DISEASE-RELATED NEEDS OF BLACK PATIENTS WITH CERVICAL CANCER

The high incidence o f cen>ical cancer amongst South African black women is complicated by late presentation for treatment as well as by misconceptions and ignorance which adversely affect the quality of their lives. The aim of the research was to determine the disease-related needs ofpatients suffering from cervical cancer which would serve as a basis for planning on providing for these needs. Needs for the following were identified: • Education on early detection in the community. • Education on nutrition and hygiene. • Information on and assistance in obtaining financial relief by means of subsidised transport and disability pensions. Opsomming Die hoë insidensie van servikale karsinoom onder swart vroue in Suid-Afrika word gekompliseer deur aanmelding vir mediese behandeling op ’n gevorderde stadium van die siekte sowel as deur wanopvattings en gebrekkige kennis wat die Icwaliteit van hul lewens nadelig belnvloed Die doel van die studie was om die behoeftes van servikale karsoom pasiente te identifiseer sodat beplan kan word hoe om in die behoeftes te voorsien. Behoefte aan die volgende is geidentifiseer: • Inligting aan die gemeenskap oor die vroeë opsporing van karsinoom • Inligting aan pasiente na ontslag oor voeding en higiëne • Inligting oor en steun in die verkryging van finansiële bystand in die vorm van ongeskiktheidspensioen en reistoelae.

Needs for the following were identified: • Education on early detection in the community.

IN TR O D U C TIO N
Statistics kept by the oncology nurses at the Ga-Kankuwa Hospital revealed that cancer o f the cervix comprised 30% of the total o f 962 cancers treated at the hospital in 1986.This high incidence concurs with findings published in the 1986 Cancer Registry of South Africa according to which cervical cancer accounted for 43% of all specific incident cancers amongst a total of 2274 black women.
This high incidence is aggravated by the fact that blacks suffering from cervical cancer w ho seek help at a hospital often have cancer in an advanced and incurable stage with resultant poor survival rates.Such late presentation is very costly -not only in terms of human lives but a lso fin a n c ia lly .T h ese p a tie n ts are hospitalised for five weeks to receive chemoand radiotherapy.The hospitalisation costs alone amount to R4 130 per patient i f calculated at a figure o f R118 per day as quoted by a hospital administrator in 1988.
O n c o lo g y n u rse s from the G a -R a n k u w a Hospital reported to the researcher that apart from having a poor prognosis the diagnosed p a tie n ts' su fferin g is often ag gravated by ignorance and misconceptions which adversely affect the quality o f their lives.This study was aimed at identifying these patients' needs for information on disease-related matters which could be provided by health professionals.

P R O B L E M S T A T E M E N T
The high prevalence of cervical cancer amongst black South African women is complicated by late presentation for treatment as well as by m isconceptions and ignorance which adversely affect the quality o f their lives.

A IM
The aim o f the research w as to determine the disease-related needs o f hospitalised black patients suffering from cervical cancer which would serve as a basis for planning in order to meet these needs.

O B JE C T IV E S
To do a survey of hospitalised black patients su fferin g from cervical cancer in order to determine It w as hoped that clarification of the above v a riab les w ould allow recom m endation of n ursing m easures to help meet needs thus identified.potentially preventable neoplasm (Kahn et al., 1987:89).

