The result of this study is organized and presented in three parts. The first section describes findings from the qualitative study highlighting the types and location of psychosocial services available for breast cancer patients.
The second section deals with the findings from the quantitative survey describing with the proportion of women who received psychosocial services in those health facilities. The analytic result of the survey was conducted among 428 patients, with a response rate of 96.4%. The third section narrates the reasons for not providing psychosocial services for breast cancer patients in those facilities.
Table 1: Characteristics of participants involved in the qualitative study.
Code
|
Age
|
Place of residence
|
Time since diagnosis
|
Educational status
|
Occupation
|
Type of treatment received before
|
Current treatment
|
Type of hospital
|
P01
|
36
|
Addis Ababa
|
Four years ago
|
First degree
|
Bank teller
|
Surgery (mastectomy, 1 breast)
Chemotherapy
Hormonal 3 yrs 4 months
Radiotherapy
|
Second round chemo (6th cycle)
|
Private
|
P02
|
42
|
Debre Markos
|
Two years ago
|
Unknown
|
House wife
|
Surgery (partial excision)
Chemotherapy
Hormonal therapy (>1 yr)
|
Second round chemo (8th cycle)
|
Government
|
P03
|
51
|
Addis Ababa
|
Six months ago
|
Unknown
|
Merchant
|
Surgery (Mastectomy both breasts)
|
First cycle chemo (2nd cycle)
|
Private
|
P04
|
35
|
Dire Dawa
|
One year ago
|
First degree
|
Bank branch manager
|
Surgery (Mastectomy 1 breast)
|
First cycle chemo (4th cycle)
|
Government
|
Section one: Qualitative study findings
Theme 1: Available psychosocial services
The psychosocial services available for breast cancer patients were described and categorized in to two main sub thematic areas: i) from the community and ii) from the health facilities.
Subtheme 1.1: From the community
Despite the fact that there is an awareness gap and the way the community provides social support has its own limitations, most of breast cancer patients who participated in this study testified that they received various types of emotional support from different groups of people in the community.
a) From family members
“The good thing, I receive a lot of support from my family. My husband is very supportive, my sisters, my mother and friends. All are very supportive.” (P01: 36 years)
b) From close friends
“My close friends know about it and we always discuss about everything. They comfort me a lot…they are very supportive.” (P04: 35 years)
c) From colleagues
“Even at work, people usually support me. For example, they reduce workload and give me permission when I have an appointment.” (P01: 36 years)
Subtheme 1.2: From health professionals at the health facilities
a) Disclosure and counseling services
In those visited health facilities, there was no structured way of disclosing breast cancer patients. But most of the time, the physician who made the diagnosis was the one who disclosed the diagnosis to patients; this was also reported by patients.
“There was a doctor who did the diagnosis and disclosed me as I have cancer.” (P04: 35 years)
“The doctor is the one who handles most of these issues using the short time he has for examining all the patients. He provides the counseling service based on patient’s knowledge and condition.” (HP04: Health officer, private)
On the other hand, there were breast cancer patients who accidentally got disclosed during the waiting time or when they were linked to an oncologist. Sometimes cancer patients remained undisclosed about their status. Respondents mentioned caregivers who informed the health professionals not to tell the patient about cancer because of fear of discontinuing the treatment and in order to prevent hopelessness.
“They didn’t tell me anything about the disease except telling me that I will be linked to another doctor …Then, I heard from other patient beside me that we are waiting for a cancer doctor.” (P01: 36 years)
“Sometimes, patients bring their pathology result without being informed about their diagnosis...the family members insist us not to tell them and the doctor will not say anything.” (HP03: BSc nurse, private)
All breast cancer patients who participated in the qualitative study reported that they did not receive any counseling services. They even mentioned that they were not properly disclosed and the health professionals didn’t provide any emotional support or counseling at the time of diagnosis.
“The way he disclosed me was really shocking. Then, I isolated myself from any kind of medical treatment. The doctor told me as its breast cancer, and as there is no option other than removing my breast. I even asked him about the cause and he said we don’t have time to discuss about this; rather we have to focus on the solution. That’s all what he said to me.” (P04: 35 years)
In contrast, the health professionals reported that they were providing counseling services and emotional support for cancer patients as much as the situation allowed them. However, except having short and brief discussions with each patient, there were no structured psychosocial services, which included counseling, emotional support and discussion sessions with cancer patients either individually or as a group. The physicians and nurses who were working in the oncology unit provided these services along with their other routine tasks.
