are associated with poor survival rates and have been attributed to a low level of cancer awareness and ignorance amongst patients [3]. Health care systems are gradually moving toward new models of care based on integrated care processes shared by different care givers and on an empowered role of the patient. Mobile technologies are assuming an emerging role in this scenario. This is particularly true in care processes where the patient has a particularly enhanced role, as is the case of cancer supportive care [4]. The Ebola crisis that occurred in Nigeria in 2014 was quickly curtailed partly because there was accurate information available to the public and vigorous and rapid public health response [5]. Efforts to educate the public will also empower them to proactively attend cancer screening, live a healthy life style and know the right place to go to, should the need arise, for a cancer related matter. Secondly, more patients can be educated on their disease, linked to resources and referred to approved cancer centres and this will significantly reduce the number of patients treated by untrained health care professionals as providing accurate and timely cancer information should be a high priority.
A Cancer Information Service (CIS) is a service created to meet the cancer information needs of the public. It may provide patient education, emotional support and counselling services to people affected by cancer, a CIS is primarily about giving good quality, one to one information about cancer in response to people's questions [6]. A CIS can be provided by phone (mobile health), email, SMS (short message service) text, online chat or through social media (e.g. Facebook). A CIS does not give medical advice and does not replace a doctor, but helps the caller understand prevention, early detection of cancer and their individual situation [6]. The benefits of a CIS are immense especially in developing countries were resource allocation is a constraint.Most successful CIS are dependent on volunteers; information by phone is cheaper than travelling to rural settings, easy to start up and not financially tasking. However, quality-assurance must be maintained to ensure the accuracy of information disseminated [7]. Mobile health (mHealth) is the most important component of CIS and it describes the use of portable electronic devices with software applications to provide health services and manage patient information. With approximately 5 billion mobile phone users globally, opportunities for mobile technologies to play a formal role in health services, particularly in low-and middle-income countries, are increasingly being recognized. Although still limited, there is growing evidence of success in using mobile phones for health (mHealth) to support the performance of health care workers by the dissemination of clinical updates, learning materials, and reminders, particularly in underserved rural locations in low-and middle-income countries where community health workers deliver integrated community case management [8,9].  (Table 1). An age range of 24-55 years was reported with majority being in the 45-49 years age group. Up to 80% of the inquirers were based in Lagos state while 52% were married and 72% had tertiary education. About 90% of the callers owned a mobile phone.

Discussion
Throughout the world, there is growing interest in people taking more responsibility and involvement in their own health and having information that will enable them to understand how they can maintain a healthy lifestyle [13]. However, there was still a gross underutilisation of the mobile health technology in accessing cancer information as evidenced by the low number of callers recorded in this study despite of the intensive 3 months sensitization period.
This may likely be due to the remarkable poverty in the country which has resulted in the lack of interest in the health and health seeking behaviour of the populace.
With the majority of callers being in the 45-49 years age group; this suggests that health seeking behaviour of individuals usually peaks at about the beginning of the middle age although this may not be generalizable within this sample population. It was not surprising that up to 80% of the inquirers were based in Lagos state as the public awareness program was designed to cover only the Lagos metropolitan and thus those inquirers from outside Lagos could possibly have heard of the service from friends or relatives who reside in Lagos state. The high level of education (72% tertiary Page number not for citation purposes 4 education) probably confirmed that education plays a pivotal role in the health seeking behaviour of the public. The high number of participants who called the cancer center with their personal mobile phones is also a confirmation of the findings from most studiesthat have suggested the rapid growth of mobile phone users in the low and middle income countries [4,[8][9][10][11]. Majority of the callers called primarily to understand cancer prevention and early detection, it is clear that the public seeks information and the breast help lines can bridge the wide gap in cancer education for the public.
In several telephone based CIS studies [5,18] and the current study; women comprised the overwhelming majority of callers (80%). This can be explained by the fact that women are often the ´gatekeepers´ for health information and healthcare decisionmaking for their families [19] and also because breast cancer is predominantly a female disease which may thus cause more enquiries to emanate from the female gender.
Since mHealth seems to be employed only for limited uses and during limited phases of the care process [4,8,9] as it had been demonstrated in this study where only a few callers were recorded to have accessed the system during the study period. Therefore, it is unlikely that it can really contribute to the creation of new care models in the short-term. This under-utilization may depend on many issues, including the need for it to be embedded into broader information systems through policy formulation by creatinga higher level of targeting at all stages and in all health care delivery activities and not just in cancer care. A major limitation of the study was the inability to ascertain the actual number of intending callers who the center may have missed their calls especially during the non-working days of the week or those who are willing to do so but not able to have access to a telephone line.

Conclusion
There is still a gross lack of awareness and underutilisation of the CIS in Nigeria. Therefore the rapid growth of mobile phone use in the Nigeria has presented a unique opportunity and promise where the formation of partnerships between governments, technologists, non-governmental organizations, academia, and industry, can provide a great potential to improve cancer care via the use of mHealth. By harnessing the increasing use of mobile phones among diverse populations, there is promising evidence to suggest that mHealth can be used to deliver increased and enhanced health care services to the increasing population of cancer patients in the country. However, as with many other health improvement projects, a key challenge will be on how to move the mHealth approach from a regional pilot project to a national scalable program while properly engaging health workers and communities in the process. It is therefore imperative that a more robust national pilot program should be carried out to assess the acceptability and utilisation of this laudable innovation.  Table 1: Socio-demographic characteristics of callers (N=294)