L IT E R A T U R E ST
The control o f cervical cancer in many countries is impressive and the prevalence low.In the United Kingdom, for instance, cervical cancer comprises only 4.3% of all incident cancers (Butcher, 1987:7).The corresponding figure for black women in 1986 w as an alarming 43% (C an cer reg istery o f S o u th A frica 1986).Presentation for treatment is also at a later stage than in whites, w hich results in poorer survival and cure rates (Kahn et al., 1987:89).
Gordon Grant ascribes the fact that cervical carcinoma has been reduced to a minor problem in other countries to the mass screening of c e r t a in a g e g r o u p s a n d p ro p a g a n d a disseminated via the press, radio and television.M ass prophylaxis in South A frica poses a problem since free Papanicolaou (Pap) smears at state fami ly planni ng cli nics have been curbed since 1975 (Gordon Grant, 1982:821).
A study done amongst Johannesburg women on their knowledge of and attitudes toward cancer o f the cervix revealed although only 27% o f the black women had cervical smears taken, 83% indicated a willingness to have a free Pap sm ear done after the significance w as explained to them.Although 72% o f the black patients indicated a desire for further information only 33% had asked their doctors for information on their disease (Kahn et al., 1987:91).
It is important to note that although the level of k n o w led g e o f a co m m o n c a n c e r an d its prevention w as found to be markedly deficient a m o n g st b la c k w o m en , they in d ic a te d a w illingness and readiness to participate in preventive as well as therapeutic m easures once they have been informed o f the nature o f the disease (Kahn et al, 1987:92).On the other hand they are rel uctant to undergo hysterectomy since, according to black culture, a w oman is considered to be less valuable in marriage, even divorcable, if she can no longer bear children (Kahn et al, 1987:92).Ill health concerning the reproductive system therefore stri kes at the core of African lifestyles and beliefs.It has so many socio-cultural implications that the opportunity for early diagnosis and treatment is negated (Searle, 1986:7).
T ra d itio n a l h e a le rs h av e an e n tre n c h e d relationship w ith their com m unity (Searle, 1986:6) and are usually the first to be consulted when health problems occur.W estern doctors are the second choice and this phenomenon leads to patients seeking Western health care at a late stage and with a poor prognosis (Van Rcnsburg, 1981:42).
The psychological impact o f cancer is often devastating and therefore treatment aimed at stress reduction and emotional support should be an i ntegral part of the management o f patients with cancer pain (Warfield, 1987:101).Most patients want to discuss their problems with not only health professionals but also with other p a tie n ts w h o h a v e u n d e rg o n e a s im ila r experience (Ariel and Cleary, 1987:534).
Findings therefore indicate a failure in primary health education as well as a need for more explanation to women attending clinics and to p atien ts u n dergoing th erapy (K ahn e t al., 1987:92).

M E T H O D
A q u e stio n n a ire w as c o m p ile d to o b tain information on the respondent's stage o f disease on adm ission, reasons for late presentation, physical problems, beliefs, support and input from health professionals.The instrument was tested for face validity and pilot tested by interviewing five patients.
In order to overcom e language problems the q u e stio n n a ire s w ere co m p le te d by b la ck professional nurses w ho had been briefed beforehand.These nurses were lecturers in the Nursing Science Department and a B Cur (I et A) student at Medunsa as well as an oncology nurse at the Ga-Rankuwa Hospital.* All the patients had children, the number ranging from 2 to 13.Although the mean number w as 5,1 the majority (63% ) of the sam ple had 2 to 4 children.
* The average annual income per family was low (R5 132).
Unfortunately the number of dependants per family is not known.

Stage of cancer on admission
It w as found that the majority o f the respondents (83,3% ) had cancer in an advanced stage i.e.Stages 2 and 3 on admission (Fig. 2).Surgery w a s p e r f o r m e d o n o n ly 6 ,7 % o f th e respondents.

Possible reasons for late presentation for treatment
* The main reasons given for seeking medical help (T ab le 1) w ere vaginal discharge, bleedi ng and pain, the latter bei ng a very late symptom.None of these patients had ever had a PAP sm ear taken as routine checkup.* The main physical problems experienced ( F i g .3 ) w e re a s s o c ia te d w ith the gastro-intestinal tract namely constipation, weight loss, nausea, vomiting and anorexia.The occurence of these problems was at least 3 tim es m ore freq u en t than any other problem.

Beliefs about sequelae of disease
M ost o f these beliefs were centered around marital relations (Table 3).

Support groups
In hospital 30% of the patients were supported by others suffering from cervical cancer.

