The Experiences of Cervical Cancer Patients During Follow-Up Care in Ethiopia: A Qualitative Study

Introduction

Cervical cancer affects women, including their families worldwide.¹ The impacts (physical, psychological, social, and economic) of cervical cancer mortality in developing countries of the world are very high.¹ In Ethiopia, cervical cancer is the second commonly diagnosed cancer accounting for 9.6% of cancer cases, and it is the second cause of cancer death responsible for 10.3% of cancer mortality in 2020.² In 2020, a total of 7445 women were diagnosed with cervical cancer and 5338 died as a result of cervical cancer. The age-standardized incidence rate was 21.5 per 100,000 and the age-standardized mortality rate was about 16.0 per 100,000.²

Despite great developments in diagnostic and therapeutic approaches for gynecological cancer, psychosocial adjustment problems instantly after its detection and at the moment of treatments is consistently documented in the literature.^3,4 Physical and psychological consequences have paramount significance in women living with cervical cancer.^5,6 In several countries, cervical cancer also poses a substantial economic difficulty for families. This difficulty includes the inability to be productive because of the illness, high expenses related to medical care, and the need for caregivers to quit or reduce working hours to look after women suffering from cervical cancer.^7,8

All issues related to illness and treatment affect psychosocial adjustment to illness. It involves managing multiple changes connected with a diagnosis of cancer and all types of treatment methods. Psychosocial adjustment to illness consists of positive or negative influences on the progress of cervical cancer.⁹

Psychosocial adjustment during the immediate post-cancer treatment period has been described as taking place within the emotional, physical, interpersonal, and practical domains.¹⁰ During the completion of treatment, cancer patients face problems related to returning to their social roles in the family, workplace, and their community.¹¹ Early detection and treatment of those conditions in cancer victims not only significantly improved their adaptation and wellbeing but also increased their survival rates.¹²

So far, few studies have been conducted on the experiences of cervical cancer in low- and middle-income countries. A qualitative study among women with cervical cancer in Zambia¹³ revealed that women had experienced the physical, socioeconomic, and sexual consequences of the treatment. Further, the study showed that patients experienced spiritual matters concerning cervical cancer and faced health system challenges.

Psychosocial services are not commonly available in low- and middle-income countries, as it is in developed countries.¹⁴ Ethiopia has only one Radiotherapy center at Tikur Anbessa Specialized Hospital in Addis Ababa.¹⁵ The hospital’s Chemotherapy and Radiotherapy Center is the only facility that provides radiotherapy services to cancer patients in Ethiopia. All cancer patients have to travel from different regions of the country to this hospital to get the radiotherapy service. In Ethiopia, although there are irregular counseling and emotional support services at health institutions psychosocial services are not available in a structured and organized manner.¹⁶

Even though cervical cancer is one of the leading causes of morbidity and mortality among women in Ethiopia, to the best of our knowledge, there is no existing studies that examined patients’ experiences. It is therefore important to know the experiences of cervical cancer patients during follow-up treatment in the Ethiopian context. Understanding of experiences assist in recognizing the effects of illness and its treatment modalities. It is also a significant step towards improving treatment outcome and provide holistic care for these patients.

Lazarus & Folkman’s (1984) theory of stress, appraisal, and coping¹⁷ was used as a theoretical framework in this study to the explore experiences of cervical cancer patients. It provides a comprehensive picture of the elements involved in the process of coping and the individual’s cognitive and behavioral responses to a stressful situation. Adaptation is the outcome of the model and is conceptualized as emotional well-being, functional status, and health behaviors. Therefore, the objective of this study was to explore the experiences of cervical cancer patients during follow-up treatment in Ethiopia.

Methods

Study Design

Exploratory qualitative research design.

Study Settings

The study was conducted in Tikur Anbessa Specialized Hospital (TASH) Oncology Centre in September 2020. TASH is the large referral teaching hospital, under the administration of Addis Ababa University, located in Addis Ababa, Ethiopia. The Oncology Centre of TASH is the only oncology referral and radiotherapy center in the country.