“We do not have such structured system, even the psychological support and counseling is not provided adequately. But we are trying our best and we need both counselors and clinical psychologists.” (HP01, Oncologist)
Table 2: Characteristics of key informants participated in the qualitative study
Code
|
Profession
|
Year of experience
|
Year of experience at the oncology department
|
Type of the hospital
|
HP01
|
Oncologist
|
27 years
|
10 years
|
Government
|
HP02
|
Oncologist
|
15 years
|
11 years
|
Government
|
HP03
|
Clinical nurse
|
10 years
|
8 years
|
Private
|
HP04
|
Clinical nurse
|
5 years
|
4 years
|
Government
|
HP05
|
Health officer
|
2 years
|
2 years
|
Private
|
b) Provision of adequate information and brochures
Few participants reported that they received some information from health professionals about the treatment options, side effects and duration of treatment.
“When I start chemotherapy, the doctor told me that the treatment has an effect on my hair and as I should not be worried about it.” (PO2: 42 years)
However, most of the patients indicated that the information provided by health professionals was not adequate and the majority of breast cancer patients discussed among themselves and got a lot of information from other patients who were diagnosed earlier.
“No, I was not even informed about the no of cycles prescribed for me. On the third cycle, I asked the nurse and told me as its six cycles.” (PO4: 35 years)
“We usually talk among ourselves and get a lot of information from those patients who took the medication earlier.” (PO2: 35 years)
Concerning the provision of leaflets and brochures, none of the participants mentioned that they received such kind of educational materials. The health professionals also reported that they did not usually give those materials to their patients.
“No, noone gave me such kind of materials.” (PO1: 36 years)
“We try our best to help the patients with what we can but we do not provide educational materials or other supports.” (HP01: Oncologist)
Section two: Quantitative study findings
Concerning psychosocial services received, our quantitative study revealed that only 47 (11.0%) of these patients have received any kind of psychosocial service in the current health facility, either in the form of counseling, emotional support or provision of information from health professionals. Out of these patients, more than half 27 (57.6%) received information from the health professionals, while the others received other forms of psychosocial services. Most 356 (83.2%) of the breast cancer patients stated that they preferred to visit health facilities in order to receive psychosocial services, 70 (16.4%) of them preferred religious places and only 2 (0.5%) preferred traditional healers or other people.
Even though, majority of participants are still involving in different social activities, 75 (17.5%) of the total participants reported that the disease affected different aspects of their life. Out of these, 46 (61.3%) and 32 (42.6%) of the patients stated that the disease affected their social and spiritual life respectively (Table 3).
Table 3: Type of psychosocial service received in selected health facilities in Addis Ababa, Ethiopia
Variables
|
|
n
|
Percent (%)
|
Patients reaction at the time of diagnosis (n = 354)
|
I was shocked & cried
Deep sadness
Hopelessness and fear of death
I didn’t feel anything
Others*
|
207
60
14
50
23
|
58.5
16.9
4.0
14.1
6.5
|
Know about their disease status
|
Breast cancer
Breast Tumor and inflammation
Don’t know
|
354
61
13
|
82.7
14.3
3.0
|
Ever received counseling service
|
No
Yes
|
371
57
|
86.7
13.3
|
Currently receiving any psychosocial service in this facility
|
No
Yes
|
381
47
|
89.0
11.0
|
Type of psychosocial service received
(n = 47)
|
Counseling service
Emotional support
Provision of information
|
9
11
27
|
19.1
23.4
57.4
|
Participate in different gatherings
|
No
Yes
|
28
400
|
6.5
93.5
|
Type of gatherings
(n = 428 for each type)
|
Spiritual
Only Funeral
Social
Women
Political
|
328
323
240
125
32
|
76.6
75.5
56.1
29.2
7.5
|
Challenges in relation to the disease
|
No
Yes
|
353
75
|
82.5
17.5
|
Type of challenges encountered
(n = 75 for each type)
|
Problem on social activities
Problem on spiritual life
|
46
32
|
61.3
42.6
|
|
Problem with family
Problem with employer
|
27
22
|
36.0
29.3
|
Preferred place to receive psychosocial support
|
Health facilities
Religious places
Traditional healers’ other people
|
356
70
2
|
83.2
16.4
0.5
|
According to the multivariate analysis, residence was one of the sociodemographic factors that was significantly associated with receipt for psychosocial care. The odds of breast cancer patients who live in Addis Ababa were 2.54 times more likely to receive any psychosocial services as compared to those who came from outside of Addis Ababa [AOR = 2.54 (95% CI 1.30, 6.27)]. Clinical factors such as severity of pain and date of diagnosis, also had a significant association with receiving psychosocial services. Breast cancer patients who had moderate pain were three times more likely to receive psychosocial services as compared to those women without any pain. [AOR = 2.84 (95% CI 1.02, 7.94). The odds of women who were diagnosed more than 1 year ago were three times more likely to receive the service as compared to those who were recently diagnosed (< 1 year) [AOR = 3.17 (95% CI 1.27, 7.89)] (Table 4).
