Study Area and Setting
The study was conducted at the Oncology center, TASH, Addis Ababa. Addis Ababa is the capital city of Ethiopia. It is the largest city in Ethiopia, with a population of 3,475,952 according to the 2007 population census with an annual growth rate of 2.7%. Its area is estimated to be 540km2 altitudes ranging from 2200- 3000m above sea level, the average temperature of 22.8oc and an average rainfall of 1,180.4mm. Addis Ababa has 41 hospitals (13 public and 28 NGO and private), 29 health centers 122 health stations, 37 health posts and 382 modern private clinics (17).
Tikur Anbassa Specialized Hospital is a government-owned large referral teaching hospital, located in Kirkos sub-city under the administration of Addis Ababa University, College of Health sciences. The oncology center at the Hospital is the only referral center in the country. The hospital has 600 beds of which 18 are allocated to cancer treatment. Of the 201 physicians at the hospital, only two are hematologists, four are medical oncologists, four are radiotherapists, two are surgical oncologists, and one is a pediatric oncologist. Three palliative pain specialists moreover work on the hospital. Only 26 of the Tikur Anbessa’s 627 nurses are dedicated, oncology nurses. In 2010, more than 260 000 patients in total were treated in the hospital, including more than 2000 adults and more than 200 children with cancer. Most of the patients, more than 9229 were females and found in the reproductive age group. Treatments offered at Tikur Anbessa hospital cancer center contain anti-cancer drugs, surgery, and radiotherapy(19).
Study Design and Period
An institutional-based cross-sectional study was conducted from March 1 to April 30/ 2019.
All breast cancer patients being evaluated and treated in oncology units were considered as a source population.
Those breast cancer patients visiting the hospital and being evaluated or treated at the oncology unit during data collection time and who met the eligibility criteria were invited.
All-female breast cancer patients who visited the hospital during the data collection were eligible for participation in the study.
Patients who are unable to respond and those who didn’t take chemotherapy treatment were excluded from the study.
Sample size determination
To describe the distribution of quality of life scores, social networks, and associated factors, the sample was calculated by using the prevalence of breast cancer patients 14.8% (18), marginal of error: d=5% and confidence interval: CI= 95%, So that the sample size was:
(1.96)2 (0.148) (0.852) = 193.76=194
By adding 10% non- response rate, the total sample size was: 194+19.4=213.4=214
Tikur Anbessa Specialized Hospital was selected because it is currently the only referral hospital that provides different types of therapy including radiation therapy for cancer patients in Ethiopia.
According to the one-year record of female breast cancer, 8000 cases were seen in the oncology unit at Tikur Anbessa Specialized Hospital (TASH). Since the duration of the study was four weeks, the calculated flow within the four weeks was 667 and the required sample size was 214 study cases that were come for initiation of treatment and on follow-up during data collection period was asked. Therefore, “K” was 3. Based on a systematic random sampling technique every 3 study participants were enrolled in the study during the data collection period.
Socio-demographic (Age, educational status and religion)
Socioeconomic (occupation and monthly income)
Clinical factors: Body mass index (BMI), stage of the diseases, time since diagnosis and type of treatment.
Lifestyle (smoking, alcohol intake and physical activity)
Social networks: defined as the overall connectedness or relationship of the twelve domains include (spouse, children, parents, partner’s parents, other relatives, close friends, religious, education, employment, neighbors, volunteer works, and other social groups(21).
Limited social networks: based on Social Network Index (SNI) score, participants who were scored 0-3.
Medium social networks: based on Social Network Index (SNI) score, participants who were scored 4-5.
Diverse social networks: based on Social Network Index (SNI) score, participants who were scored ≥6(22). Social networks of the respondents were assessed using Cohen’s social network index (SNI) which contains 12 items(20). This index counts the number of social roles in which the respondent has regular contact, at least once every 2 weeks, with at least one person:(spouse, children, parents, partner’s parents, other relatives, close friends, religious, education, employment, neighbors, volunteer works, and other social groups). The maximum SNI score is 12. Three categories of social network diversity were formed based on the SNI score: SNI 0–3 represents a limited social network, 4–5 as a medium social network and SNI ≥6 as diverse social networks.
Good social networks: based on social network index (SNI) score, participants who were scored ≥4.
Poor social networks: based on social network index (SNI) score, participants who were scored <4.
Quality of life: Assessed by using functional scales, symptom scales, and global health status scales(23). The functional scale includes - Physical, Role, Cognitive, Emotional, Social Functioning, body image, sexual functioning, sexual enjoyment, and future perspective. Global health status assessed by two items. And symptom scales include - fatigue, nausea and vomiting, pain, dyspnea, insomnia, appetite loss, constipation, diarrhea, financial difficulty, systemic therapy side effects, breast symptoms, arm symptoms and upset by hair loss.
Not affected quality of life: Participants who were scored 75 and above for functional and global health status scale and 25 and below for symptom scale.
Affected quality of life: Participants who were scored below 75 for functional and global health status scale and above 25 for symptom scale(23).
Data collection tools
Data was collected by face to face interview using structured questionnaires that were adapted from literature (10, 22,23). The questionnaire was prepared in English language and then translated to the Amharic by experts who are expert in both languages, then back to English by another expert to ensure the uniformity of the instrument. Five percent of the sample size was pre-tested in Haleluia hospital to check whether the study populations understand the questions and modified accordingly (if needed). The questionnaire contains three parts. The 1st part was used to assess socio-demographic characteristics of the respondents, the 2nd was asses social networks of the respondents using Cohen’s social network index (SNI) which contains 12 items(19). And the last was used to assess the quality of life of the respondents were using the European Organization for Research and Treatment of Cancer (EORTC) version 3.0 of QLQ-C30 (23,25).
Data collection procedure
Six BSc nurses and two MSc supervisors were used for data collection. One day training was given for clarification of some terms and assessment tools, the aim of the study concerning the need for strict confidentiality of respondent’s information and time of data collection. Supervisors have closely monitored daily data during data collection.
Data quality control
Data quality control was made by pre-tested in 5% of the total sample size. One full-day training was given for data collectors and supervisors regarding the study, the questionnaire and the data collection procedure by the main investigator. The Collected data were checked every day by supervisors and principal investigators for its completeness. Confidentiality was ensured by not recording names or any personal identity. Data was checked again for its completeness before data entry. Finally, data was kept in the form of a file in-secured place where no one can access it except the investigator
Data processing and analysis
First, data were checked for completeness then cleaned and coded before entered to epi-data manager version 4.2. Next data from the completed questionnaire was entered (double entry) into epi-data and transferred into SPSS version 25 for analysis. Descriptive statistics were used to analyze demographic characteristics. Logistic regression models were used to evaluate associations between social networks, social support, and quality of life. Bivariate and multivariate analysis with 95 % CI was employed. Variables found to have a P-value<0.2 in the binary logistic regression were entered into multivariate analysis and strength of association was declared at P value<0.05.
Ethical clearance was obtained from the institutional review board of Addis Ababa University, College of Health Sciences, School of Nursing and Midwifery. A support letter from the School of Nursing and Midwifery was submitted to Tikur Anbesa Specialized hospital. Informed written consent was gained from all study participants. Participants were informed about the importance of the study. After information was provided about the purpose of the study, non- invasiveness of the data collection procedure, confidentiality of the information and respondents were reassured that they would be anonymous (unnamed). Then respondents were given a chance to ask anything about the study and were free to refuse or stop at any moment they want if their choice.