Participants and Recruitment

Cervical cancer patients receiving treatment at TASH Oncology Centre were the participants of the study. Participants who were thoughtful and able to provide descriptions of their appraisal experiences with cervical cancer diagnosis were purposively selected from those who met the inclusion criteria. The inclusion criteria were any women who were receiving treatment for cervical cancer, have signed a written consent form, and were willing to participate in the study. An attempt was made to achieve the principle of maximum variation of participants by considering the sociodemographic and clinical characteristics (age, marital status, occupation, place of residence, duration of diagnosis, stage of cancer, and type of treatment). The participants were recruited with the help of an Oncology Nurse working in the triage room. After conducting eleven face-to-face in-depth interviews, it was decided that data saturation has been reached and information collected became repetitive as no new themes were emerging.

Procedure

A semi-structured interview guide was used to elicit responses related to participants experience with cervical cancer follow-up treatment. The data was collected through individual face-to-face in-depth interview. This interview guide comprised demographic, clinical, and an open-ended question where the participants can best describe their illness and treatment-related experiences. The interview guide was refined during the pilot interviews. In addition, probes were employed to elicit more information from the participants. The first author conducted all the interviews in Amharic language. Each interview lasted for 30–45 minutes and was audio-recorded after getting the permission from each interviewee. During interview, participants’ gestures and other nonverbal communications were noted and documented. Patients’ medical charts were also assessed for clinical data after the patients gave their consent. All interviews were conducted in a private, mutually agreed upon location with adequate lighting and acoustics distance at the hospital’s premises.

Data Analysis

The dataset was analyzed manually via thematic analysis. The audio-recorded interviews were transcribed verbatim and translated into English. Braun and Clarke provided methodological guidelines for thematic analysis.¹⁸ This analysis was used because it allowed identifying relevant themes that can capture the women’s experiences. This study employed these recommendations. Phase 1) reading and re-reading the interviews to ensure familiarity with the material; Phase 2) generating initial codes by coding interesting features line by line; Phase 3) searching themes by gathering data from individual subjects; Phase 4) reviewing themes; Phase 5) defining, naming and writing a detailed analysis of each theme; Phase 6) writing and re-writing of the analysis was undertaken. Verbatim quotes were also used. All authors (AD, WM, ZB) contributed to data analysis. Reflexivity was employed to create self-awareness with regard to how the authors current position and past experiences might affect the study findings.

Achieving Trustworthiness

To enhance the credibility, member checks were performed by providing a verbal summary of the discussion, allowing participants to respond regarding the validity of the summary. To ensure dependability and conformability, an audit trial was performed by providing a detailed account of the methods, procedures, and decision points in carrying out the study using the study protocol. Transferability was ensured by analyzing the experiences of the different patients and efforts were made to provide a rich description of the findings with illustrations by quotations to enhance the decision-making for application if necessary. Bias and subjectivities were avoided and managed during regular analysis meetings among all authors.

Ethical Approval and Informed Consent

This study was approved by the School of Social Work, College of Social Sciences, Addis Ababa University. All study participants were briefed about the purpose of the study and written informed consent was obtained from each participant including the use of anonymous data for publication and that this study was conducted in accordance with the Declaration of Helsinki. Issues of confidentiality were maintained by assigning a code to each participant.

Results

Participants’ Characteristics

A total of eleven women participated in the in-depth interview. The age of the women ranges between 39 and 62 (with a median 48 years). Most of them were currently married and urban residents. Of all the women, eight of them have got some form of schooling ranging from elementary to tertiary. At the time of the interview four of them were housewives and three of them were self-employed. The participants monthly mean household income was of $67.73. Two of the participants reside less than 50 km away from the Hospital. Five of the participants travel more than 100 km in order to arrive at the Hospital from their place of residence. Four of the participants came from places that are more than 500 km away from the Hospital. The mean distance of the patients’ residence from the Hospital was 351.36 km. All women had had been diagnosed with cervical cancer from between six and twenty-four months (with a mean of 14.82 months) and five of them are in stage III. In terms of treatments, five of them did radiation therapy (Table 1).

Table 1 Sociodemographic and Clinical Characteristics of the Participants

Women reported a variety of psychosocial adjustments difficulties with their illness and treatment. Being diagnosed with cervical cancer was a life-threatening experience for the women. Their life changed in one or another way following the diagnosis of cervical cancer. Five themes were drawn from the collected data related to psychosocial adjustment: health care adjustment, relationships, daily activities/routines, having stress, and financial difficulties. The themes and the various subthemes that emerged are described in detail below.

