COPING MECHANISMS FOR PEOPLE WITH CANCER: A CASE STUDY OF

HOSPICE, UGANDA.

BY

NABBOSA LILLIAN

17/U/14020/SWD/PD

A RESEARCH REPORT SUBMITTED TO THE DEPARTMENT OF SOCIOLOGY

AND SOCIAL ADMINISTRATION AS PARTIAL FULFILMENT OF THE
REQUIREMENTS
FOR THE AWARD OF THE DEGREE OF BACHELOR OF SOCIAL WORK AND
SOCIAL ADMINISTRATION OF
KYAMBOGO UNIVERSITY

AUGUST 2021
 DECLARATION
I Nabbosa Lillian hereby declare that this research report is original and that it has never been
presented to any university, college or institution for any award.

…………………………….. …………….…………………

Signature Date

Nabbosa Lillian

ii
 APPROVAL
I confirm that the work reported in this research report work was conducted by the candidate
under my supervision.

Sign: …………………………………………… Date: …………………………..

DR. TWEHEYO ROBERT (supervisor)

iii
 DEDICATION
This report is above all dedicated to the Almighty God who has enabled me to study up to
this level. It is also dedicated to my family members for unending support they have rendered
to me throughout field attachment (financially, socially, guidance and spiritually)

iv
 ACKNOWLEDGEMENT
I wish to express my sincere gratitude to the various people who assisted me in various ways
to make this research run smoothly.

I wish to thank my supervisor, Tweheyo Robert for the time he spent advising, scrutinizing
and correcting my work, which inspired me to do my best.

Special thanks to my family who inspired me to keep going. My appreciation goes to my

friends who gave me valuable advice as the study was being carried out. I will forever be
grateful for the time you spent to guide me.

Finally, to the Lord Almighty for his provision and guidance that enabled me to excel.

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 TABLE OF CONTENTS
DECLARATION......................................................................................................................ii

APPROVAL............................................................................................................................iii

DEDICATION.........................................................................................................................iv

ACKNOWLEDGEMENT.......................................................................................................v

TABLE OF CONTENTS........................................................................................................vi

ABSTRACT.............................................................................................................................ix

CHAPTER ONE.......................................................................................................................1

INTRODUCTION....................................................................................................................1

1.1 Background to the study.......................................................................................................1

1.2 Statement of the problem.....................................................................................................2

1.3 General Objective.................................................................................................................2

1.3.1 Specific objectives............................................................................................................2

1.5 Scope of the study................................................................................................................3

1.6 Relevance of the study.........................................................................................................3

CHAPTER TWO.....................................................................................................................4

LITERATURE REVIEW........................................................................................................4

2.1 Introduction..........................................................................................................................4

2.2 The means of survival of cancer patients.............................................................................4

2.3 The Challenges faced by cancer patients of hospice Africa................................................6

2.4 The effects of the coping strategies used by cancer patients of hospice Africa...................7

CHAPTER THREE.................................................................................................................9

RESEARCH METHODOLOGY...........................................................................................9

3.1 Introduction..........................................................................................................................9

3.2 Research design....................................................................................................................9

3.3 Area of study........................................................................................................................9

3.4 Study population..................................................................................................................9

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3.5 Sampling technique and Sample Size..................................................................................9

3.6 Data sources.........................................................................................................................9

3.7 Data collection methods.....................................................................................................10

3.8 Data analysis......................................................................................................................10

3.9 Ethical consideration..........................................................................................................10

3.10 Challenges of the study and delimitations.......................................................................10

CHAPTER FOUR..................................................................................................................11

PRESENTATION, INTERPRETATION AND ANALSIS OF THE FINDINGS...........11

4.0 Introduction........................................................................................................................11

4.1 Demographic characteristics of the respondents................................................................11

4.1.1 Sex of the respondents....................................................................................................11

4.1.2 Age of the respondents....................................................................................................11

4.1.3 Marital status of the respondents.....................................................................................12

4.2 The means used by cancer patients to cope up with cancer in hospice, Uganda...............13

4.3 The challenges faced by cancer patients of hospice...........................................................17

4.4 The effects of the coping strategies used by cancer patients of hospice Uganda..............19

CHAPTER FIVE....................................................................................................................21

SUMMARY, DISCUSION, CONCLUSIONS AND RECOMMENDATIONS OF THE

STUDY....................................................................................................................................21

4.0 Introduction........................................................................................................................21

4.1 Summary of the findings....................................................................................................21

4.1.1 The means used by cancer patients to cope up with cancer in hospice Uganda.............21

4.1.2 The challenges faced by cancer patients of hospice........................................................21

4.1.3 The effects of the coping strategies used by cancer patients of Hospice, Uganda..........21

4.2 Discussion of the findings..................................................................................................22

4.2.1 The means used by cancer patients to cope up with cancer in hospice Uganda.............22

4.2.2 The challenges faced by cancer patients of hospice........................................................22

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4.2.3 The effects of the coping strategies used by cancer patients of Hospice, Uganda..........23

4.3 Conclusion..........................................................................................................................23

4.4 Recommendations..............................................................................................................24

4.5 Areas for further research...................................................................................................24

References...............................................................................................................................25

APPENDICES........................................................................................................................27

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 ABSTRACT

The main objective of the study was to investigate the coping mechanisms of people with
cancer in hospice Uganda. The specific objectives of the study included to find out the means
used by cancer patients cope up with cancer, to find out the challenges faced by cancer
patients in adapting to realities and to find out the effects of the coping strategies used by
cancer patients. This is in order to solve the increasing cases of cancer in Uganda given the
few studies that have been carried out in relation to coping mechanisms of cancer patients.
The study adopted a cross sectional research design which involved qualitative methods such
as interview guide for data collection and analysis and the study involved examining 10
respondents. 4 of the respondents were staff at hospice, Uganda while 6 were cancer patients
both male and female. The results revealed that patients use active coping, social support,
prayers and counselling. The patients faced a challenge of depression, stress and anxiety in
order to cope with realities. The study found out that coping mechanisms help patients to
reduce stress, depression and hence improve their mental wellbeing. The study concluded that
active coping by patients, religious coping, social support and counselling sessions were the
main means that were being used by cancer patients to cope up with cancer at Hospice
Uganda.

