Background The proportion of women diagnosed with
metastatic breast cancer (mBC) in Southern Thailand has
remained stable at 10.5–11.7Percent over the past decade.
Healthcare system-level
and provider-level
barriers
contributing to these delays remain poorly understood.
Objectives To identify patient-related
and healthcare
system-related
factors influencing referral delays for mBC
in Southern Thailand, and to co-design
implementation
strategies with stakeholders to address these barriers.
Methods This co-produced
qualitative study, developed
in partnership with a breast cancer survivor support group,
employed Force Field Analysis to identify barriers and
facilitators influencing mBC referral in Health Region 12.
Data were generated through semi-structured
interviews
with 8 women living with mBC and 13 medical interns,
documentary analysis of 3 national policy documents and
a stakeholder co-design
workshop. Reflexive thematic
analysis was undertaken, with findings synthesised across
macro, organisational and micro levels.
Results Four barriers and three facilitators were
identified. At the macro level, inequities in insurance
scheme restrictions and the incomplete implementation
of national guidelines created structural filters that
delayed access to specialist care. At the organisational
level, limited diagnostic resources, fragmented medical
information systems and a culture of caution surrounding
referral further compounded delays. At the micro level,
socioeconomic constraints and reliance on traditional
medicine interacted with system-level
barriers, indicating
that late presentation is more reflective of systemic
dysfunction than of individual health literacy deficits.
Facilitators were informal, fragile and largely dependent on
individual clinician initiative.
Conclusions Referral delays are driven by cumulative
and reinforcing structural barriers rather than patient-level
factors alone. Through co-design,
stakeholders prioritised
two key interventions: a regional integrated queue system
to enable urgency-based
access, and a digital health
platform to enhance care coordination. Future research
should focus on feasibility testing and pilot implementation
of these interventions to evaluate improvements in
timeliness, equity and sustainability of cancer care.