Theme 1: Health Care Adjustment

Four sub-themes pertaining to health care adjustment were drawn from the interview data. These are lack of satisfaction with care, communication difficulties with health care professionals, and dealing with treatment side effects.

Lack of Satisfaction with Care

Even though women hoped that the treatment they are receiving helped them, most of them were not satisfied with their healthcare experience. They described that the health care professionals were not supportive and caring. The health care professionals did not explain all aspects of their illness. They were not assured regarding their treatment side effects. They felt that the healthcare professionals were not attentive to their needs. Women also expressed harry and chaos in the reception/waiting area and card room. The following excerpt shows this response well:

Those workers in the waiting area and card room were not kind. They do not have ethics at all. We show up early in the morning, but we may not get service until noon. Traveling from far area for treatment and looking at such things makes me think that it is better if I stayed home. (Participant 9)

Another woman described her experience with health care as:

There are some professionals in the reception who showed a lack of respect and kindness. I was so disappointed and even tried to leave once. This is what I usually experience during my follow-up treatment. (Participant 5)

In addition, women also described they have waited for a long period (months) to receive the medical service here in this hospital because of delay in receiving their diagnosis result and interruption of radiation treatment. The following excerpt showed their difficulties in getting the treatments:

I have waited for many months to get the medical care … they repeatedly give me appointments by saying my result is not ready … there are also a lot of people waiting to get the treatment. (Participant 11)

There is repeated interruption with the treatment I receive (Radiation therapy) … the say that the machine is broken … sometimes after coming here, I may not receive the service … I think the hospital should do something. (Participant 7)

Communication Difficulties with Health Care Professionals

Women also expressed the importance of receiving cervical cancer information from health care professionals to adjust to their situation. Though the women believe that the important source of such information were health care professionals, this does not happen. This enabled them to have adequate information about cervical cancer, side effects, how to deal with other situations.

Some of us are without adequate information about our illness and rely on rumors about our illness and uncertain about our situation, the health care professional should have to clarify things for us. (Participant 9)

Women have reflected various experiences regarding their communication with health care professionals. Most of the participants described that they have less information, though they want to know more about their illness and treatment. Most of the women described their treatment care lacked compassion and proper communication and kindness. This makes them unsatisfied with the follow-up care. Some women reported that the doctors did not communicate well regarding their illness or treatment.

Though I have asked repeatedly why I am taking the medicine, the health care professionals told me very little. (Participant 10)

All women reported that they did not receive adequate counseling and emotional support when they receive their diagnosis and treatment. One woman reiterated the issue as follows:

He (the health care provider) just told me he doesn’t have time to discuss in detail about my illness. (Participant 6)

Most women found that communication with health care professionals was more difficult. The communication was very shallow, prescriptive type, and they found it confusing. Many women felt less empathy with their health care professionals, and this made them feel less comfortable and uncertain with the treatment choice and decision. The absence of rapport established with the health care professionals leads women to feel less reassured in the treatment process, satisfied with the care received, experience adjustment difficulties.

Dealing with Treatment Side Effects

The time of treatment was a challenging experience for women as this was a time when they faced physical, psychological, social changes, and side effects related to the treatment. For women the treatment regimens were difficult to tolerate, resulting in frustration with adjusting to a new identity as a cancer patient.

They described that treatment-related side effects had negatively affected all of them. Side effects began to appear as soon as they begin treatment. Patients experienced the side effects of the treatment such as fatigue, nausea, loss of appetite, and so on. These side effects were very challenging and have limited their physical activities. As evidenced in the following excerpt:

I repeatedly feel tiredness and lost my appetite. I couldn’t do things the way I did them before my illness. (Participant 1)

The women also stated that the treatment side effects were negatively affecting their lives. They felt they were easily got tired and could not work as they had done before their illness. One of the women explained it as:

During my treatment, I feel exhausted; my body does not feel good. I told my doctor, and he said to me “it was just a side effect”. This has deteriorated my body function (Participant 8)

Though women have such difficulties related to the treatment side effects, they are trying as much as they can to manage the problems.