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 CHAPTER ONE

INTRODUCTION
1.1 Background to the study
Cancer is the second leading cause of death worldwide, with over 18 million new cases and
9.6 million cancer deaths estimated to have occurred in 2018 (Ferlay et al, 2018). By 2030, it
is projected that there will be approximately 26 million new cancer cases and 17 million
cancer deaths per year. Approximately 50% of all new cancer cases and 70% of all deaths
due to cancer worldwide occur in low- and middle-income countries and cancer burden in
Africa is estimated to double by 2030 (Bray et al, 2018).

It has been documented that people suffering from cancer disease, in most cases, experience
high level of stress that can provoke negative symptoms such as anxiety, depression or fear
(Marcia, 2020). In fact, some people may live through it as a traumatic experience that
threatens their physical and psychological well-being. The impact that this will have on them
will vary according to the resources that they use. In this respect, the function that different
coping strategies have when adapting to this type of oncological processes has not been
investigated.

According to Lazarus and Folkman (1984), coping is defined as “constantly changing

cognitive and behavioural efforts to manage specific external or internal demands that are
appraised as taxing or exceeding the resources of a person” (p.141). Coping is a process that
is changeable over time and related to the type of situation in which it occurs.

Literature has demonstrated that certain coping strategies are more adaptive and widely used
than others, leading to a more constructive, positive and active coping processes (Park et al,
2017). For cancer, coping effectiveness can vary depending on several factors, such as
cancer stage, time since diagnosis, medical treatment, etc. For instance, some authors have
found that coping strategies such as acceptance, positive reappraisal and seeking social
support are associated with higher adaptation, well-being and quality of life in cancer (Phillip
et al, 2019). On the contrary, disadaptive coping strategies such as self-blame, avoidance and
negation are related to poorer mental health outcomes.

In Uganda, 32,000 new cases and 21,000 deaths caused by cancer occurred in 2018 and
56,238 people were living with cancer by 2018 (Bray, et al, 2018). According to the
Globocan cancer statistics report of 2018 (Bray, et al, 2018), the top seven cancers in Uganda

1
– cancer of the cervix, Kaposi sarcoma, breast, prostate, non-Hodgkin lymphoma, liver and
esophageal – account for 70% of new cancer cases. Late presentation that is estimated to
stand at 80% and limited access to diagnosis and treatment services contribute to the high
cancer death rate in Uganda. despite this increasing case of cancer in Uganda, it is rather
inquisitive to explore how patients with cancer survive or adopt to the cognitive and
behavioural effects of cancer. This study was intended to investigate the coping mechanisms
of people with cancer: a case study of hospice Africa, Uganda.

1.2 Statement of the problem

Coping helps adapting to the disease process and is important in achieving or maintaining
quality of life. However, some adaptive coping strategies have been linked to lower mental
health (more depressive and anxiety symptoms) and poorer physical and psychological
quality of life (Macia et al, 2020).

Despite the increasing cases of cancer in Uganda, cancer patients still face several challenges
in adapting to cancer realities. This has also led to certain coping mechanisms of patients at
various levels of cancer. Unfortunately, few studies have been carried out to study the coping
mechanisms of cancer patients. This has created a gap where new patients are greatly stressed
and are not aware of how to adopt to behavioural changes. Care takers in many Ugandan
homes are still not sure of how to cope with the cancer affecting their patients. This study
therefore aimed at bridging the gap and therefore aimed at investigating the coping
mechanisms of people with cancer: a case study of hospice Africa, Uganda.

1.3 General Objective

The general objective of the study was to investigate the coping mechanisms of people with
cancer in hospice Uganda.

1.3.1 Specific objectives

i. To find out the means used by cancer patients cope up with cancer
ii. To find out the challenges faced by cancer patients in adapting to realities.
iii. To find out the effects of the coping mechanisms on the mental wellbeing of cancer
patients.

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1.5 Scope of the study
The study focused on coping mechanisms of people with cancer of hospice Africa, Uganda.
The study was carried out in hospice Africa, Makindye and was carried out for a period of
two months that is from November to December 2020.

1.6 Relevance of the study

i. The study would contribute more literature for further scholars.
ii. The study would help the organisation by contributing coping strategies for patients of
cancer in hospice Africa.
iii. The study would also be helpful for the ministry of health as they may adopt the
coping strategies to help cancer patients in Uganda.

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 CHAPTER TWO

LITERATURE REVIEW
2.1 Introduction
This chapter presents the scholarly literature about the coping mechanism of people with
cancer. This was presented in relation to challenges faced by cancer patients of hospice
Africa, coping strategies used by cancer patients and effects of the coping strategies used by
cancer patients of hospice Africa.

2.2 The means of survival of cancer patients

Saita, Acquati and Kayser, (2015) investigated coping strategies in Italian breast cancer
women considering the influence of personality traits and close relationships. They found that
perceived strength of relationships predicted the use of active and adaptive coping strategies,
being the women with high assertiveness and social anxiety who most used an active coping
style. These results showed that patients adopted an active coping when experimenting high
levels of distress (anxiety, for example) in different stressful situations. They highlighted an
active coping pattern in patients who considered the disease as a challenge which threatens
their assertiveness and social sphere.

Another concept closely linked to adjustment and coping with cancer is resilience. It has been
defined as the ability to cope with traumatic and stressful events and to overcome them in an
effective and positive way. Becoña (2006) stated that resilient people are able to emerge even
stronger from difficult situations, improving their coping strategies and adaptation to the
adverse situation. Resilience involves protective personal attributes including cognitive
flexibility, positive emotions and an active coping (Min et al, 2013).

