Lived Experiences of Women Receiving Medical Treatments for Breast Cancer in Ghana: A Qualitative Study

Breast cancer diagnosis and its treatment present women with significant challenges which require adjustment in several domains to ensure good health outcomes. Any psychosocial interventions to address the challenges need to be informed by empirical evidence. However, there is dearth of empirical literature in this regard in the Ghanaian context. To address some of these gaps, we explored the lived experiences of women living with breast in Ghana to inform healthcare practice and breast cancer research. In-depth individual interviews were conducted among 11 breast cancer patients receiving medical treatment for breast cancer. The interpretative phenomenological approach was used in the data analysis. Findings from the study showed that participants’ lived experiences cluster around three major themes; burdens of breast cancer treatments, alternative/herbal medicine use, and breast cancer stigma. These findings underscore the need for a multidisciplinary treatment approach to achieve optimum health outcomes among these groups of women.


Introduction
Breast cancer diagnosis and treatment among women present significant burdens which are likely to influence their quality of life. These challenges include physical, psychosocial, and spiritual distortions which negatively impact on the health and wellbeing of women living with breast cancer (Aziato & Clegg-Lamptey, 2015;Kagee et al., 2018;Kugbey et al., 2019a). Evidence suggests that women diagnosed with breast cancer differ in their reactions to the illness and these reactions influence their coping strategies and disease management (Kaptein et al., 2015). The experiences of women living with breast cancer are likely to be influenced by several individual, family, community, and larger societal factors. Thus, the lived experiences of breast cancer may be rooted in the sociocultural contexts and therefore, understanding the experiences of women living with breast cancer becomes paramount. These experiences are likely to shed light on the plights of women living with breast cancer to inform appropriate psychosocial interventions tailored to the unique experiences of these women.
Studies conducted among breast cancer patients in Ghana showed that sadness, fear, guilt, and anxiety, severe pain and suicidal ideation as some of the key challenges which characterize the breast cancer trajectories of these women (Bonsu et al., 2014;Clegg-Lamptey et al., 2009;Opoku et al., 2012). Stigma, which is an important psychosocial challenge, has also been reported among breast cancer patients elsewhere (Maree & Mulonda, 2015;Wong-Kim et al., 2005), whereas research findings from other contexts revealed little or no stigma attached to breast cancer (Ernst et al., 2017;Lebel & Devins, 2008). Since the socio-cultural contexts of patients may influence peoples' attitudes and beliefs about breast cancer, there is a need for studies to explore stigma among women living with breast cancer in Ghana, particularly in the absence of any published literature in this regard. This is because culture to a large extent, influences several facets of human life including the experience of and adjustment to chronic medical conditions. Another important challenge faced by women living with breast cancer is the economic burden of the illness. Poverty among Ghanaian women living with breast cancer has been found to be a major concern to their delay in commencing and adhering to treatment as well as healthcare utilization (Clegg-Lamptey et al., 2009;Opoku et al., 2012;Sanuade et al., 2021). This is because within the Ghanaian healthcare system, the national health insurance does not cover all the treatment costs for breast cancer patients and such patients are expected to bear the remaining cost which is relatively expensive (Opoku et al., 2012). The enormous economic and financial burdens of breast cancer treatment and care in the face of poverty among the populace could compound the challenges women face and impact their health seeking behavior patterns which in turn may affect their overall health and wellbeing.
Understanding of the lived experiences of women receiving treatment for breast is likely to help tailor the treatment strategies to their needs. This is important as cost-effective interventions are needed to address the unmet needs of breast cancer patients, the lived experiences as expressed by the women may serve to generate knowledge which is likely form the basis of such interventions. This study explored the lived experiences (physical, psychosocial, economic, and relational) of Ghanaian women receiving medical care for breast cancer.