Currently I have focused my effort to manage the difficulties related to the treatment side effects. (Participant 2)

Many women experienced a range of hardships during cervical cancer diagnosis and follow-up treatment. In addition, they experienced problems with their sexual functioning and in a few of them; this resulted in a disagreement with their husbands. This hardship posed challenges, especially the treatment side-effects that led the women to experience adjustment difficulties.

Somewhat Helpful Treatment

The women indicated that, even though their illness has put a strain on them, they feel that the treatment they are receiving will help them to overcome their illness soon and get back to the way they were before. One woman described:

Nowadays I think that I am getting well … the improvements in my health are the result of my treatment. (Participant 2)

According to the women, at the time of diagnosis, they have lost hope about their recovery. Nowadays, half of them restored their hope of recovery, as they have relatively felt better about their illness compared to what they have in the beginning. Other women mentioned that they restored their hope of recovery since they are undertaking the treatment.

Few (three) of the women had experiences of their cervical cancer treatment is going as they expected. Those women who felt that the medical staff has done all they could have done for them were able to have hope for positive treatment outcomes. On the other hand, few women noted that the doctors cared for and encouraged them to have a reassuring view of their progress. This is evidenced by the following explanations.

The doctor who treats me is very caring. He always listens to my concerns and gives me advice. When I came for follow up, I always ask the nurses to take me to him. (Participant 3)

I believe that most of the health professionals are helping us to get well. I know if they continue with their help, I am going to get well soon. (Participant 1)

Few women also experienced gratitude for the medical personnel providing the treatment for them. One woman described her experience as:

For me, most of the health professionals who treated me here in this hospital are kind. They did give me all the care. It was really helpful for me to see such understanding; I am so grateful for the caregivers. (Participant 2)

Though half of them agreed about the helpfulness of the treatment, one participant does not agree that the treatment is effective in relieving the problematic health condition, and it is further destroying her wellbeing.

Though I am taking the treatment, I don’t think that it is helping me to cure my condition … I am further losing my wellbeing day to day … I don’t know how I am going to continue with the treatment. (Participant 5)

Theme 2: Relationships

Two sub-themes pertaining to relationships were drawn from the interview data. These are relation with family members and social relationships.

Relation with Family Members

All women expressed their cancer had brought negative effects or burdens on their family members. Their diagnosis of cancer made the family members with great concern and confusion. A woman explained how her son reacted with her diagnosis:

During my diagnosis with this disease, I have a son who was learning in 11th grade. He just cannot focus on his study … he could not be able to see me getting tired and feeling pain. He wanted to be near me, dropped out of school because he repeatedly was absent from school to stay with me. (Participant 8)

Women acknowledged the family also experienced emotional distress in the hardships because of their cervical cancer. They described empathy and closeness to their children as important in relieving the distress and hardship situation. Some women also described the situation as created a greater sense of closeness with family members. It contributed to increased affection for family, greater support to the family, and improved communication with family members. One woman said this:

I believe that the closeness with my children and my husband was important in relieving the difficulties related with my condition. (Participant 1)

They also expressed openly the presence of difficulties in their relationship with their husbands after their diagnosis of cervical cancer and during follow-up treatment sessions. Their illness also affected their husbands. Nevertheless, for some of them through their illness journey, the presence of emotional connectedness, discussion about the problems, and caring for each other helped them get the strength to adjust to their situation. One woman described how her husband helped her adjust to her situation as:

I don’t have words to express how my husband gave me love and care during this time … we always talk about our situation … things we should do, this gave me strength to adjust myself with my illness process. (Participant 3)

Disruption with Social Relationships

Women reported that they have experienced disruption in their social relationships. The decrease in social interaction was due to feeling ill and being fatigued all the time to go out. Few participants even reported that their relationships with their friends and neighbors have been significantly affected. One woman showed this response by saying:

My social interaction is not the same as it used to be … now I don’t engage in social activities like going to funerals, mourn someone’s death, drinking coffee with my neighbors … it is terrible for me not participating in those social practices … (Participant 4)

Others reported that they re-evaluated their lifestyles, participating in social activities, and take appropriate action to maintain their wellbeing.

I am trying to make things right for my health. I have changed my habit, started doing some activities with my neighbor, going out to mourn someone’s death and thinking that is beneficiary. (Participant 2)

Theme 3: Changes in Daily Activities/Routines

Two sub-themes pertaining to daily activities/routines were drawn from the interview data. These are changes in activities at home and changes in activities at home and at work.