In this regard, Smith, Saklofske, Keefer and Tremblay (2016) found out that individual
differences in resilience moderated the effects that the fact of actively coping with the disease
has on the negative affect or on depression, whereas the fact of coping with the disease in an
emotion-oriented way was not related to resilience. In fact, emotion-oriented coping
strategies were linked to poorer psychological outcomes.

In this context, Ye et al (2017) studied the mediating effect of resilience in the association
between emotional distress and quality of life in the case of patients with cancer. They found
out that resilience was a predictor of high levels of quality of life in patients. Likewise, results
showed that high levels of resilience were linked to a 64% reduction in the risk of emotional

4
distress, producing a significant buffering effect of resilience on depression. When a patient
has some personal characteristics that imply being resilient, these could help him/her to better
tolerate negative feelings and emotions. This tolerance, in turn, would promote a way of
coping better with cancer disease.

An additional way to handle a stressful event as, e.g., cancer, may be to reconsider different
aspects of life. Changes in patients’ health status may then result in changes in their internal
standards and values, and in the conceptualisation of quality of life. This is often termed
response shift (Guan et al, 2020). As the attainment of various life values may be changed as
a result of the disease, individuals would perceive the same life values as less important.
Compared to e.g., coping, patients’ satisfaction with life, viewed in terms of the discrepancy
between the perceived attainment and subjective importance of various life values, has been
less studied. It has been suggested that a discrepancy between importance and attainment of
life values is of importance for life satisfaction.

Social support; Social support is a factor which may influence the “outcome” of the coping
process. Social support has proved important for well-being (Akechi et al., 2004; Ganz et al.,
2003) and more specifically has personal support been positively associated with good QoL
(Manning-Walsh, 2005). Moreover, among patients with a variety of cancer diagnoses, those
with more social support recorded better QoL in the mental health domain and less anxiety
and depression (Kye, et al, 2020). Social support was also predictive of QoL among long-
term breast cancer survivors in Roomaney et al, (2018). Thus, social support can be supposed
to be a buffer between the stressful events and well-being. Lack of social support also means
poorer overall and cancer specific survival in a large study on breast cancer patients
(Roomaney et al, 2018).

Kyei et al, (2020) revealed intercessions made by the professional participants for patients
while they were on treatment were reassurances, explanations of the entire treatments and
side effects, and counseling. Other interventions were encouragement, advice (such as doing
something they love doing, get relief from work, and relaxation), monitoring, coping,
debunking any negative pieces of information from them, prescriptions for medications, and
on few occasions, referring to counselors outside the department.

Another comment from patients as reported by the participants was feeling fatigued after
treatment, and more apprehensive after explanations. Patients become less anxious when they
know what is wrong with them, how treatment will be delivered when proper explanations on

5
the side effects is given and the more importantly what to do as and when an issue arises.
Both participants involved in the study indicated the need for counsellors or psychotherapist,
spirituality or prayer, medication, and physical therapy.

2.3 The Challenges faced by cancer patients of hospice Africa.

Okello et al, (2014) revealed that the health system and policy issues affecting access to
primary and secondary prevention of cancer in Uganda are the burden of competing health
care priorities, lack of the required basic cancer knowledge and skills among the primary
health care workers, and limited cancer screening facilities. The technical challenge that the
standard test for breast cancer screening option of mammography misses 27% (Okello et al,
2014) of breast cancer disease that ultrasound could detect needs urgent breast screening
policy review to adopt or add the use of portable ultrasound scan to improve breast cancer
screening validity.

Azzani et al, (2019) wrote that cancer patients experience anxiety. It is manifested as
apprehension, uncontrollable worry, restlessness, panic attacks, and avoidance of people and
of reminders of cancer, together with the signs of the autonomic arousal. In certain
circumstances anxious patients may overestimate the risks associated with the treatment and
the likelihood of a poor outcome. The anxiety may also exacerbate perceptions of physical
symptoms (such as breathlessness in lung cancer), and post-traumatic stress symptoms (with
intrusive thoughts and the avoidance of reminders of cancer). Certain cancers and treatments
are associated with specific fears. Thus, patients with head and neck cancers may worry about
being able to breathe and swallow. Some patients may also develop phobias and conditioned
vomiting in relation to unpleasant treatments such as chemotherapy.

Given the constraints posed by the limited resources, the availability of cancer care may
depend on the patient’s financial contribution. At the same time, there is a lack of resources at
every level of cancer care. In 1998, there were only two radiotherapy units and one
chemotherapy unit in the country, and only an estimated 5% of patients had access to these
facilities (Baqutayan, 2012).

Within a variety of areas of research, science takes a starting-point in the fact that a somatic
disease is associated with distress for the individual. Within philosophy the concept of
“Homelessness” has been used to characterize the state when an individual has become ill
(Macia, et al, 2020). This form of “Homelessness” in the disease affects the individuals’
thoughts and movement pattern. The term refers to a state of understanding rather than a state

6
of psychiatric condition. Within the domain of psychology, an individual’s disease is an
important life event that must be taken into account when assessing risk for stress and stress-
related diseases (Roomaney et al, 2018). Chronic diseases and their treatments pose a number
of threats both to those afflicted and their spouses, cancer being no exception.

According to Baum and Posluszny (2001), different aspects (e.g. emotional and social) of the
patients’ life are potentially affected by the cancer and its treatment, both of which are
considered as stressful. The potential stress of having cancer may put the spouse in a stressful
situation as well and, according to some studies, spouses experience more psychological
distress than the patients themselves (Vickery, Latchford, Hewison, Bellew, & Feber, 2003).

A cancer threatens not only the patients but also indirectly their spouses. Factors correlating
with depressed mood among the spouses are their low levels of daily emotional support, low
scores on mastery and appraisal of care giving tasks as negative (Smith et al, 2016). When
compared with cancer patients, their spouses experience more psychological distress
(Kornblith, et al, 2016).