Participants
Women receiving care at the Nuclear Medicine and Radiology Department of the Korle-Bu Teaching Hospital in Accra, Ghana were purposively sampled from the total number of women who participated in a quantitative study (Kugbey et al., 2019a(Kugbey et al., , 2019b(Kugbey et al., , 2020. The sample size of 11 was determined by the data saturation method as the interview data from the 11 participants showed similar patterns and therefore, did not warrant sampling of more women living with breast cancer. The choice of sample size in qualitative studies are dependent mainly on the issues being explored and in most cases data saturation, where no new information are emerging from the participants, determines the sample size (Guest et al., 2006;O'Reilly & Parker, 2013). Details of the participants are presented in Table 1 Procedure Ethical clearance was obtained from the Humanities and Social Sciences Ethical Committee of the University of KwaZulu-Natal, South Africa (HSS/1428/016D), the Scientific and Technical Committee and the Institutional Review Board of the Korle-Bu Teaching Hospital in Ghana (KBTH-IRB/00035/2016). The contact list of the women who participated in the quantitative phase was consulted and the prospective participants were contacted. Those who voluntarily agreed to participate in the qualitative phase of the study were visited in their homes. All ethical guidelines were strictly followed. An interview guide was used to conduct in-depth individual interviews with the women living with breast cancer. The interview guide focused on the lived experiences and the responses from the participants were used to generate further probing questions for clarifications. The interview guide was structured in line with pertinent literature within the breast cancer domain and served to inform conversations between the researchers and participants. However, the interview guide was not prescriptive as efforts were made at gaining rich data from the participants. Those who voluntarily agreed to participate in the study signed the informed consent document and the individual interviews lasted between 30 and 60 minutes.

Data Analysis
The audio tapes from the field were transcribed verbatim to reflect the views of the participants. All the interviews were conducted in English with local language interjections as and when necessary to gain a deeper insight in the lived experiences of the women. These interjections were appropriately translated as the researchers who collected the data understand the predominant language which is Twi. The data analysis was informed by the Interpretative Phenomenological Approach (IPA) which involves exploration of participants' own subjective real life experiences with no attempts at measuring the objectiveness of the experiences (Smith & Osborn, 2007). The key principles and guidelines outlined by Storey (2007) informed the qualitative analysis. These pertain to: (1) gaining an understanding of the transcribed interview by reading and re-reading of the data and identifying points of interest, (2) linking identified and harmonized quotes together to form themes, (3) making connections with identified themes, and (4) summarizing main themes and relevant sub-themes with their appropriate quotations. To ensure the validity and reliability of the data, the researchers gave the transcribed data to two other experts in qualitative data analysis for the generation of themes and sub-themes. The outcomes of the analysis of the two experts and the researchers were compared and points of divergence were addressed. Additionally, the researchers ensured communicative validity throughout the data collection by using rephrasing and summaries to be sure that the accurate views of the participants were vividly captured. All these were done to ensure that meanings as expressed by the participants were not lost during the transcription and interpretation of the results.

Results
The analysis of the interview data from the participants revealed three major themes along which participants' lived experiences with breast cancer can be understood.  These are the burden of medical treatment, alternative medicine, and breast cancer stigma. Each of these three major themes have their respective sub-themes which represent the details of the narratives as expressed by the participants.

