Study Area and Setting: The study was conducted at the Oncology center, TASH, located in Addis Ababa. Addis Ababa is the capital and the largest in Ethiopia. Tikur Anbassa Specialized Hospital (TASH) is a large government-owned 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.
Study Design and Period: An institutional-based cross-sectional study was conducted from March 1 to April 30/ 2019.
Source Population: All breast cancer patients being evaluated and treated in oncology units were considered as a source population.
Study 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.
Inclusion criteria: All-female breast cancer patients who visited the hospital during the data collection were eligible for participation in the study.
Exclusion criterion: Patients who are unable to respond and those who didn’t take chemotherapy treatment were excluded from the study.
Sample size determination and Sampling procedure: 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 of 14.8% (18), by adding 10% non- response rate, the total sample size was calculated to be 214.
According to the one-year record of female breast cancer, 8000 cases were seen in the oncology unit at 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, “K” was 3, so every 3 eligible women were enrolled in the study during the data collection period. This included women who came to the hospital for initiation of treatment or follow-up during the data collection period.
Dependent variables: Social networks among female breast cancer patients and Quality of life among female breast cancer patients.
Independent Variables: 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 of the respondents were assessed using Cohen’s Social Network Index (SNI) which contains 12 items(at Cronbach's Alpha coefficient of 0.72 was obtained) (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 represented a limited social network, 4–5 as a medium social network and SNI ≥6 as a diverse social network. A dichotomous variable was created for SNI, with a good social network defined as an SNI greater than or equal to 4 and a poor social network a score of less than 4(21).
Quality of life was assessed by using functional scales(The alpha coefficient (internal consistency) for the total score was high (alpha = .90) 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 SNI and Quality of life and global health status scales(The alpha coefficient (internal consistency) for the total score was high (alpha =0.94) (10, 22, 23).The QLQ-C30 is the main questionnaire which is aimed to address health-related quality of life of cancer patients in general and it incorporates 30 items. Five functional scales (Physical, Role, Cognitive, Emotional and Social Functioning); three symptom scales (Fatigue, Pain and Nausea or Vomiting), a global health status scale, and a number of single items assessing additional symptoms commonly reported by cancer patients (dyspnea, loss of appetite, insomnia, constipation and diarrhea) and perceived financial impact of the disease. While, QLQ-BR23, which assesses the quality of life for breast cancer patients, has 23 items assessing disease symptoms, side effects of treatment, body image, sexual functioning and future perspective to predict the specific breast cancer related QoL predictors(24).
Thus, the 53 questions from EORTC (30 questions QLQ-C30 and 23 questions QLQ-BR23) were used to assess QOL. From the EORTC-C30 questions 1-15 were used to assess functional scale, from question 16-28 were used to assess symptom scale and the last 2 questions (29-30) were used to assess global health status scale. And from the EORTC-BR23 questions 1-8 were used to assess functional scales and 9-23 were used to assess symptom scales. The participants of the study were requested to select only one answer from (1- Not at all, 2- A little, 3- Quite a bit or 4- Very much) for the first 28 questions and they were asked to select one between the range from 1 (which means Very poor) to 7 (Excellent) in the EORTC QLQC30 items for global health status questions. When it comes to EORTC QLQ-BR23 questions, the participants were requested to select only one answer (1-Not at all, 2-A little, 3-Quite a bit or 4-Very much) for each question.
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. Ethical clearance was obtained from the institutional review board of Addis Ababa University, College of Health Sciences, School of Nursing and Midwifery. Informed written consent was gained from all study participants. 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 during the study.
Data processing and analysis
Descriptive statistics were used to analyze demographic characteristics. Logistic regression models were used to evaluate associations between social networks, 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.