Anxiety and depression; For the total cancer group, anxiety and depression are frequent
psychological reactions. The reported prevalence rates range from about 5 to 50% (Sharpe et
al., 2004). In comparison with population-based controls, there seems, however, to be no or
only slight differences regarding psychological distress (Osborne et al, 2004). Depression is
related to reduced quality of life (Tsunoda et al., 2005) and is also a strong predictor to
reduced quality of life later on (Skarstein et al, 2000). Depressive symptomatology due to the
disease and its effects has also been associated with a shorter survival prospect (Roomaney et
al, 2018).

Kyei, et al (2020) found out that almost 95% of patients with breast cancer had anxiety and
depression in different categories. This result was very high compared to studies conducted
Baqutayan, (2012) and Hassan et al., (2015). The first explanation could be the late stage of
presentation, the high cost of treatment, lack of financial support, lack of insurance,
inadequate family support, family dejections, ignoring by spouses, separation, divorce, fear,
and the fact that some think it is communicable as described by the professional participants
during the interviews.

2.4 The effects of coping mechanisms on the mental wellbeing of cancer patients.
Studies show that resilient people most commonly tend to cope with the disease in an
adaptive way, which in the same time relates to favourable outcomes in terms of quality of

7
life and their mental welling. These results match the ones obtained by Guil et al (2016), who
evaluated the relation between resilience, optimism and psychological well-being in women
that had survived breast cancer. They found out that the level of resilience and well-being in
participants was higher than the levels provided by the average values of the scales that were
used to measure them. The fact of having experienced traumatic events could help people
develop their capacity for personal growth and development, being able to bring meaning to
that event, in the absence of denial of the experience.

Parker (2003) revealed that social support helps to give company and social welfare to the
patients helping to reduce stresses and unhappiness. Parker found that patients with more
social support recorded better QoL in the mental health domain and less anxiety and
depression (Parker, Baile, de Moor, & Cohen, 2003). The present thesis also concludes that
support coming from outside the family is frequent among patients with poorer emotional
well-being.

Burgess et al., (2005) indicated that indicated worse emotional well-being and QoL among
patients with present and previous psychiatric problems. This is in accordance with the
findings of Burgess and co-workers where the patients’ anxiety and depression around
diagnosis were predicted by their history of psychological treatment

Quality of life; within cancer treatment there has been a movement from a major focus on the
patient’s quantity of life with assessment of biological markers of therapeutic outcome
towards including also the patient’s QoL, i.e. evaluating the impact of the disease and its
treatment on other aspects of the patient’s life (Nipp et al, 2017). Further, due to prolonged
survival after diagnosis and treatment consideration has moved to survivor’s QoL and disease
related distress (Vachon, 2006). However, QoL is a concept with a broad range of definitions
and there is no established consensus concerning the term. Different aspects of the concept
have been and still are in focus.

The finding is in relation to Folkman & Greer, (2000) who stated that coping strategies as
direct action and seeking social support are used, the individual has less anxiety. These
results may be due to that the individual tries to handle the anxiety through the usage of these
coping strategies. Another explanation may be that although the individual uses these coping
strategies anxiety is apparent. The positive correlation between the coping strategy
Acceptance and Global QoL indicates a better QoL when this coping strategy was in use.

8
This may be explained by that the usage had effect on the QoL. Thus, acceptance of a
stressful event seems to be good for the patient’s QoL.

9
 CHAPTER THREE

RESEARCH METHODOLOGY
3.1 Introduction
This chapter presents the methods that were used in data collection, these included research
design, study population, sample size, sampling techniques, data sources and data collection
methods.

3.2 Research design

The study adopted a cross sectional research design. This involved qualitative methods of
data collection and analysis. This design was chosen because it is easier and involves
collecting data at one point in time. The study employed interview guides to collect data from
the cancer patients.

3.3 Area of study

The study was carried out at hospice, Uganda in Makindye Uganda which takes care of
cancer patients. Makindye Division is in the south-eastern corner of the city, bordering
Wakiso District to the south and west. The eastern boundary of the division is Murchison
Bay, a part of Lake Victoria. Nakawa Division lies to the northeast of Makindye Division.
Kampala Central Division lies to the north and Lubaga Division lies to the northwest.

3.4 Study population

The study population was comprised of a total of 20 men and women, who were diagnosed of
cancer in Hospice Africa, Uganda.

3.5 Sampling technique and Sample Size

The sample size comprised of 10 respondents who were selected using purposive sampling
because of their informed mind and experience in handling cancer patients. 4 of the
respondents were staff at hospice, Uganda while 6 were cancer patients both male and
female. The sample involved respondents from different backgrounds and different cancers.

3.6 Data sources

The study also included primary data sources who were the respondents and secondary
sources which included journals, papers, reports and medical analysis reports of different
patients and their coping mechanisms.

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3.7 Data collection methods

Interviews were also administered face to face which helped to interpret both verbal and non-
verbal communication - through reading the interviewee non-verbal expressions. The
researcher recorded verbal communications from the respondent.

3.8 Data analysis

After data collection, data was sorted, checked and edited. The study used qualitative analysis
to put together the respondents’’ views into emerging themes.

3.9 Ethical consideration

The study followed ethical rules and procedures to ensure the principles of ethics are
followed.

i. Anonymity; the researcher disguised the identity of the respondents to make sure that
the findings would not link back to them.
ii. Confidentiality; the study ensured that the responses from the respondents were kept
without publishing them.
iii. Informed consent; The study also asked for permission from respondents to
participate in the study.

3.10 Challenges of the study and delimitations

The researcher met respondents who asked for money to participate in the study but this was
solved by assuring them that the study was for research purposes.

The researcher met respondents who did not want to open up but this was solved by
explaining to them that the study would ensure confidentiality of their data.