Burdens of Medical Treatment
Medical treatments constitute the largest component of breast cancer treatment aimed at dealing with disease progression as well as complete cure. It thus plays a major role in participants' lived experiences. However, patients have expressed concerns about their experiences with the medical treatment regimen. Three sub-themes were identified namely physical, economic, and social burdens which have emotional impacts on the lives of women living with breast cancer. These themes are not mutually exclusive as the concerns expressed by the patients are inter-related. The three sub-themes are presented with their illustrative quotes.
Physical burdens. The majority of the participants reported that the medical treatment had significant negative effects on their physical health due to the unpleasant side effects associated with the treatments especially chemotherapy and radiotherapy. The following narratives from the participants illustrate the physical burdens of the medical treatment.
". . .it is not easy. Especially with the chemotherapy, when they started with the treatment, the body is not used to that kind of harsh medication and it really breaks you down. The first time I was given, I was down for three weeks. I was in bed for three weeks. I was very weak. . .vomiting, diarrhoea and all manner of things will happen to you. . ." (P11).
"You will feel you have neuropathy in your fingers and in your toes. . . You feel like pins and needles in your fingers. When I started the radiation too, I do not know if it is from the radiation or from the tablets. . .but it is becoming worse" (P9).
These narratives from the women suggest that the medical treatments resulted in disruptions in their physical abilities and the treatment tended to present several unpleasant physical side effects. However, the effects transcend the biological disruption to include loss of energy to carryout daily routine activities and changes in physical appearance. This is illustrated from the narrative below: The above severe physical discomforts with the medical treatments have negative emotional impact on the participants. These emotional experiences range from worry about the curability of the disease, sadness due to the loss of a breast through a mastectomy, and the negative side effects of the medical treatments. Some of these negative emotional experiences reported by the women are presented below: From this narrative, it was clear that living with the illness itself, has negative emotional consequences for the patients and the fact that one has to live with "one breast" also presents another challenge to the psychological wellbeing of the women.
Another participant stated that breast cancer and its treatment regimen are "very scary." This participant was focused on the short-term impact of the treatment especially the negative side effects which were driving her anxiety. She perceived her life to be in a circle as she kept going back and forth in terms of her health. She stated that: It can be seen from the quote above that the participant's anxiety and fear stemmed from the uncertainties surrounding the prognosis of her breast cancer which keeps her in constant fear. Another participant presented an instance of worry about the negative side effects of the treatment procedure especially chemotherapy, with little attention to the ultimate outcome of the medical treatment. She stated that: "My worry is about the 'chemo' (chemotherapy). For now, I am only praying about the chemotherapy because I was told when you are doing that therapy, you will lose your hair. . .feel sick and a whole lot. . .and that is what I am praying against" (P8).
Economic burden. The majority of the participants interviewed were concerned about the cost of medical treatment which they see as a major hindrance to their effective participation and adherence to the required medical treatments. For these participants, not having the financial strength to afford the expensive treatment regime may lead to reduce quality of life and by extension death. Examples of quotes from the participants to illustrate the economic burden of breast cancer are as follow: These quotes illustrate the significant financial burden involved in the medical treatment of breast cancer. This clearly showed that some patients may stop treatment not because they do not want to follow the medical treatment regimen but financial constraints could push people to abandon their treatments. The unaffordable treatment regimens of breast cancer as reported by some of the participants have resulted in an exhaustion of savings and collapse of businesses as the savings for the business were pumped into the treatment. The narrative below illustrates their views: "I had my own money. The money that I was using to trade was the one which I used to take care of myself and foot the other bills. It is now that I know that my financial strength is very low and business has gone down. . ." (P10).
One significant domain of the economic burden of living with breast cancer and its treatment is job loss due to the illness. One participant recounted that she was relieved of her duties at her workplace when her boss got to know that she had breast cancer and was undergoing treatment. Although she indicated her fitness and readiness to continue working, they managed to get her to leave her job and became unemployed. She described how her boss got her to leave her job as follows: ". . .before then (breast cancer diagnosis), I was working at a printing press. . .so after my treatment it's like the boss couldn't put the thing straight but if you are a matured person and someone is talking to you, you know where he is driving towards. . .So I opted out voluntarily because if I force my way there, he will find ways and means to frustrate me. . ." (P4).
The narrative above showed that breast cancer and its treatment pose a significant threat to the economic survival of patients as poor knowledge among the Ghanaian populace could lead to discriminatory actions as reported by this participant. This raises issues about social protection and labor legislation regarding ill health.

Social Burden
One of the participants highlighted the social burden placed on her by the breast cancer treatment. This burden is in the form of role limitation both at church and at home as she could no longer do a lot of the things, she used to do including leadership positions in her church and being able to do domestic chores. The quote from the participant is presented below: ". . .I was a leader in church and I have told them to even replace me but they are refusing to do so because they are expecting that I will get well and come and join them but I don't have the strength and I don't want to put so much pressure on myself. So someone is handling the position until I get well" (P11) She further continued that: ". . .and at home, a lot of things that you used to do as a woman and a mother, you realize you do not have much strength to do. Sometimes, you even desire to do it but the strength is not there.

Because of the surgery, I am not supposed to use the left hand to lift heavy things so even when you are in the room and wants to bring something down, you have to call someone. It limits you in your duties in the home" (P11).
The above shows the burden of medical treatment on the women living with breast cancer which are likely to affect their overall health and wellbeing. In light of the experiences with medical treatment, the use of alternative medicine seems a viable option.

Alternative/Herbal Medicine
Alternative medicine including herbal preparations are very common in the Ghanaian society and persons living with chronic illnesses such as breast cancer are no exception. This theme thus describes the complexities in the health-seeking patterns of persons living with chronic conditions in Ghana including breast cancer. Three sub-themes are described: sources of information on alternative/herbal medicine, use of alternative/herbal medicine, and previous use of alternative/ herbal medicine.

