P2B105: Application of the Explanatory Models Framework to Real-world Clinical Interactions at a Pediatric Cancer Center in Guatemala

Background: Beliefs and cultural contexts shape how patients interact with the healthcare system. In medical anthropology, “disease” refers to biologic processes, while “illness” describes the personal or cultural interpretation of symptoms. Arthur Kleinman’s concept of explanatory models (EM), which includes perceptions of “occurrence,” “causation,” “pathophysiology,” “course of sickness,” and “treatment,” can be used to characterize individual understandings of illness. Patient EMs of cancer influence risk-perception, participation in screening, and treatment adherence. In low- and middle-income countries, where 90% of children with cancer live, treatment abandonment contributes to disparities in cancer outcomes. EMs may provide a framework to improve patient-clinician communication as well as outcomes such as abandonment. This study investigated how Kleinman’s EM framework applied in real-world clinical encounters at a pediatric cancer center in Guatemala.

Methods: This qualitative study was conducted among caregivers of 20 children with newly diagnosed cancer at Unidad Nacional de Oncología Pediátrica (UNOP) in Guatemala City, Guatemala. UNOP’s diagnostic process includes social work intake, psychoeducation with a psychologist, and a diagnostic conversation with an oncologist and psychologist. Psychoeducation and diagnostic conversations, as well as semi-structured interviews to evaluate caregivers’ experiences, were audio-recorded, transcribed, and translated from Spanish. Transcripts were coded using a priori codes based on Kleinman’s five components of the EM, as well as disease and illness accounts. Thematic content analysis using constant comparative methods explored how Kleinman’s theory of EMs applied to the data.

Results: All five components of the EM were addressed during the diagnostic process at UNOP. Overall, clinicians initiated conversation around aspects of the EM more than caregivers, and the majority of EM related discussion occurred during psychoeducation. “Treatment,” “course of illness,” and “causation” were the most frequently discussed components. Caregiver references to EM components were mostly prompted by clinicians. Some caregivers spontaneously brought up aspects of the EM except for “pathophysiology,” which was only mentioned when asked about it by clinicians. In their responses, caregivers used the language of the clinicians who had explained “pathophysiology” to them in earlier encounters. “Disease accounts” were used primarily by clinicians to explain “causation,” “course of illness,” and “pathophysiology;” while caregivers used “illness accounts” to describe myths around cancer “causation.” Throughout the encounters, clinicians validated existence of both “disease” and “illness accounts.” Representative quotations are presented in Tables 1 and 2.

Conclusion: Clinical communication at UNOP involved interactions between caregiver and clinician EMs. UNOP’s interdisciplinary team elicited families’ beliefs and facilitated in-depth discussion of all aspects of the EM, leading to a shared understanding of cancer and its treatment. Utilizing the EM framework in clinical practice may improve cross-cultural communication and health outcomes. This study demonstrates the potential utility of introducing these anthropologic concepts into the field of pediatrics in order to support culturally-competent care.