11
 CHAPTER FOUR

PRESENTATION, INTERPRETATION AND ANALSIS OF THE FINDINGS

4.0 Introduction
The purpose of the study was to investigate the coping mechanisms of people with cancer: a
case study of hospice Uganda. This chapter is presented according the findings about the
research objectives namely; to find out the means used by cancer patients to cope up with
cancer in hospice, Uganda, to find out the challenges faced by cancer patients of hospice,
Uganda, and to find out the effects of the coping strategies used by cancer patients of hospice
Africa, Uganda.

4.1 Demographic characteristics of the respondents

The study assessed the various demographic characteristics of the respondents of the study
according to sex, age, and the marital status of the respondents. The results were as tabulated
in the tables below;

4.1.1 Sex of the respondents

Table 4.1: Sex of the respondents

Sex of the respondents Frequency Percentage

Male 8 40%
Female 12 60%
Total 20 100%
Source: primary data

Table 4.1 above presents that 8(40%) of the respondents who were interviewed were male,
and 12(60%) of the respondents were female. This implicated that most of the cancer cases
were common among women.

4.1.2 Age of the respondents

Table 4.2: Age of the respondents

Age group Frequency Percentage

25-34 years 4 20%
34-44 years 6 30%
45+ years 10 50%
Total 20 100%

12
Source: primary data

13
The data presented in table 4.2 above about the age of the interviewed respondents reveals
that 4(20%) of the respondents were aged 25-34 years, 6(30%) of the respondents were aged
34-44years and 10(50%) of the respondents were aged 45 years and above. This implicated
that most of the cancer cases were most common among aged people.

4.1.3 Marital status of the respondents

Table 4.3 Marital status of the respondents

Marital status Frequency Percentage

Single 6 30%
Married 3 15%
Divorced 11 55%
Total 20 100%
Source: primary data

Results presented in table 4.3 revealed that 6(30%) of the respondents were single, 11(55%)
were divorced, and only 3(15%) were married. This implied that most of the cancer victims
who were interviewed were either single or divorced due to their health conditions.

14
4.2 The means used by cancer patients to cope up with cancer in hospice, Uganda
The study investigated on the means that were being used by the cancer patients to cope up
with cancer in hospice Uganda. The study established that there are some few mechanisms
used by cancer patients to cope with cancer and these were as below.

4.2.1 Facing the Reality of Your Illness

Patients respond in different ways to their diagnoses, the initial medical workup, subsequent
test results, and the implications of all that is happening to them. Many patients respond by
confronting the full realities of their illnesses. They ask pointed and brave questions about the
seriousness of their conditions and the pros and cons of the various treatment options. They
read up on these matters on their own. They react as if they are strongly motivated to know
what they are facing.

One of the patients had this to say;

I was diagnosed with cancer in April 2020 but I accepted the reality and decided
to adopt to the situation because there was nothing I could do. I have managed
to understand more of the problems am going to face as time comes to an end.

4.2.2 Being hopeful and optimistic

Another patient stated that he has tried to remain hopeful and maintain optimism. He had this
to say:

You should try to maintain as much hope and optimism as possible. Not
surprisingly, patients who are hopeful and optimistic about the future course of
events show a better adjustment to their illness than patients who are pessimistic.
Some studies have also shown that optimism is associated with better medical
outcomes. Of course, it would be hard to only feel optimistic (some legitimate
fear is normal); but in most cases, there is a solid and realistic basis for a certain
degree of hope and optimism.

4.2.3 Social support and active coping;

The study also established that social support and active coping seeking out others or
developing a plan of action may also help individuals find meaning by fostering engagement
and emotional expression to others. In turn, expression facilitates further processing of the

15
event and its significance and enables individuals to view an event from a more meaningful
perspective.

One of the staff of Hospice had this to say;

Active coping may also impact meaning in life by increasing feelings of self-efficacy
and personal control. Changing one’s behavior (calling a nurse to ask questions
about a treatment rather than continuing to worry) provides evidence to an
individual that he or she is, indeed, trying to improve a difficult situation or solve a
problem.

4.2.4 Religious coping

Religious coping, such as praying and attending religious services, may help to shape one’s
sense of meaning in life by providing a framework or system of beliefs that answers many of
the issues with which some individuals struggle.

One of the female patients had this to say;

Each day we keep praying and also religious leaders come to us and pray for us so
that our days become easy with less worry. I was diagnosed with breast cancer and
am so worried but the prayers of God has helped to remain strong in faith that all
will be well.

This is similar to the study by Feher & Maly, (2019) who stated that 64% of women recently
diagnosed with breast cancer reported that their religious faith helped them to make meaning
of the cancer experience. Patients may come to conceptualize the diagnosis as part of a larger
plan or something that has greater meaning for one’s life rather than experiencing cancer as a
random event.

Furthermore, the findings of the study about counselling sessions were in line with Kyei et al,
(2020) who revealed intercessions made by the professional participants for patients while
they were on treatment were reassurances, explanations of the entire treatments and side
effects, and counselling. Other interventions were encouragement, advice (such as doing
something they love doing, get relief from work, and relaxation), monitoring, coping,
debunking any negative pieces of information from them, prescriptions for medications, and
on few occasions, referring to counsellors outside the department.

16
The study further investigated on the types of cancer and for how long the patients had been
diagnosed by the patients, and below is what the respondents of the study had to say;

In an interview with one of the medical workers, she said that;

There are many various types of cancer cases we deal with here at
Hospice Uganda, some of the most common cases include breast
cancer among women, prostate cancer among men, cancer of the
blood, lung cancer, cervical Cancer and cancer of the eye. The
cancer patients take months’ time to recover depending on their
various responsiveness to our medication.

In interview with of the cancer patients, she said that she had been diagnosed with breast
cancer for over one year but she was currently improving, because the medical workers were
doing all their best.

In an interview with another cancer patient, he said that;

I have suffered with prostate cancer for over two years now, me
and many other elder male patients have the same type of cancer
in common. But we have hope that one day we will walk out of
here without any more cancer in our bodies.