Sources of information on alternative/herbal medicine.
The sources of information on alternative/herbal medicine were explored and two key sources (health workers and herbalists) were identified by the participants. One of the participants indicated that she was introduced to alternative/herbal medicines by a health worker, specifically a nurse. She stated that: "A nurse who is an Ecclesiastical sister from Indonesia told me that Noni is very effective for cancer and she has planted some and because it's not plenty she has not been able to distribute to many patients so when I came back after the surgery you know we have some in the house so I prepared the Noni and I took it. . ." (P1).
Another participant also reported that she was introduced to the use of alternative/herbal medicine through an herbalist who claims to be an expert in curing breast cancer. Her trust in the use of the herbal products was reinforced by many women who were with the herbalist bearing testimonies of being cured of breast cancer through the use of the herbalist's medications.
"One of these herbalists. He said he is into breast cancer and he can help me. And when I went there, there were people who were testifying that it was good" (P3).
The use of alternative/herbal medicine. Some of the participants indicated that they have resorted to the use of alternative/herbal medicine either due to the high cost of the medical treatment or the desire for a complete cure or both. The following are some of the direct quotes from the participants regarding their use of alternative/herbal treatments: One participant described her alternative/herbal medicine use by saying that; ". . .all these herbal things, anything they do I just. . .hahaha (laughs) go for it, rubbing everything and adding everything and did everything they told me" (P2).
Another woman also described her experience with the use of alternative/herbal medicine and stated that; "I have been taking these Chinese things (herbal preparations). I took Noni, and I take in some things (herbs). I have even forgotten some of them. . .I have been taking these herbs because they said they can help cure cancer. . .it is not always that I get the money to buy the hospital drugs so I have to get a solution that will help me" (P6).
The quotes from the participants suggest that lack of financial resources and desire for complete cure could push women living with breast cancer to resort to the use of alternative/herbal medicine.
Previous use of alternative/herbal medicine. Some of the participants in the study indicated that they had previously used alternative/herbal medicines but have ceased using them as at the study period. The main reasons cited for stopping the use of alternative/herbal medicine were patients' perceived ineffectiveness of the herbal products and sometimes worsening disease outcomes. The following are some of the quotes from the experiences from previous alternative/herbal medicine users: "This year September, I tried using herbal medicine but it didn't work. All the drugs were liquid. I was drinking those concoctions but they didn't work. After about a month, I realized it was even worsening my case, I wasn't able to drink water. In a day, all I could drink was the cover of a cup. I couldn't belch and so I was finding it difficult to eat and so I decided to stop" (P3).
"Initially, when it (breast cancer) was detected, I visited some herbal clinics to get some medicines. . .it was not easy. . . but later on I was not seeing any improvement so I took the decision to stick to the hospital treatment (including surgery) . . ." (P11).
These quotes suggest that the perceived ineffectiveness of alternative/herbal medicines and treatment could prevent further usage. It is important to note that the economic burdens associated with the medical treatment seemed to have created opportunities for a greater need to seek out alternative medicines including herbal preparations which may interfere with treatment received or even endanger their lives.

Breast Cancer Stigma
Stigma is one of the key challenges to health and social support seeking behaviors. Under the broad theme of breast cancer stigma, two sub-themes were identified and these include; experienced stigma and disclosure of disease status.
Experienced stigma. Some of the participants in the study reported experiencing some form of stigma as a result of their illness and the negative side effects of their medical treatments. Below are some quotes that illustrate experienced stigma among the participants: "I will say when I got this disease, I had a lot of problems, my siblings didn't want to come close to me, even talking to me was a problem. . .I don't know why, even when people see me, they try to avoid me. . ." (P5).
However, another participant indicated that although her siblings avoided her, she felt it was due to the financial pressure they were experiencing from her treatment and not necessarily breast cancer stigma; "When your siblings even see your face, they start to run away because they know that, when they see you, you will bother them with money. Money makes everyone run away from you. . ." (P7).
The experiences recounted by these participants showed that the stigma attached to breast cancer could result in feelings of loneliness and loss of social support from family and significant others which are likely to negatively impact their emotional wellbeing and the overall health of the women living with breast cancer.
One of the key issues that emerged was the willingness of the participants to disclose their breast cancer status to others. Analysis of the interview data showed that whereas some participants have disclosed and are comfortable with disclosing their breast cancer status to other people, some of the women have not disclosed their breast cancer status and will not disclose their status to other people for varied reasons.
The women who have disclosed their disease status to others did it to help create awareness of the existence of "breast cancer" and inform others to be alert for any warning signs and importantly to seek early diagnosis and treatment. Below are some quotes from the participants: "I am not shy okay. . . I am not bordered at all. It can also happen to anyone. If I tell someone, it is just to let the person know that such a disease exists, so that they can seek early treatment when they find themselves in such situations before matters worsen. . ." (P10). The non-disclosure among some women was due to the perceived negative responses they might get from the public especially those who are not their immediate family members as there are a lot of misconceptions about breast cancer in the Ghanaian context. Below are some of the views expressed by the women: From the narratives it is learned that fear of stigma and other unknown reactions from people are the key reasons for nondisclosure of their disease status.