Input of health workers
A comparison o f the availability and input of health care w orkers regarding consultation and discussion o f the disease appear in Fig. 4: * A s can be expected the doctor had the greatest input.
* The clinic nurse, available to 90% o f the respondents, w as only consulted by 3 % of the respondents before hospitalisation.
* The traditional healer w as available to 97% o f the respondents.
* A lth o u g h trad itio n a l h ealers discussed cancer with onl y 3% of the respondents (Fig. 4 ), 4 6 ,7 % v is ite d and to o k m ed icin e prescribed by a traditional healer.The mean number o f such visits was 1,3.

Media for health education
* M a s s m e d ia a re a v a il a b le to m o st respondents but seem s to be underutilised (Fig- 5): Seventy-seven percent o f the respondents were literate but only 23% had seen literature in the form o f brochures on cancer.
All the resp o n d en ts listen to the radio frequently but no regular cancer-education program m es on cancer are being broadcast.

CONCLUSIONS
From the data analysis the following needs were identified:- -th e traditional healer still plays a major role in African culture and is readily available.
-mass media are available to the majority of re s p o n d e n ts b u t are u n d e ru tilise d for educational purposes.
-a telephone is available to all but 3,3% which implies that counselling and referrals in some instances could be done without the inconvenience and cost o f travelling.

R E C O M M E N D A T IO N S
In the lig h t o f the fin d in g s n urses could undertake the following actions to meet the identified needs o f cervical cancer patients: - Unfortunately a national screening programme in South Africa does not exist although it has been advocated since 1982 as an urgent priority in o rd e r to re d u c e th e e n o rm o u s cost of treatment o f an advanced malignant disease which potentially is preventable (Gordon Grant, 1982:821).Since the scope of nursing practice includes physical assessm ents and Pap smears the question arises as to reasons why existing clinic facilities cannot be extended to provide for cancer screening.

Ilealth
Nurses should be involved in the planning and im p le m e n tio n o f s u c h a p ro g ra m m e (M clnerney, 1988:29).

Education of patients
Patients w ho experience health problems as reported above should be guided on nutrition and hygiene.Patients may be counselled to rule out m isconceptions about their disease.
Initiate support groups made up of women suffering from cervical cancer.
Patients can be referred to their nearest clinic a f t e r b e in g d is c h a r g e d a n d g ro u p meetings/visits can be arranged or co-ordinated by the clinic sister or a contact person.

*
The convenience sample for this descriptive survey comprised thirty hospitalised patients suffering from cancer o f the cervix.The respondents received radio-and chemotherapy and were in different stages of their five week h o s p ita lis a tio n p e rio d .P e rm iss io n w as o b tain ed for each in terv iew w hich lasted approximately twenty minutes.Due to the busy schedules o f the fieldw orkers, the patients selected were all those w ho were in the w ards at times convenient for the fieldworkers.The stu d y w as c a rrie d o u t d u rin g the period December 1987 to March 1988.R e s p o n s e s to th e q u e s t io n n a i r e s w e re co m p u ter-an a ly se d by the D epartm ent of Biostatistics o f the Medical Research Council.The peak incidence of cervical carcinoma (F ig .l)w as in the 30 to 39 year age group with a mean o f 34 years.This is at least 10 years younger than fi ndings of i n te m a tio n ^ studies (Angell & Riche, 1981:568).

**
Figure 2 Stage of Cancer on Adm ission

*
Figure 3 Health Problems education to the public * T he im portance o f early detection and treatment should be emphazised.Printed information on warning signs o f cancer is a v a ila b le fro m th e N a tio n a l C a n c e r Association.These are easily obtained and can be distributed and further explained at clinics.* E d u c a tio n on c a n c e r p re v e n tio n and detection through the mass media should be encouraged since all the respondents listen to the radio and most (77% ) are literate.* Health education should not only be given but also critically evaluated by testing the comprehension of the public (M c ln e m e