“If I am diagnosed with breast cancer, my husband would need to sell our house to pay the medical expenses,” says Hanaa, a 52-year-old woman from Abba, south Lebanon.
Hanaa worries about not being able to afford the cost of breast cancer-related tests and treatment. Likewise, Zeina, a 45-year-old from Mina, north Lebanon, says, “We barely make it until the end of the month with the money that we get. We know that we have to do a mammogram, but we cannot afford it.” Many women, from regions across Lebanon, feel that they are struggling economically. A household income below minimum wage barely covers their essential needs, let alone pays for medical services.
Hanaa and Zenia’s views, along with the other findings of this article, are based on research for my PhD thesis into the barriers to and facilitators of Lebanese women’s participation in breast cancer screening services. This research included a survey administered to 231 Lebanese women, as well as 17 focus group discussions with 163 woman over the age of 40 living across all eight governorates in Lebanon.
My research found that affordability, as well as availability, were important factors that influence a woman’s decision to seek medical care and breast cancer screening. During the past few years, many awareness campaigns have been launched in Asian and Middle Eastern countries that share similar cultural and religious characteristics, but the majority of women with breast cancer in developing countries are still being diagnosed in late stages. This is reflected in the overall five-year survival rate ranging between 10 to 40 percent in developing countries compared to 80 percent in developed ones.
In 2002, the Lebanese Ministry of Public Health (MoPH) launched an annual breast cancer awareness campaign that ran throughout October. The ministry specifies 40 as the recommended starting age for screening, advising women who have reached or surpassed that age to undertake annual mammograms. Most western countries recommend screening from age 50, but in Lebanon breast cancer is regularly diagnosed among a slightly younger demographic.
For the past two years, this awareness campaign has been extended by three months. During this period, mammograms are offered for free at governmental hospitals and for the reduced price of up to LL40,000 ($26.66) at private ones. An ultrasound is also offered at the reduced price of LL30,000 ($20) at governmental hospitals and LL40,000 ($26.66) at private ones.
An evaluation of the first three years of this program found that women are less likely to go in for repeated mammograms year after year than they are to go in for an initial screening. By 2013, the proportion of women who had had a mammogram at least once was 43 percent, while the proportion of women who had had a recent mammogram was just 20 percent.
Financial barriers to treatment
Financial concerns may influence whether a woman chooses to get a mammogram on a yearly basis, or when required by her doctor. In Lebanon, where 51.7 percent of the population does not have medical coverage, access to such services is already limited. Even if the mammogram or the screening tests are covered by the MoPH, additional perceived costs—future follow-ups or additional tests—may discourage many women from seeking one in the first place.
Sometimes physicians ask patients to undergo multiple mammograms within a single year. In the absence of social security or any other type of medical coverage, a woman might choose to skip or postpone the initial mammogram for fear of being asked to pay for multiple tests. Even in public hospitals, where the majority of women choose to go due to cheap or even free appointments, some of the tests required after the first visit could be costly. Many women go for a free mammogram without having the funds on hand for any additional tests, such as an ultrasound, which costs a further LL30,000 ($20). Even if a woman is covered under the NSSF, they still might not be able to afford the outstanding 15 percent of the medical expense, or the cost of further required tests or medical procedures.
Outside of the awareness-raising months, these services are offered at full prices. At private medical centers and hospitals, a mammogram and an ultrasound each cost LL60,000 ($40). In public hospitals, a mammogram costs LL50,000 ($33) and an ultrasound LL60,000 ($40). For those earning Lebanon’s minimum wage of just LL675,000 ($450), these tests would consume 16 or 18 percent of a monthly salary at public or private hospitals respectively.
Women are also concerned about the affordability of breast cancer treatment, if they happen to receive a positive diagnosis. They worry that they would not be able to afford the costs of drugs, chemotherapy, radiotherapy, or medical procedures that were not covered by the MoPH. The economic burden on breast cancer patients is real. Many patients even stop their treatment once they can no longer afford the price of chemotherapy.
Currently, the ministry does not cover outpatient services, doctors’ fees, or other diagnostic tests for breast cancer. It is extremely difficult to change this, since such an alteration would require a legal modification, as well as resources that the MoPH does not have. Between 2014-2016, the MoPH spent around $140 million dispensing free cancer drugs. Complete coverage remains a challenge; the average cost of drugs per patient per year—measured across all cancer types—increased from $7,000 in 2014 to $8,400 in 2016, according to a study on oncology costs in Lebanon.
The cost of transportation from home to hospitals or medical centers also acts as a barrier to women’s participation in breast cancer screening activities. There are women residing in rural areas who struggle to afford the cost of a taxi to reach the closest hospital.
When economic resources are limited, many women prefer to go without medical screening in favor of spending what little money there is on their families. They prioritize their family’s needs and household expenses over their own health and access to medical services.
How can we change this?
There are several avenues to increase the take up of breast cancer screening among Lebanese women. These include:
Tailoring awareness campaigns: National and other campaigns around breast cancer screening seek to increase awareness and target women from various backgrounds. It is important to tailor awareness-raising campaigns and messages to the women that the campaign needs to reach (taking into account, for example, their location, age, socioeconomic status, and religion).
Placing more attention on women in rural areas: Women residing in rural areas face greater barriers to medical screening than their peers in urban areas. This is not only due to the limited availability of services, but also to the level of trust in service providers, and cultural as well as financial barriers. Increasing participation in screening activities in Lebanon’s rural areas would require a structural approach that addresses the different barriers identified.
Increasing personalized communication with women: The current campaigns adopt a mass population approach and place less attention on direct communication and cues to action. Direct targeting is more likely to prompt women to take positive actions toward screening. Women could start getting direct phone calls, emails, or messages from their hospitals or doctors reminding them of follow-up visits and mammograms, as well as counselling if diagnosed.
Such a program could also include a free, designated hotline run by the MoPH, in collaboration with the Ministry of Telecommunications, for women to call with any question on breast cancer. Peer to peer education built around positive word-of-mouth communication, could be promoted through household visits, which are widely acceptable according to Lebanese cultural norms and traditions.
Increasing the engagement of community-based organizations: The engagement and support of local community-based organizations, especially in rural areas, can address different barriers to screening. Entities such as municipalities and NGOs can spread awareness on breast cancer as well as access to healthcare institutions by providing transportation.
Religious representatives can provide support by tackling beliefs and misconceptions perceived to be founded in religion. This can also help to emphasize the role of religion as a facilitator rather than a barrier.
Working on prevention in addition to early detection: Framing awareness raising campaigns and efforts to increase screening for breast cancer could be included in a more comprehensive initiative toward the prevention, not only detection, of the disease. Women need to know more about preventative measures and changes required. The latter would include more attention to risk factors, environmental determinants, and healthier lifestyle choices.
Encouraging breast self-examination: The level of information and attention given to self-examination of breasts should be increased via doctors or national campaigns, as this is an easy, affordable, and acceptable method of primary screening for all women, regardless of their socioeconomic backgrounds and health coverage.
