Evidence-based feedback about emotional cancer challenges experienced in South Africa: A qualitative analysis of 316 photovoice interviews

"Let him die. He caused it": A qualitative study on cancer stigma in Tanzania

Cancer stigma presents a critical barrier to care seeking, contributing to delayed presentation and poor cancer outcomes worldwide. The burden of cancer in Tanzania is on the rise, with cancer being the third-leading cause of death in the country. Despite rising incidence and poor outcomes of cancer, cancer-related stigma interventions have received low prioritization. There is a need for sound research that focuses on understanding attitudes driving stigma, its impact on care-seeking and treatment adherence, and intervention models to reduce stigma. We used a cross-sectional qualitative study design. We administered three open-ended qualitative questions to 140 adults newly diagnosed with cancer in Moshi, Tanzania. The questions explored common attitudes toward people with cancer, the perceived impact of cancer-related stigma on care engagement, and ideas for reducing cancer stigma. Patients were recruited during routine appointments at the Cancer Center at Kilimanjaro Christian Medical Center. Data were analyzed using a team-based, applied thematic approach and NVivo 12 software. All participants described stigma as a significant challenge for treatment and receiving support from their social networks. Perceptions of financial burden, misconceptions about cancer, such as the belief that it is contagious, and fear of death, were common attitudes driving cancer stigma. Most participants feared that symptoms would prevent them from being able to work and that the cost of cancer care would drive away loved ones. Stigma was not a ubiquitous response, as some participants reported increased care and social support from family members after a cancer diagnosis. Experiences of stigma contributed to feelings of shame, fear of burdening the family, reduced resources to access treatment, and disengagement from care. Common substitutes to medical therapies included religious interventions and traditional medicine, perceived as less expensive and less stigmatizing. Many participants felt they would benefit from improved financial support, professional counseling, and education for families and communities to reduce stigmatizing attitudes and enhance social support. There is a need for intervention studies focused on improving cancer literacy, community advocacy to reduce cancer stigma, and increasing emotional and practical support for people with cancer and their families. There is also a clear need for policy efforts to make cancer care more affordable and accessible to reduce the financial burden on patients and families.

Stigma in Pediatric Cancer: An Exploratory Study of Osteosarcoma and Retinoblastoma in Guatemala, Jordan, and Zimbabwe

PURPOSE

Stigma is an understudied barrier to health care acceptance in pediatric oncology. We sought to explore the stigma experience, including its impact on cancer treatment decision making, and identify strategies to mitigate stigma for patients with osteosarcoma and retinoblastoma in Guatemala, Jordan, and Zimbabwe.

METHODS

Participants included caregivers, adolescent patients (age 12-19 years), and health care clinicians. A semistructured interview guide based on The Health Stigma and Discrimination Framework (HSDF) was adapted for use at each site. Interviews were conducted in English, Spanish, Arabic, or Shona, audio-recorded, translated, and transcribed. Thematic analysis focused on stigma practices, experiences, outcomes, drivers, mitigators, and interventions.

RESULTS

We conducted 56 interviews (28 caregivers, 19 health care clinicians, nine patients; 20 in Guatemala, 21 in Jordan, 15 in Zimbabwe). Major themes were organized into categories used to adapt the HSDF to global pediatric cancer care. Themes were described similarly across all sites, ages, and diagnoses, with specific cultural nuances noted. Pediatric cancer stigma was depicted as an isolating and emotional experience beginning at diagnosis and including internalized and associative stigma. Stigma affected decision making and contributed to negative outcomes including delayed diagnosis, treatment abandonment, regret, and psychosocial fragility. Overcoming stigma led to positive outcomes including resilience, treatment adherence, pride, and advocacy. Identified stigma drivers and mitigators were linked to potential interventions.

CONCLUSION

Participants describe a shared stigma experience that transcends geography, cultural context, age, and diagnosis. Stigma manifestations have the potential to impact medical decision making and affect long-term psychological outcomes. Stigma assessment tools and interventions aimed at stigma mitigation including educational initiatives and support groups specific to pediatric cancer should be the focus of future research.

Use of photo methods in research studies with cancer survivors and their caregivers: a scoping review

PURPOSE

Photo methods such as photo-elicitation and photovoice have traditionally been implemented as knowledge-generation techniques; however, they have also been conceptualized as tools for community impact and as interventions in and of themselves. We performed a scoping review to document how photo methods have been used in studies of cancer, to describe participant populations, and to identify opportunities for future directions for the use of photo methods in cancer.

METHODS

An a priori search strategy was implemented across health-related databases with the following inclusion criteria: (1) study participants were diagnosed with cancer and/or were caregivers of those with cancer; (2) study participants were asked to take and/or respond to photographs as part of the study protocol; (3) articles were published in peer-reviewed journals; (4) articles were written in English.

