Health Seeking Behavior on Breast Cancer Therapies: Patients’ versus Providers’ Views

Background: Reviewing the system of health care services, the development of health services in a country, like Indonesia, is strongly influenced by the education system based on health sciences, such as medicine, nursing, public health. Then, the output produced by the education system will be implemented in the form of health care, both hospital and community based. Method: This qualitative study assessed the patterns of health behavior in seeking health cservices for treatment by the breast cancer patients, whether conventional, complementary, or traditional. This study assessed the different views, both from the health providers’ perspective and patients’s perspective. The subjects of the study involved the patients and health professionals coming from hospitals or directly in the community (community-based and hospital-based study) in West Java province. Results: Based on the thematic analysis, it obtained the pattern of health care services option from breast cancer patients’ point of view, as follows: (1) generally, the initial choices of health treatment were traditional and alternative therapies; (2) If it is not effective, then the conventional therapy was chosen; (3) furthermore, the conventional therapy was performed in parallel with the complementary and traditional therapies. On the other hand, majority of health professionals expressed: (1) the importance of only-conventional therapy, and only a small number of them supported the complementary therapy; (2) the expectation that one day, an effective and appropriate therapy can be found, with less side effects on the breast cancer patient, by combining the conventional and complementary therapy. Conclusion: In conclusion, despite some similarities, there are differences in the point of views between patients and health professionals regarding the pattern of seeking health care services of the breast cancer patients. In general, the patients tend to choose a therapy that is more comfortable to themselves, rather than making assessment on the conventional or complementary therapies. Meanwhile the health professionals consider the conventional therapy as the best and right choice for the breast cancer patients.


Background
One of the goals of Primary Health Care Strategy of the WHO is to consider the non-medical factor issues, such as socio-economic and cultural factors in determining the health determinants and utilization of health services. Therefore, the development of public health status, health care services, and formal health education system should constantly consider the sensitivity to the national culture.
The National Health System of Indonesia relies on the System of Health Education and Health Services. As an integral part of the health system of Indonesia, the health education system and the health care system should be able to accommodate an interactive process between patients, community needs with provider demands. Therefore it needs a form of ideal health system that is holistic, comprehensive and integrated with the ability to build client and patient empowerment in both the hospital and community basis. In addition, it is important to notify the stakeholders and let them be conscious about the system of health care services that is based on the services users' needs and cost effectiveness.
The prevalence of disease and death in some cases of malignant tumors or cancer at both global level and national level of Indonesia is still high. For the cases of diseases among women, breast cancer incidence occupies a highest place, especially in 7 countries, such as: Indonesia, Japan, Malaysia, Philippines, Singapore, Sri Lanka and Taiwan. Related to cancer morbidity and mortality, WHO has stated specifically that about 508,000 women died of breast cancer in 2011 [1][2][3].
The high prevalence of breast cancer morbidity and mortality cases is a threat to the quality of life of women in Indonesia. Moreover, patients and families often face the problems related to the adequate information about signs and symptoms of early and advanced stages of breast cancer; the difficulty in deciding the choice of therapy: whether Journal of Community and Public Health Nursing to use conventional therapy or others, such as complementary therapy. In particular, Indonesia is known as a developing country with the type of plural medical system health services, from both the institutional and health professional aspects [4].
The practice of integrative health (combination of both conventional and complementary therapies) in Indonesia still raise many questions, especially among health professionals, though it has already started to reach, for example, some government referral hospitals. Although, it cannot be denied, that many health professionals are also well-aware that some conventional nursing therapies are originated and rooted in the modality and complementary therapies [5,6].
Recognizing the diversity of treatment options available for breast cancer patients, and the lack of clarity of regulation and assessment of the health sciences, thus, the exploratory study is needed to provide initial answers to these problems. This research thus seeks to answer the question: how is the health services search pattern of breast cancer patients, as viewed by the patients and the health care professionals?"