Table 4: Multivariate logistic regression model for factors for receiving psychosocial service among Breast Cancer Patients in Addis Ababa, Ethiopia
Variables
|
|
Crude OR (95% CI)
|
Adjusted OR (95% CI)
|
Health facilities
|
Government
Private
|
1
1.57 (0.58, 4.13)
|
1
1.67 (0.46, 6.03)
|
Age
|
|
1.04 (1.01, 1.08) *
|
1.04 (0.99, 1.08)
|
Residence
|
Outside Addis
Inside Addis
|
1
1.87 (0.97, 3.52)
|
1
2.54 (1.30, 6.27) *
|
Marital status
|
Single
Married
Cohabitated
Divorced
Widowed
|
1
2.00 (0.87, 4.62)
0.87 (0.23, 3.24)
2.70 (0.76, 9.30)
3.01 (0.92, 9.56)
|
1
2.35 (0.91, 6.08)
1.53 (0.25, 9.52)
2.61 (0.63, 10.91)
2.05 (0.49, 8.62)
|
Severity of pain
|
None (0)
Mild (1-3)
Moderate (4-6)
Severe (7-10)
|
1
2.09 (1.02, 4.28) *
3.21 (1.29, 7.99) *
2.78 (0.59, 13.12)
|
1
1.93 (0.82, 4.53)
2.84 (1.02, 7.94) *
2.44 (0.46, 12.92)
|
Final stage of cancer
|
Stage I
Stage II
Stage III
Stage IV
|
1
0.62 (0.13, 2.81)
0.42 (0.09, 1.89)
1.20 (0.16, 9.04)
|
1
0.88 (0.17, 4.49)
0.65 (0.13, 3.29)
1.18 (0.14,10.17)
|
Chemotherapy
|
No
Yes
|
1
0.53 (0.18, 1.52)
|
1
0.34 (0.076, 1.57)
|
Duration of Dx
|
Less than 1 yr
More than 1 yr
|
1
2.95 (1.26, 6.86) *
|
1
3.17 (1.27, 7.89) *
|
Section three: Qualitative study findings
Theme 2: Determinants of psychosocial services provision
Reasons for not providing psychosocial services in these health facilities were also explored in the qualitative part of the study, and several justifications were given by the key informants. These included shortage of staff, high workload and not having an assigned person who will deliver these services in an organized way.
“The main problem is staff shortage and high patient flow…umm….we do not have a staff who is assigned for psychosocial activities…” (HP04: BSc nurse, government)
In addition to this, there was high patient flow in these health facilities due to the limited number of cancer centers in the country. Therefore, it was difficult for the health professionals to spend more time with each patient and address their emotional and psychosocial needs.
“I don’t know the reason, but I think it’s because of high patient flow. Let alone to spend some time with you and discuss about your disease condition, the medication by itself is given in hurry.” (PO2: 42 years; BC patient)
“…because of the high patient flow, doctors are forced to see many patients per day specially in government hospitals.” (HP02: Oncologist)
The other justification was lack of skill / training on how to provide counseling and other professional supports. They also stated that the setup by itself was not convenient to provide individual counseling for the patients.
“There are no trained personnel which makes it difficult to provide counseling service.” (HP05: Health officer, private)
“The patients are very eager to listen. But the issue is we do not have adequate room for counseling services” (HP04: BSc nurse, government)