RESULTS

Eighty non-duplicative articles were identified; of these, 30 articles describing 24 individual studies were included for review. All but one (95.8%) of the studies utilized photovoice solely as a knowledge-generation technique without participant outcome measurement or analysis. Across all included studies, participants were largely women with breast cancer; other demographic and cancer-related variables (e.g., race and cancer stage) were not consistently reported. Caregivers were included in 37.5% of studies.

CONCLUSION

Photo methods are most frequently used in order to capture qualitative data in cancer populations; however, there are missed opportunities in their lack of use for intervention and systemic change. In addition, inconsistent reporting of demographics and cancer characteristics limits our ability to synthesize these data across studies.

Culturally-informed adaptation and psychometric properties of the Cataldo Cancer Stigma Scale in Northern Tanzania

BACKGROUND

Cancer-related stigma impacts patients' emotional health, care engagement, and cancer outcomes, but few measures of cancer stigma exist. We culturally adapted and assessed psychometric properties of the Cataldo Cancer Stigma Scale (CCSS) in Tanzania.

METHODS

We administered the CCSS short version (21 items), plus 12 locally-derived items, to 146 adult cancer patients. We conducted exploratory factor analysis, examined internal consistency/reliability, and assessed convergent validity with relevant measures.

RESULTS

We identified a 17-item cancer stigma scale with strong psychometric properties and four subscales: enacted stigma, shame and blame, internalized stigma, and disclosure concerns. Stigma was rare except for disclosure concerns. Stigma was positively associated with depression and anxiety and negatively associated with social support, quality of life, and illness acceptance.

CONCLUSIONS

The scale provides valid, culturally-informed measurement of cancer stigma in Tanzania. Future studies should assess associations with care engagement, which will inform interventions to reduce stigma and improve outcomes.

Psychosocial aspects of adult cancer patients: A scoping review of sub-Saharan Africa

OBJECTIVE

Psychosocial aspects of adult cancer patients in sub-Saharan Africa (SSA) have been described in silos of research articles. Integrative analysis of regional evidence is lacking. This review aimed to describe the scope of existing research on mental health problems, identify research gaps and make informed research, policy and practice recommendations.

METHODS

Search was conducted for original peer-reviewed research articles, irrespective of their quality, on psychosocial aspects of cancer in all SSA countries using PubMed, Google Scholar, Google search, African Index Medicus and direct searches of reference list of pertinent journal articles. Publications in English or translated to English were included. Case reports, dissertations, abstracts, publications without primary focus on psychosocial issues, psychosocial issues in children and studies conducted with SSA populations living outside the sub-region were excluded. The methodological framework described by Arksey and O'Malley was used to synthesize and present the results. Inductive approach was used to arrive at the thematic areas. Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guideline was used to describe the review.

RESULTS

Eighty-three studies conducted across 15 countries were identified. Six thematic areas emerged namely; psychosocial needs, psychiatric disorders, coping strategies, suicidality, psychometrics and psychosocial interventions. Fifteen of 46 countries had at least one study with the majority of articles emanating from Nigeria. Research articles on psychosocial needs, psychiatric morbidities and coping strategies appears adequate for systematic review in SSA region. Despite the overwhelming evidence of high unmet psychosocial needs, a huge gap exists regarding psychosocial interventions.

CONCLUSION

Further research is needed into identified gaps in the region and quality of evidence of these studies need to be improved upon. Comprehensive policies and action plan development are sin qua non for addressing psychosocial problems of adults with cancer in SSA.

Patient experiences of living with cancer before interaction with palliative care services in Zimbabwe: A qualitative secondary data analysis

OBJECTIVE

Cancer patients in Zimbabwe typically access health services with advanced disease, limiting treatment choices and lessening the likelihood of positive treatment outcomes. We outline experiences of patients with advanced cancer prior to interaction with palliative care services to identify targets for future intervention development to enhance care delivery in Zimbabwe.

METHODS

Participants were purposively sampled adult patients with advanced cancer. We adopted a thematic approach to guide a qualitative secondary data analysis exploring factors influencing support sought by participants, external factors influencing decision making across the disease trajectory and the process for seeking and accessing palliative care.

RESULTS

Participants reported fragmented and uncoordinated care, from initial symptom experience and throughout disease progression. A recurring notion of disjuncture was present through participants' experiences of gaps, breaks and discontinuity across the disease trajectory. Each step had a beginning and end without clear routes for transition with movement between steps as a result of happenstance or informal encounters.

CONCLUSION

Targets for intervention development at the patient and family level exist that may reduce the disjuncture currently experienced between need and care provision. A holistic response that incorporates engagement with policy actors is critical to addressing prominent financial constraints for patients.

