The impact of psychological educational intervention program in improving psycho-sexual health of married women with breast cancer in Khartoum State.

Abasher, Sana Mohamed ; Magied, Ahmed Abdel

Introduction

Psychological and sexual disturbances affect many aspects of the life of women with Breast Cancer (Abasher 2008; Ganz et al. 2003; Wong-Kim et al. 2005; Avis et al. 2004). This is mainly due to treatment side effects, especially surgery (DeGenova & Rice 2002; Casso et al. 2004). The role of Chemo and Tamoxifen therapy in aggravating the problems cannot be ignored as well (Bergland et al. 2001; Ganz et al. 1998; Alfano et al. 2006). The International Consensus Conference on Psychosocial Interventions on Cancer Patients suggested that psychosocial interventions should be offered to patients with adjustment problems that lead to high levels of psychosocial distress (Sollner et al. 2004). Psycho-education may be most effective during the diagnosis/pre-treatment time period when patient's information needs are high (Carlson & Bultz 2004; Hewitt et al. 2004; Fukui 2001). This is effective in enhancing coping with cancer, reducing emotional distress, and improving quality of life (Katz, et al. 2004). Psycho-education was found useful in reducing anxiety and depression (Dolbeault et al. 2008). Information provided through psycho-education facilitates discussion of related issues, reduce anxiety and promote women's trust and confidence in themselves (Heather & Phyllis 2006). The psycho-education consisted of coping strategies and communication skills (Baum & Andersen 2002). Visualization, relaxation training and deep breathing were also included (Stern & Sekeres 2004). Other researchers have also evaluated the efficacy of group cognitive-behavioral therapy for psychologically distressed cancer patients and for some patients who suffered from chemo and radiotherapy side effects (Kissane et al. 1997; Schofield et al. 2009; Hunter et al. 2009) Although some Sudanese studies investigated the psychological and sexual disturbances among breast cancer women (Abdelhalim 2002; Abasher 2008), this study has shown how the psychological intervention programs can improve the psychological and sexual life of patients with Br Ca. Hence, this study represents a pilot and the first research on Muslim women with Br Ca in Sudan. Accordingly, the main objective of this study is to investigate the role of the educational intervention program in improving the psychosexual health of Sudanese Muslim women with Br Ca.

Methods

This study was carried out in the Radiation and Isotopes Center in Khartoum (RICK). Participants were approached in the chemo and radiotherapy day unit and they were provided with information on the objectives of the study. Verbal consent from the participants was first sought for participation in the relevant part of the investigation. Quasi-experimental designs (Gribbons & Herman 2009) was used to select the participants (n=59) who were sexually active women diagnosed with Br Ca. Of those, 29 were the experimental group (E) and 30 were the control group (C). The experimental group (E) was divided into 3 sub-groups of 10, 10 and 9 participants. Each sub-group was exposed to 7 sessions and every session lasted for 2 hour. The intervention program adopted psycho-educational approach with focus on the cognitive behavioral theory. The components of the 7 sessions were as follows:

--Briefing the patients with the components of the intervention program.

--Medical information that patients need in different stages of their treatment (by the Oncologist)

--Psychological problems associated with cancer (e.g. anxiety and depression)

--Different types of communication skills

--Stress Management, relaxation techniques and coping skills.

--Body image and sexuality

--Coping with bad times.

All participants (E and C groups) for the pretest filled in Watts Sexual Function Questionnaire (WSFQ), Hospital Anxiety and Depression Scale (HADS) and the questionnaire constructed by the researcher. The latter included socio-demographic characteristics of the participants. Group E was subjected to an intervention program that lasted for 17 days. For the posttest, the same period of time was given to group C before both groups (E & C) were asked to fill in the WSFQ and HADS.

Results

Sample characteristics

The demographic characteristics of the E and C groups which include the age group, years of marriage, level of education, occupation, type of treatment, diagnosis time, and stage of disease and status of menstruation are summarized in table (1) bellow:

Table (1) The demographic characteristics of the E and C groups

Variables                  Group E    Group C

Age group in
years

Less than 30                1 (3%)    3 (10%)
31- 40                     13 (43%)   14 (47%)
41--50                     13 (43%)   11 (37%)
50 & above                  3 (9%)     2 (6%)

Years of
marriage

1--10                      8 (28%)    10 (33%)
11--20                     14 (48%)   13 (44%)
20 & above                 7 (24%)    7 (23%)

Level of
education

Illiterate                  1 (3%)     2 (7%)
Primary                     1 (3%)     1 (3%)
High School                11 (38%)    5(17%)
University                 16 (57%)    2(73%)

Occupation

Unemployed                 21 (70%)   12 (40%)
Employed                   08 (28%)   18 (60%)

Type of
treatment

Surgery                    27 (93%)   24 (80%)
Chemo                      28 (97%)   28 (93%)
Radio                      16 (55%)   16 (53%)
Tamox.                     5 (17%)     2 (7%)