Methods
This qualitative study is aimed to analyze the pattern of behavior in choosing the health care services for breast cancer therapy, both from the point of view of patients and health care providers. This case study was conducted in several areas in Indonesia, especially in West Java province. The location of West Java was chosen based on several assessments to the cancer patients in the region, in which many of them chose several types of non-conventional or alternative therapies.
The subjects of the study were the cancer patients who were undergoing out-patient treatment or in-patient treatment in the hospital, or other therapies in the society. The sample of the study was non-probability sampling, i.e., the samples were chosen with purposeful sampling on 17 patients and 12 health professionals (physicians, nurses, dieticians, and pharmacists). The number of qualitative research subjects was focused on the saturated point situation, i.e., when there is no more new data or information obtained, so the number of subjects is considered enough. Then the indepth interview was done to explore the views and experiences of therapy in relation to breast cancer.
In addition to in-depth interview, the study also required supported documentation and archived data. The process of in-depth interview followed the following steps: (1) thematizing: why and what has been and will be studied with regard to health-seeking behavior in breast cancer patients; (2) designing: planning interviews in research by using thematized interview guides on two groups of subjects, namely patients and health providers; (3) interviewing: conducting interviews based on prepared interview guides; (4) transcribing: preparing the interview results to be analyzed; (5) analyzing: deciding the purpose, the topic of natural process of interviews and appropriate method of analysis; (6) verifying: validating the results of the interview; (7) reporting: making the report in accordance with the study criteria that has been done.
The approach in qualitative analysis has four types of measurements, namely: (1) credibility: refers to the way of describing the phenomenon; (2) transferability, refers to the results of research being used to describe the situation, which could be used to make generalizations to other situations; (3) dependability: that the researcher has conducted all the research procedures; made data interpretation; and reflected on the situation; (4) confirmability, is part of the triangulation used to reduce bias. The stages of qualitative analysis process consist of: (1) data reduction; (2) doing construction on the data to be displayed; (3) describing and verifying conclusions. In qualitative research, the data collection and analysis of process occur at the same time and then the researcher conducted a continuous interpretation to describe the study.

Ethical Considerations
This study has received approval from the Ethics Committee of Health Researches of the Faculty of Medicine, University of Padjadjaran, no. 277/UN6.C1.3.2/KEPK/PN/2015. The ethical decision is related to the information to be obtained in accordance with the purpose of research and subjects involved in the study, namely breast cancer patients and health professionals. Preparation of informed consent to complete the ethical consideration aims to provide the right information to the subjects involved in the study, then the subject is able to understand the information provided, and further to decide in freedom whether to participate in the study voluntarily or not.

Health seeking behavior: Patients' views
Through the thematic analysis, there were five main themes obtained with respect to cancer patients' perceptions of the disease and the selection of therapy at the time of acquiring the disease symptoms: (1) the subjective concept of illness and legalized by socio-cultural factors; (2) the selection of the treatment received by the family; (3) the perception of recovery in any type of treatment; (4) the existence of positive meaning of the concept of illness in life; (5) the high expectation of recovery.
Furthermore, there was a tendency of four general patterns of choosing breast cancer therapy by the patients, beginning from the moment of obtaining the symptoms, the process of seeking health services, until the orientation for recovery from breast cancer, as shown by the Figure 1 below.