The staff at hospice revealed that Finding a Positive Meaning s another means by which
cancer patients manage to cope up. One of them stated that while the diagnosis and treatment
of cancer is an awful experience in many respects, it also can be a challenge and even an
opportunity for positive change. In response to their illnesses, many patients step back and
take stock of who they are and how they have been living. They reflect on their values and
priorities, and often identify changes that are warranted (and perhaps overdue) in their
lifestyles and personal relationships. This is often called the “enlightenment” or “gift” that
comes with cancer, or the “wake-up call.” Patients who embrace this aspect of their cancer
experiences have been found to be especially well adjusted and better able to deal with the
many trials and disruptions caused by their illnesses. It is often noted that growing old forces
us to pay attention to what is important in life. The same can be said of a diagnosis of a life-
threatening illness.

Substance use, self-blame, and behavioral disengagement were reported as harmful coping
strategies by several studies. Although creating a temporary relief from the burden, it was

17
reported that the utilization of these maladaptive coping strategies is related to psychological
distress such as depression and anxiety.

18
The study furthermore, the study investigated on whether the patients had faced any
difficulties/challenges with the general situation of cancer. The results from revealed that all
the respondents agreed that they had faced difficulties/challenges with the general situation of
cancer. This implies that cancer is associated with challenges/ difficulties, since all of the
interviewed respondents at Hospice Uganda agreed that they were facing difficulties.

19
4.3 The challenges faced by cancer patients of hospice
The study assessed the challenges that were being faced by cancer patients of hospice Uganda
and the findings from the interviewed respondents were as below.

4.3.1 Depression

The study found out that the patients were experiencing anxiety and depression as the most
common psychological problem encountered in patients with cancer as a result of the
treatment and the worries brought about by uncertainty. In this study patients experience
moderate levels of anxiety and depression.

One of the respondents revealed that patients live in despair, unhappiness and worry when
they are first diagnosed with cancer. This is what she had to say:

I remember the first time I was diagnosed with breast cancer; I thought my life
had ended because I had sleepless nights and I found it challenging to cope up
with the situation. But in the end am trying to restore my mental wellbeing. But
for many new diagnosed patients, they are in constant worry and this has stolen
their happiness.

The above revelation points to the challenges posed by cancer to the patients who have been
diagnosed with it at hospice Uganda.

4.3.2 Self Denial

The study found out that many patients face denial where they do not accept the fate of their
deteriorating quality of life (QoL). In an interview with one of the nurses, this is what he had
to say:

The patients we have here normally experience denial as a mechanism of disagreeing about
the presence of illness and medical diagnosis. It is normally activated after the first stages of
a shock, and usually disappears after a short time. The denial may have a favourable effect
when it appears in the first phase of coping, after the diagnosis has been established because
it reduces anxiety. However, some negative effects of the denial have been observed, for
example: it interferes with the getting treatment such as a delay in going to the doctor, not
showing up for follow-ups, non-compliance) or it disrupts the process of assimilating the
stressful event. Furthermore, it adversely, affects interpersonal relations and constitute a
cumulative stress depression - even immunocompetence.

20
4.3.3 Delayed Psychological Response

The pressure on people from family, friends and even themselves, to return to normal after
treatment was emphasised as having a negative impact on mental health. The patients
revealed that feeling unable to return to previous norms could lead to anxiety and distress
relating to the confusion of not being able to understand why a return to ‘normal’ was often
not immediately possible.

This is what one of the patients said:

“Everyone expected me just to be normal and return to what they considered my normal self
and I crashed and burned”.

Delays in treatment initiation and adherence to cancer treatment

Participants mentioned that they had delayed initiating their cancer treatment after diagnosis
and that they had missed or delayed some medical appointments after initiating treatment.
Delayed or missed appointments were mainly due to lack of money for treatment, medicines
and transportation. Other reasons included: family responsibilities; not healthy enough to
continue treatment; and failure to find accommodation in Kampala.

One of the respondents said:

After my diagnosis, I did not have money to come for the appointment with the
doctor and I was living far plus given my nature. I am a poor farmer far from
Lwengo district and accommodation plus treatment here at hospice is
expensive and if it was not for good Samaritans to help me, I wouldn’t be
here.

This revelation was common among other patients that were interviewed at hospice Uganda
and many revealed that they have been surviving on community support and their relatives
financial contributions.

In an interview with one of the health workers about the challenges faced by the cancer
patients at Hospice Uganda, she said;

Most of the cancer patients who come at Hospice Uganda, cannot

afford the high costs of cancer treatments like the chemotherapies,
cancer operations which require hiring expert neuro surgeons, who

21
 are very expensive. Eventually most of these patients end up losing
their lives helplessly. Which is a very big challenge.

4.3.2 Side-effects of cancer treatment

Participants reported experiencing many side effects due to their cancer treatment including:
general weakness; loss of appetite; darkening of some body parts; loss of hair; and/or
vomiting, Participants indicated that oral wounds, weakness, vomiting and constipation were
the most worrying side effects.

Some patients revealed that they were fond of other side effects like diarrhea, hair loss and
loss of appetite very troublesome. These side effects were most worrying because they
affected participants’ ability to perform normal duties, like eating or drinking. In addition,
participants did not know if the side effects would disappear; they feared worsening of the
side effects and facing death; and being embarrassed and ashamed in public because of their
appearance.

4.3.3 Transportation challenges

The respondents revealed that they travelled long distances to make it to hospice, some of the
participants travelled about 130 km to and from Hospice. Those who were residing in the
hospice travelled an average of about 13 km, while those from upcountry travelled an average
of 312 km to and from hospice. Many of the participants indicated that they used public
transportation to travel from their permanent home to Kampala. When in Kampala that is
from the Kampala accommodation to hospice, some used public transport while others stated
that they were using motorcycle (commonly known as boda-boda) and some few used other
means, such as walking or taxi.