Improving Timely Access to Diagnostic and Treatment Services for Lung Cancer Patients in KwaZulu-Natal, South Africa: Priority-Setting through Nominal Group Techniques

Background: Lung cancer is the most common cancer worldwide, and it disproportionately affects low-income countries (LICs), where over 58% of cases occur. It is an important public health concern, given its poor healthcare outcomes, yet it is under-researched compared to other cancers. Lung cancer is also very difficult for primary care physicians to diagnose. In many settings, health researchers and clinicians’ resort to engaging in collaborative efforts to determine the best way to implement evidence into routine clinical practice. Methods: This was a grounded theory study comprising seven experts providing oncological services. A Nominal Group Technique (NGT) was used to articulate ideas, identify key problems and reach consensus on the order of priorities for the identified problems. Results: The study findings revealed that access to healthcare facilities providing oncology services and diagnosis was the major barrier to lung cancer care. This was further exacerbated by the manner in which health systems are configured in South Africa. The priorities for the health providers were focused on the lack of specialized resources, whereby referral of patients suspected to have lung cancer was delayed and compounded by the limited availability of treatment. Conclusion: The inadequacy of supportive systems for access to healthcare services negates the government efforts to curb the rising lung cancer-related fatalities in South Africa.

Competencies for Nurses Regarding Psychosocial Care of Patients With Cancer in Africa: An Imperative for Action

Psychosocial care is considered an important component of quality cancer care. Individuals treated for cancer can experience biologic or physical, emotional, spiritual, and practical consequences (eg, financial), which have an impact on their quality of living. With the establishment of cancer centers in Africa, there is growing advocacy regarding the need for psychosocial care, given the level of unmet supportive care needs and high emotional distress reported for patients. Nurses are in an ideal position to provide psychosocial care to patients with cancer and their families but must possess relevant knowledge and skills to do so. Across Africa, nurses are challenged in gaining the necessary education for psychosocial cancer care as programs vary in the amount of psychosocial content offered. This perspective article presents competencies regarding psychosocial care for nurses caring for patients with cancer in Africa. The competencies were adapted by expert consensus from existing evidenced-based competencies for oncology nurses. They are offered as a potential basis for educational program planning and curriculum development for cancer nursing in Africa. Recommendations are offered regarding use of these competencies by nursing and cancer program leaders to enhance the quality of care for African patients with cancer and their family members. The strategies emphasize building capacity of nurses to engage in effective delivery of psychosocial care for individuals with cancer and their family members.

Cancer care reform in South Africa: A case for cancer care coordination: A narrative review

OBJECTIVE

This review provides an overview of the existing literature on the importance of care coordination for lung cancer care and other cancers in general. The review is inclusive of the burden of cancer, with a special reference to lung cancer, as well as challenges and achievements relating to cancer care coordination.

METHOD

We conducted a search of online databases of peer-reviewed studies published in the English language. The analysis for this review has been packaged into themes in order to generate results that can inform researchers and cancer health professionals, on the existing gaps necessary for developing appropriate intervention strategies and policy guidelines.

RESULTS

Cancer is a complex condition that often requires multiple interventions provided by a variety of health professionals within the healthcare continuum. This paper reviewed research studies that explored the supportive care needs of cancer patients. The results are presented in three superordinate themes, namely (a) cancer as a healthcare priority in South Africa (SA), (b) making a case for coordinated cancer care in SA, and (c) care coordination: a poorly defined, yet complex concept. One major need identified was the requirement of informational support. Other essential needs included referral, emotional, and financial support.

SIGNIFICANCE OF RESULTS

The identification of current obstacles has the potential to guide the development of a model to improve quality coordinated cancer health care. It remains that limited research exists around cancer services and cancer care in the South African region. This narrative review identified common elements and barriers to care for lung cancer patients and survivors, and offers recommendations for developing clinical care models.

Exploring grassroots feedback about cancer challenges in South Africa: a discussion of themes derived from content thematic analysis of 316 photo-narratives

INTRODUCTION

Cancer is an important health problem in Africa with projections that incidence could double by 2030. While sparse, the literature on cancer control in African low- and middle-income countries suggests poor cancer planning, overburdened services and poor outcomes. South Africa has established oncology health care services but also has low cancer awareness, poor cancer surveillance and widespread service challenges.

METHODS

Data for this study was derived from 316 photovoice interviews with cancer patients, families of cancer patients and oncology workers across South Africa. The objectives of the study were to collect first-hand feedback about cancer challenges and to develop recommendations for the improvement of cancer control strategies.

RESULTS

9 themes of cancer challenges were distinguished via thematic content analysis of the photo-narratives. The identified themes of cancer challenges were physical and treatment challenges, emotional, poor services, transport, finances, information, powerlessness, stigma, and schooling challenges.

CONCLUSION

The findings of this study offer the patient and family perspective of cancer challenges as a valid contribution to our body of cancer knowledge. The 9 themes of cancer challenges profile the emotional, physical and social impact of cancer on patients and families, and offer detailed subjective information about problem occurrence in the trajectory of care. Recommendations following from the 9 themes of cancer challenges include training for improved patient-centred care standards, the need for cancer surveillance, innovative and locally appropriate cancer awareness campaigns, private and government health care partnerships and the development of psychosocial services. The advocating of findings and recommendations to influence cancer control strategies in South Africa, is indicated.