Health seeking behavior: Health providers' views
According to some health professionals, breast cancer is caused by human lifestyle choices, such as: 1) exposure to chemicals through the consumption of fast foods, foods containing carcinogenic substances, cigarette, alcohol; 2) exposure to pollution and radiation (including radiation of electronic equipment); 3) blunt trauma on the breast area;  Based on the view of providers, generally a patient who came with breast cancer symptoms had the complaints, such as: 1) an abnormal lump on the breast; 2) lump mild and severe pain, reddish, swelling, sometimes fester and with bad odor; 3) inverted nipple; 4) in addition to the lump, patient also felt pain and lacked of appetite, immune system decreased; 5) a sense of prolonged stress, sleeplessness that led the cancer to spread.
According to the health providers, the choices of initial therapy of the patients before coming to the health centers or hospitals were generally herbal therapies or acupuncture. Some patients came to the general practitioner physicians and asked for pain relievers. These patterns of seeking therapy by the patients were motivated by the fear of undergoing medical treatment in the hospital, especially to undergo surgery and chemotherapy.
Furthermore, according to health professionals, generally the client finally decided to go to the hospital for several reasons: 1) existing therapies did not cure the disease; 2) they had spent a lot of money but the disease was getting worse; 3) there was no effect of cancer cure, even if the body felt better and increased body resistance; 4) the recurrence of disease symptoms.
The common advice given by health professionals when dealing with clients who have early symptoms of breast cancer were: 1) controlling to the health centers and contacting the oncologist; 2) undergoing chemotherapy; 3) changing lifestyles; 4) having conventional therapy in combination with complementary products such as honey, habatussauda, and spiritual therapy to enhance personal relation with God.
The following were the advantages and disadvantages of various therapies according to some health professionals: Conventional therapy: Positive factors include: the treatment is fast and precise because it is supported by many studies, including the dose of medicine; the stages and the treatment process are clear, beginning from pre-diagnostic, post-diagnostic, until after the cancer has spread; chemotherapy can kill and inhibit cancer cells; the surgery to remove the canter mass could reduce the cancer spread; treatment cost can be paid by BPJS; and handled by expert. Meanwhile, the negative factors include: chemotherapy also kills healthy cells; has the side effect of nausea and vomiting; radiation affects the body to feel hot, mouth sores, fever, hair loss, fatigue, appetite loss. Other deficiency could be that due to the increase of the number of cancer patients, sometimes the hospital finds difficult to handle all or gets slower in service; the services become less communicative.
Traditional/alternative therapy: the positive factors include: less complicated or not at all; low cost; easy to find; patient comfort as the priority. The negative factors, however, include: only rely on experience; not yet proven scientifically; not so effective in curing diseases, even can worsen the disease; if calculated well, the alternative medicine is more expensive but zero result. For example: in using the Chinese herbal medicine or coming to the traditional healers who are not experts in medicine.
Complementary therapy: Positive aspects: it is a medical complementary to increase body resistance; is used preferably to complement the medical treatment. The negative aspects: it adds the medication for the patients; may cause time and cost spending for treatment; and it is not yet well-known widely.
Meanwhile, the health professionals generally gave general information, such as: definition of chemotherapy, signs and symptoms of cancer, cancer treatment, effective cancer therapy through chemotherapy, side effects of chemotherapy, the benefits of routine and regular control to the hospital. There were two health professionals who told the significance of maintaining good nutrition during the chemotherapy. Besides, a health provider said that those who gave health information had received respective assignment. The role of the physician was to inform the patient about treatment or medication and the prescription of medicine, while the nutritionist played the role in explaining and preparing matters related to nutrition. The nurse in the breast cancer treatment case usually provided information about wound care, treatments for medical side effects, and information on the control schedules and other matters; although, however, based on the patient assessment, they did not receive a lot of information, which they needed, from the professionals. Generally, some methods of communication of information to the patients involved: lectures, faceto-face dialogue with patients and families, and through mass media like leaflets, hospital posters, etc.
In general, according to health providers, the method and media being used in giving information were already effective, although with some advantages and disadvantages. The advantages include: (1) the effectiveness in disseminating information and let it be understood in the short period of time; (2) the leaflets could also be taken home by the family and patient for further reading, and they could get some more complete brochures; (3) there were hospitals that provided additional spiritual guidance to the patient. However, weaknesses of the method and media were: (1) the information was usually received quickly, yet not so profound; (2) some leaflets only contained some points but were not detailed; (3) communication in the limited span of time due to busy health workers might result in the ineffectiveness of method and media. If there was no effective communication, patients usually tended to hesitate to ask questions and even discontinued the treatment.
Encountering some patients who underwent various therapies, some health professionals had different attitudes, like: (1) providers who recommended the therapy when it had positive benefits, or recommended the patient to choose only one therapy when it was proven otherwise; (2) three providers did not provide any comment on the patient's selection of multiple therapy; (3) providers gave support to the patient as a personal right to choose therapy; 4) providers gave explanation to the patient about the advantage and disadvantage of therapy selection in order that the patient could understand and make the right choice.
The main advices of the providers upon knowing the patient suffering from breast cancer were: 1) recommending the medical treatment; 2) recommending immediate right therapy in the hospital by taking biopsy to check if it was cancer or not; 3) encouraging to increase the patient's self-confidence regarding the information being given in order to make treatment choice; 4) giving health education for healthy living; 5) avoiding stress and never be afraid to face the disease.
If the patient has been positively diagnosed with breast cancer, the health provider usually: 1) gave support and motivation to face the disease without fear; 2) explained the treatment according to the direction of the physician; 3) recommended to take chemotherapy completely; 4) performed medical treatments with complementary herbs; 5) encouraged many cancer patients to return to daily activity after therapy; 6) shared a lot of knowledge and information with fellow cancer patients; 6) recommended to surrender all to the Almighty God.
Health providers in this study also said that some of the following might be helpful for breast cancer prevention through healthy lifestyle, namely: 1) breast self-examination for early detection of cancer signs and screening; 2) eating nutritious foods; reducing saturated fatty foods; reducing fast foods and foods containing artificial flavorings; no to smoking and alcohol; 3) exercising regularly; 4) avoiding the use of hormonal contraceptives, 5) avoiding stress; 6) for nursing mothers, making it complete for 2 years.
The program which could be planned for cancer patients involve : 1) regular campaign for both the adolescents and the health young mothers, by involving the schools, public health centers, health department, and NGOs who support the cause; 2) making early detection through self-treatment or free screening, or free laboratory check up and services by the government; 3) supporting the studies on herbal therapy which are very effective in preventing breast cancer recurrence; 4) advocacy for healthy lifestyle; 5) establishing the breast cancer community to share experiences of and provide motivation for patients.
The expectation to have appropriate therapy model for cancer patients from the providers included: 1) the availability of scientifically tested therapy and which causes little side effects; 2) natural therapies that are scientifically proven; 3) complementary therapies that can coexist with conventional therapy; 4) an effective therapy and affordable by all levels of society from the aspects of information, implementation and cost; 5) simple therapy with optimum results.