This finding is consistent with other studies of Low et al (2019) who mentioned that
travelling long distances for cancer treatment imposes financial burden on patients and their
families, resulting in poor adherence to cancer treatment and treatment abandonment. Two
regional cancer centers, one in western and one in northern regions, are being established to
increase geographical access to cancer treatment in Uganda.

4.3.4 Lack of social support

Some participants did not have people who had accompanied them to hospice while others
had a young child on their bed sides. Some of the patients mentioned that they did not have
someone to talk to or even explain to their fears.
22
In interview with a cancer patient at Hospice Uganda, he said;

I have been neglected by family members due to my condition which is

worsening every single day I wake up. Am just at God’s mercy that am
still alive, besides that am not financially doing well however am
supported by a few good hearted Samaritans, who give me a little they
can.

4.3.5 System and facility-based challenges

The most frustrating challenges included: medicines stock-outs; not having access to clean
toilets; being hungry and thirsty throughout the day; waiting for long hours to be seen by the
doctors; not having a place to rest throughout the day; not understanding what comes next;
and having their records lost by hospital staff

Furthermore, the findings of the study above are in relation to Kyei, et al (2020) who found
out that almost 95% of patients with breast cancer had anxiety and depression in different
categories. This result was very high compared to studies conducted Baqutayan, (2012) and
Hassan et al., (2015). The first explanation could be the late stage of presentation, the high
cost of treatment, lack of financial support, lack of insurance, inadequate family support,
family dejections, ignoring by spouses, separation, divorce, fear, and the fact that some think
it is communicable as described by the professional participants during the interviews.

23
4.4 The effects of the coping mechanisms on the mental wellbeing of cancer patients.
The study also investigated on the effects of the coping strategies on the mental wellbeing of
cancer patients that were being used by the cancer patients of hospice Uganda, and the results
from the various respondents of the study who were interviewed were as below.

4.4.1 Reduces stress

This study indicates that the avoidance strategies are strictly associated with the
psychological status of patients with cancer. Patients are observed to avoid stressful events
with the increasing levels of anxiety and depression. Similar to our findings, studies
performed on patients with various types of cancer have shown that there is a positive
relation between the avoidance strategy and the level of depression and anxiety.

4.4.2 It encourages acceptance;

Most cancer patients have reported that acceptance of the sickness is part of religious belief.
They highlighted that they accepted cancer because it came from God and they did not have
the power to change God’s wills. Others reported that they were among the chosen ones, and
God was testing their faith. Therefore, they accepted cancer. Moreover, most patients
reported that when they sincerely accepted cancer, they emotionally felt better and hence
have experienced an improved wellbeing.

The below statements depict acceptance.

“I believe that God loves me and he wants me to be closer to him, therefore I have
to accept what God wants”.

“Yes, I cried but at the end of the day I have to accept”. “My religion teaches me
to accept whatever comes from God, therefore, I accept my cancer”.

“Cancer taught me how to be patient and how to accept God’s will. At the end
there are people worse than me, so why shouldn’t I accept”.

From the above revelations, it can be understood that the coping mechanisms have helped to
encourage acceptance of the cancer patients.

4.4.3 Treatment of stress

The study found out that religion and spirituality play an important role in the treatment of
stress and anxiety associated with cancer. Different research works have shown that religious

24
coping has been widely used by patients with all types of chronic diseases, including cancer.
One of the patients revealed that religious coping has helped her to overcome worry and
unease she used to experience. With resolving all the stress through religious coping, this has
helped to improve the mental wellbeing of the patients.

4.4.4 Better psychological disease compliance;

The respondents reported that patients who share their cancer experiences with others
develop effective coping strategies and have better psychological disease compliance. One of
the nurses reported that they have encouraged patients to share their experiences in their
social groups which has helped them to overcome psychological torture.

In relation to the above, Singer et al, (2012) reported marked improvement in the levels of
anxiety and depression of patients participating in cancer support groups compared to patients
not participating in such groups. A positive association was found between social support,
depression, and anxiety in the study. It has been reported that patients who receive adequate
support from family and friends present with better disease-compliance and manifest less
depressive symptoms.

25
 CHAPTER FIVE

SUMMARY, DISCUSSIONS, CONCLUSIONS AND RECOMMENDATIONS OF

THE STUDY
4.0 Introduction
This chapter presents the summary, discussion, recommendations, and conclusions of the
study in accordance to the objectives.

4.1 Summary of the findings

4.1.1 The means used by cancer patients to cope up with cancer in hospice Uganda
The findings of the study revealed that active coping by patients, resilience among some
patients, social support, prayers and counselling sessions were some of the means that were
being used by cancer patients to cope up with cancer at Hospice Uganda. However, the
findings revealed that most of the cancer patients at hospice, Uganda were copying up with
cancer through counselling sessions. Since most of the respondents agreed on the use of this
mechanism.

4.1.2 The challenges faced by cancer patients of hospice

The study found out that depression, self-denial, delayed psychological response, lack of the
required basic cancer knowledge and skills among the primary health care workers, limited
cancer screening facilities, the high costs of treatment, lack of financial support, lack of
insurance and inadequate family support were some of the challenges that were being faced
by cancer patients at Hospice Uganda. However, the biggest challenge that was being faced
by the cancer patients at hospice Uganda was the high costs of treatment, since most of the
respondents agreed that high costs of treatment was a challenge.

4.1.3 The effects of the coping mechanisms on the mental wellbeing of cancer patients.
The study found out the effects of the coping mechanisms on the mental wellbeing of cancer
patients which included reducing stress, encouraging acceptance, treatment of stress and
better psychological disease compliance. The biggest finding was that the coping mechanisms
have helped to reduce stress, depression and anxiety.

26
4.2 Discussion of the findings
4.2.1 The means used by cancer patients to cope up with cancer in hospice Uganda
The findings from the respondents of the study revealed that most of the cancer patients at
hospice, Uganda were copying up with cancer through counselling sessions.