Variables                  Group E    Group C

Diagnosis time

Less than 6 months         12 (41%)   3 (10%)
7--11 months               10 (34%;   11 (37%)
12 months and more         7 (25%)    16 (53%)

Stage of disease

2                          6 (21%)    5 (17%)
3                          5 (17%)    12 (40%)
4                          10 (35%)   11 (37%)
Don't know                 10 (28%)    2 (7%)

Menstruation status

Still present              4 (14%)    14 (47%)
Stopped after treatment    13(45%)    9 (30%)
Stopped before treatment   7 (24%)    5 (17%)
Irregular                   5 (17%    2 (07%)

Psychosexual educational intervention for the E group

"T" test was used for the experimental group. The pre test mean for HADS and WSFQ was 13.34 and 42.76 respectively. Post test for HADS dropped to 11.24 and for WSFQ increased to 50.76. Hence, the analyzed results showed significant statistical decrease in Anxiety and Depression (p=0.001) and significant statistical increase in sexual function (p=0.001) as in table (2).

Application of HADS and WSFQ on the C group

"T" test was used for the C group to find out whether there had been some progress. The pre test mean of HADS and WSFQ was 11.90 and 54.70 respectively. The post test mean for HADS was 11.10 whereas WSFQ dropped to 53.50. Hence, no statistical significant difference was observed between pre and post test (Table 2).

However, when comparing the E and C groups, there were no statistically significant differences between them. The p value for HADS was =0.916 and for WSFQ was=0.109 (Table 2).

Discussion

In conformity with previous workers (Carlson & Bultz 2004; Hewitt et al. 2004; Fukui 2001; Katz et al. 2004; Dolbeault et al. 2008; Heather & Phyllis 2006). HADS post test analysis for the E group has shown significant decrease in depression and anxiety of the women with breast cancer. On the other hand, WSFQ post-test analysis has shown significant increase in their sexual function (Table 2). In this connection one of the patients stated: "My sexual life was negatively affected by the chemo and radio therapy, but through the relaxation techniques I managed to get over the disturbing thoughts and when my husband practiced sex with me last night, I did not feel the pain that I used to have. Not only this, but also I was relaxed and had orgasm twice last night and once this morning".

Although the E group is expected to show a positive change when compared to the C group, our post-test analysis showed no significant differences between women from the two groups. This is most probably was due to the fact that our C group was primarily better adjusted than those who opted to join the E group. This is, however, indicated by the mean score of the E group for both scales (HADS=13.34 and WSAQ=42.76) when compared to the mean score of the C group for both scales (HADS=11.90 and WSFQ=54.70) as shown in table (2).

This is in consistency with a previous study which stated that, whilst the majority of women adjust well to breast cancer, some may need psychosocial support (Thewes et al. 2004). However, if intervention is successfully directed towards at-risk patients, the escalation of depressive symptoms into major depression may be prevented (Wong-Kim et al. 2005). Nevertheless, the demographic characteristics of women in our experimental intervention program may provide further explanation for the above results. Nearly half (41%) of the E group were in their first 6 months after diagnosis. This was unlike the C group, where 53% of whom were more than 12 months after diagnosis. Moreover, most (73%) of the women from the C group were educated and 60% were employed. This is unlike the E group where 57% were educated and only 28% were employed.

It was, therefore, thought pertinent to conclude that following the psychological intervention, there was a significant decrease in the depression and anxiety as well as an improvement in sexual function among women with breast cancer. However, post-test analysis did not show any significant differences between the E group and the C group who primarily were better adjusted than the E group.

Accordingly, the following recommendations are suggested:

--Efficient psychotherapy unit should be established in hospitals receiving cancer patients.

--Oncologists should recognize the importance of psychotherapy for women with breast cancer.

--For comparative purposes, further research should include target groups of different educational level and socio-economic status.

References

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Notes on contributors

Sana Mohamed Abasher was a lecturer of Psychology at Ahfad University for Women School of Psychology and Pre-School education.

Ahmed Abdel Magied, is a professor of Biology at the School of Health Sciences, Ahfad University for Women. Professor Abdel Magied has published many articles in Female Genital Mutilation and supervised several researches in the issue in the graduate and undergraduate levels.

Table (2) HADS and WSFQ: The Mean, SD and P value of pre and post
tests.

E group                      N=    Mean    Standard     T.      P.
                                           Deviation   Value   Value

HADS              Pretest          13.34     7.20
                  posttest   29    11.24     5.35      2.65    0.001

WSFQ              Pretest          42.76     7.47
                  Posttest   29    50.76     6.29      7.14    0.001

C group

HADS              Pretest    30    11.90     5.47      .810    .425
                  Posttest         11.10     4.87

WSFQ              Pretest    30    54.70     7.44      .809    .425
                  Posttest         53.50     6.64

E and C groups
posttests

WSFQ              E group    29    50.76     6.29      1.62    0.109
                  C group    30    53.50     6.63

HADS              E group    29    11.24     5.35      0.106   0.916
                  C group    30    11.10     4.86