Discussion
The process of searching health care services generally is categorized into three, namely: (1) no intervention: although patients feel discomfort in the body however no intervention is taken; (2) the patient's internal action: the patient tries to find a cure within his/her own choice and capacity; (3) the patient's external action: in which patient who needs medical care will look for a place to determine whether to choose conventional or complementary therapy systems [7].
WHO explained the Health Care Utilization into several types, namely: (1) conventional or modern medicine, i.e., one that is rooted in cosmopolitan medical system or the concept of Western formal education; (2) the transitional treatment is the combination of modern and traditional medicine; (3) traditional medicine is the knowledge and practice of health care services acquired and developed from the process of learning from one generation to generation both in words and in writing [8].
In relation to the pattern of seeking health care services of the breast cancer patients, the theory of the Health Belief Model (HBM) explained that there are several factors associated with the willingness of someone to choose a behavior, i.e., based on the perceived susceptibility, perceived severity, perceived benefits, barriers, and trigger factors. The HBM components includes individual factors, socio-demographic factors, and socio-cultural factors such as age, ethnicity, perception, knowledge, education, and employment. This understanding helps to explain the reasons behind the choice of breast cancer patients in choosing health services and determine their ultimate choice of therapy [7].
As one of the health providers, nursing is a health profession that interacts with the patients holistically (physical, psychological, sociological, cultural, and spiritual); so it is proper if the efforts to develop complementary is necessary. This is mainly because the complementary therapy is holistic, where the health provider will provide integrated health services from different aspects and dimensions of human life to improve the patients' quality of life.
Health professionals are more likely to provide conventional therapy because they have a background of education, science and practice with the dominance of conventional therapy, even in some system of health education, nursing and medicine in Indonesia included the material complementary therapies in the small part of their curriculum.
The complementary therapy has the possibility of having cultural significance related to the healing traditions generally developing in the society, where the need for comfort is a priority for the patient. As there is a tendency differing views on health seeking behavior of the patient's age, due to possible differences in media exposure and factor information. Whereas, in younger patients lot depends on the availability of information through electronic media, while in older age patients there is a pattern to get information orally either of those 'elders' or have a position as both formal and informal leaders.
In particular, seen from the nursing perspective, the nurses work very closely with the patient, and are in the position to recognize the patient's cultural-spiritual point of view. Therefore, it is hope that health providers in general and nurses in particular are able to determine the alternative medical therapy or complementary therapy, which is more appropriate with the patient's belief and recommending one that is suitable to the needs of the cancer patient [9-12].
Furthermore, reviewing the nursing field, the application of nonconventional medicine to promote and improve the quality of health of the society involves the promotive, preventive, curative, and rehabilitative health. They serve as supporting therapy to control the symptoms, improve the quality of life, and contribute to the overall management of patient care. This capability of the provider is obtained through structured formation with high quality, safety, effectiveness based on biomedical knowledge; although it is not yet fully accepted or recognized in the conventional medical practice in Indonesia [12][13][14][15].

Conclusion
It has been recognized that conventional therapy as a product of Western medicine in science and medical practice of hospital has been helpful in curing or caring for the breast cancer patient. However the issue of improving the quality of life and life expectancy is not always based on the Western orientation. Especially for the breast cancer patients in Indonesia, giving an option of oriental medicine is important to increase their life expectancy. This reality should be recognized, not only by health providers but moreover, by those who hold the authority to make health decision and policies, whether in the line of health education system or the system of health care services.
Besides all healthcare providers who study science should not immediately reject any pattern of health behavior that emerges in the society, but rather to make necessary comprehensive assessment about it. Precisely the curiosity on the pattern of care and treatment with diverse cultural backgrounds can become a positive point in developing the palliative care, in order to improve the quality of life of breast cancer patients.