The findings of the study above were in line with Kyei et al, (2020) who revealed
intercessions made by the professional participants for patients while they were on treatment
were reassurances, explanations of the entire treatments and side effects, and counselling.
Other interventions were encouragement, advice (such as doing something they love doing,
get relief from work, and relaxation), monitoring, coping, debunking any negative pieces of
information from them, prescriptions for medications, and on few occasions, referring to
counsellors outside the department.

Furthermore, the findings of the study revealed that active coping by patients was one of the
most used means used by cancer patients to cope up with cancer in hospice Uganda.

The findings of the study on active copying by patients were in line with Saita, Acquati and
Kayser, (2015) who investigated on coping strategies in Italian breast cancer women
considering the influence of personality traits and close relationships. They found that
perceived strength of relationships predicted the use of active and adaptive coping strategies,
being the women with high assertiveness and social anxiety who most used an active coping
style. These results showed that patients adopted an active coping when experimenting high
levels of distress (anxiety, for example) in different stressful situations. They highlighted an
active coping pattern in patients who considered the disease as a challenge which threatens
their assertiveness and social sphere.

4.2.2 The challenges faced by cancer patients of hospice

The findings of the study revealed that the biggest challenge that was being faced by the
cancer patients at hospice Uganda was the depression, anxiety, high costs of treatment, since
most of the respondents agreed that high costs of treatment was a challenge.

The study further found out that lack of financial support was also one of the biggest
challenges being faced by cancer patients at Hospice Uganda.

The findings of the study above were in line with the findings of Kyei, et al (2020) who
found out that almost 95% of patients with breast cancer had anxiety and depression in
different categories. This result was very high compared to studies conducted Baqutayan,

27
(2012) and Hassan et al., (2015). The first explanation could be the late stage of presentation,
the high cost of treatment, lack of financial support, lack of insurance, inadequate family
support, family dejections, ignoring by spouses, separation, divorce, fear, and the fact that
some think it is communicable as described by the professional participants during the
interviews.

4.2.3 The effects of the coping mechanisms on the mental wellbeing of cancer patients.
The findings of the study revealed that reduced depression, anxiety and stress were the
biggest effect of the coping strategies that were being used by the cancer patients of Hospice,
Uganda.

The finding is in relation to Folkman & Greer, (2000) who stated that coping strategies as
direct action and seeking social support are used, the individual has less anxiety. These
results may be due to that the individual tries to handle the anxiety through the usage of these
coping strategies. Another explanation may be that although the individual uses these coping
strategies anxiety is apparent. The positive correlation between the coping strategy
Acceptance and Global QoL indicates a better QoL when this coping strategy was in use.
This may be explained by that the usage had effect on the QoL. Thus, acceptance of a
stressful event seems to be good for the patient’s QoL.

4.3 Conclusion
According to the findings of the study, the researcher made the following conclusions;

It was concluded that active coping by patients, religious coping, social support and
counselling sessions were the means that were being used by cancer patients to cope up with
cancer at Hospice Uganda. The researcher also concluded that depression, self-denial,
delayed psychological response, lack of the required basic cancer knowledge and skills
among the primary health care workers, limited cancer screening facilities, the high costs of
treatment, lack of financial support, lack of insurance and inadequate family support were the
challenges that were being faced by cancer patients at Hospice Uganda. The researcher
finally concluded that the effects of the coping mechanisms on the mental wellbeing of
cancer patients concluded that reduced depression, anxiety and stress were the biggest effects
of the coping strategies that on the mental well being of cancer patients.

28
4.4 Recommendations
In view of the research findings and conclusions drawn, the researcher was encouraged to
suggest the following recommendations;

i. The government of Uganda should give more support to Cancer institutions like
Hospice Uganda, to enable the poor who cannot afford the high costs that are incurred
during the cancer treatment access the treatments.
ii. The health workers should work hand in hand with counsellors, to sensitize the cancer
patients that cancer diagnosis, does not mean death. This will try to reduce on the
level of depression among the cancer patients.
iii. The cancer patients should also listen to the advice of the medical workers and take
their medications as prescribed by the health workers. This will reduce on the rate of
deaths due to un cooperative cancer patients.
iv. Family members of the cancer patients should not neglect them, they should be by
their side to give them comfort, and reduce on the levels of depression among the
cancer patients.

4.5 Areas for further research

Due to the limitations of this study, more research should be carried out on the following
topics;

i. The impact of health worker’s motivation on the recovery rate of patients in cancer
institutes.
ii. The impact of government support on access of treatment in cancer institutes.

29
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 APPENDICES
APPENDIX A: INTERVIEW GUIDE FOR CANCER PATIENTS

Section A: Demographic characteristics

2. Sex

3. Age

4. Marital status

5. Levels of education:

SECTION B

1. Please mention the type of cancer you were diagnosed with?

2. For how long have you been battling cancer?
3. Comment on the means you have used to adopt to the cancer situation at Hospice
Uganda.
a. Active coping by patients
b. Resilience among some patients
c. Social support
d. Counselling sessions
4. Please explain any other ways you have used as a means to adopt through the cancer
time.
5. From the period you were diagnosed with cancer, have you faced any
difficulties/challenges with the general situation of cancer?
6. Please mention some of the challenges you have faced because of cancer?
7. State any effects to your mental wellbeing you have experienced as a cancer patient ?
END

32
APPENDIX B: INTERVIEW GUIDE FOR MEDICAL WORKERS

1. Please mention the types of cancer you have commonly diagnosed in hospice?
2. As a medical worker, mention the means patients use to adopt to the cancer situation
in hospice Uganda.
3. In your observation as a medical worker, are the patients of cancer facing challenges
in coping up to cancer.
4. Please mention some of the challenges patients have faced because of cancer?
5. State any effects to your mental wellbeing you cancer patients have?
END

33