Discussion
Our findings from our study showed that women experience significant physical, psychological, and economic challenges which are largely attributable to the burden of the medical treatments. These findings suggest that the experiences of negative emotions and other physical challenges are not in isolation but inextricably linked. Previous studies among women living with breast cancer have reported several physical and psychosocial burdens which affect their health and overall wellbeing (Aziato & Clegg-Lamptey, 2015;Bonsu et al., 2014;Clegg-Lamptey et al., 2009;Kagee et al., 2018;Opoku et al., 2012).
One of the key issues that was pervasive among women living with breast cancer is the use of alternative/herbal medicines. This finding was not surprising as alternative and herbal medicine use are very common and acceptable among the Ghanaian population (Aziato & Antwi, 2016;Gyasi et al., 2015;Kretchy et al., 2016;Yarney et al., 2013) and also due to the financial challenges in paying for their cancer treatment. Among the participants, three categories of alternative and herbal medicine use emerged, that is, current users, previous users, and sources of herbal/alternative medicine. However, some of the women who had no experience with the use any alternative and herbal medicines indicated their willingness to try them after their medical treatments. These patterns of alternative medicine use among the women is fueled by their belief and desire to be healed and to reduce the economic burden associated with cancer treatment. Herbal products were seen as cheaper and widely accessible. It is possible that the high cost of the medical treatments could be an important push factor which drive breast cancer patients toward the use of alternative medicines. Similar findings have been reported among a sample of Ghanaians who indicated the cost and timely accessibility of alternative medicine as the key reasons for their usage (Gyasi et al., 2015;Sanuade et al., 2021). The challenge to the healthcare delivery system is whether the healthcare professionals are aware of alternative medicine use and how these can be managed holistically to the benefit of the women living with breast cancer.
In this study, stigma emerged as an important issue that confronts women living with breast cancer as some of the participants have experienced stigma from strangers and their close friends. These experiences of perceived stigma have resulted in self-stigma among the women living with breast cancer and evidenced in some of the participants' unwillingness to disclose their disease status for fear of rejection and stigmatization. These experiences have considerable negative influences on the health and wellbeing of the women as stigma is likely to prevent them from seeking the necessary and timely help and support (Meacham et al., 2016;Wang et al., 2017). Similarly, it was also observed that the financial burden on the family members of women living with breast resulted in their relatives avoiding them, maybe, not necessarily due to stigma but because of the persistent financial pressure (toxicity) associated with breast cancer treatment. All these interlinked experiences have profound negative emotional consequences on the participants in the form of feeling isolated, depressed, and anxious about the future.
These findings are congruent with some results from previous studies which found stigma to be one of the key issues that confront women living with breast cancer (Maree & Mulonda, 2015;Wong-Kim et al., 2005). This suggests that there is a need for further research into issues of stigma among women living with breast cancer to ascertain the magnitude of this problem as stigma among breast cancer patients has received little attention in the African continent (Maree & Mulonda, 2015). Cancer stigma in Africa has been attributed to a lack of adequate disease knowledge and superstitious beliefs which put the blame for the illness on the patients for wrongdoing as seen above. However, the internalized stigma which may be brought about by the financial burdens are not surprising as pertinent literature supports the significant financial implications of breast cancer treatment (Clegg-Lamptey et al., 2009).
The findings from this study imply that women living with breast cancer are faced with complex physical and psychosocial problems which require a holistic approach involving a multidisciplinary team of health professionals. For example, oncology physicians, nurses, clinical psychologists, social workers, nutritionists, and the clergy should work together to provide care that is tailored to the needs of the women. Oncology physicians and nurses have the responsibility to go beyond the routine healthcare and probe for the information and psychosocial needs of the patients. Although this may prove difficult in the face of the apparent lack of both human and financial resources, a little more personal effort and support groups may address the information and psychosocial needs of the patients. All these are importance in the face of increased alternative and herbal medicine use among the participants which may interfere with the medical treatments and care process.
The main limitation of this study was that we did not take into account the recurrent nature of the illness in some of the women, rather, we sampled both persons with first diagnosis and recurrent breast cancer which limits the interpretation of the findings. Also, our study was restricted to women from only a referral center for cancer treatment and as such, these experiences may not necessarily reflect other women living with breast cancer in other centers. However, the evidence provided by this study may help oncology healthcare professionals and other important stakeholders such as the Ministry of Health in decision making regarding healthcare delivery to women living with breast cancer.

Conclusion
Findings from this study showed that there are several physical, psychosocial, and economic challenges confronting women living with breast cancer in the Ghanaian context. Some of these issues influence their reliance on alternative treatments including herbal products which may negatively affect their health and wellbeing outcomes. This therefore, underscore the need for a multidisciplinary approach to breast cancer treatment as current medical treatments do not address all the psychosocial and economic needs of these women.