Changes in Activities at Work

Women who participated in this study reported that they have encountered interference with their ability to do their jobs because of their illness and treatment. Moreover, this resulted in creating a problem in their work environment. One woman said this:

There is some disagreement with my supervisor as a result of my frequent absence from work due to my illness. (Participant 9)

Women also discussed how cancer and treatment changed their ability to work. The following statements described how they struggle with their work capacity:

Previously I work on the farm … but nowadays I feel exhausted to travel there. This hindered my capacity to work. (Participant 10):

My capacity was affected by cancer and its treatment. I used to work a lot of hours without break, but currently it is challenging to work because I feel exhausted easily. (Participant 5)

Other women stated that how having her own business helped her not to worry about absenteeism from work in the following statement:

I have a small business. I have one worker. When I feel sick, she helps me work. If I don’t own the business and employed elsewhere, I probably get fired for being absent repeatedly from work. (Participant 6)

Women also mentioned the relationship they have with their co-workers. A woman who is a government employee said that:

During my stay here in this hospital for treatment, there is a gap in my work due to my absence. My co-worker is very helpful and helped me in filling the gap by performing my task. If she couldn’t help me, I may lose my job. (Participant 9)

Another woman described her relationship with her supervisor as:

My manager where I work was very nice to me after he came to know that I was suffering from cancer. He helped me through, providing sick leave during the months I was in treatment. I wish all supervisors were that supportive like him. (Participant 1)

Changes in Activities at Home

The women were very concerned about their duties in the household. In addition to the challenges of cancer, the women have experienced struggling in their daily lives as a result of fatigue and other side effects of the treatment. Some participants expressed that their female child had to take over more household responsibilities and this creates an additional burden for them. As one woman described:

My cancer and the treatment affected my capacity to perform the activities in the house. My children have tried to help me, but many things are left undone waiting for me. (Participant 5)

Another woman replied the difficulty encountered adjusting with her daily life during the treatment session:

My daily life situation is interrupted as a result of cancer … during my treatment session, the pain I experience has impacted me not to move in the house and do some activities. (Participant 4)

Theme 4: Having Stress

Women described that they are experiencing stress because of worrying about their treatment outcome, their children, losing their jobs, and the physical damage that may result from the treatment. One woman showed this response by saying:

As I am a mother, I repeatedly worry about my children … if I die or become inactive, they could not take care of themselves, I don’t know what to do. (Participant 6)

Another woman expressed her fear of losing her job as:

As a result of my repeated absence from work, I don’t know how far my supervisor could tolerate my situation … I have a great fear that I may be unable to continue working there. (Participant 9)

Few of them mentioned feeling sad, losing interest in things they do before, and becoming easily angry in simple situations. This is reflected by one woman as:

… currently I become simply annoyed with things in my surrounding … my behavior is not the same, I don’t know why this is happening (Participant 11)

During the discussion, women also stated that they worry about their physical appearance, especially about their hair following treatment. A woman frankly said regarding this experience:

I have heard here in this hospital from other patients that the treatment will cause a hair fall … I always look in the mirror and worry about it repeatedly. (With laughter) (Participant 10)

From the women’s response, it is understood that most of them worried about different issues related to their illness and treatment. They also reported that there is no counseling service for helping them alleviate their stress during follow-up treatment for cervical cancer.

Theme 5: Financial Difficulties

The great concern expressed by women, especially those coming from distant areas is that their inability (financially) to cover the cost of travel and accommodation here in Addis Ababa when they regularly came for follow-up treatment. They suffered a lot as a result of financial scarcity resulted from their illness.

All participants have expressed their concern regarding financial difficulties during the follow-up treatment. As mentioned by one woman:

As a result of expensive travel and accommodation costs during my follow-up treatment, I am experiencing financial difficulties. We are almost finishing our savings and I don’t know what to do about it. (Participant 7)

In the worst cases, few women mentioned that they have borrowed a significant amount of money or sold their belongings to get money to cover the cost of transportation, accommodation, and medical treatment. This was clearly stated by a woman in the following statement:

Currently it is beyond our capacity to cover the travel and accommodation costs for myself and my husband during the follow-up treatment … we are out of options … my husband sold a cow to cover the cost … (Participant 8)

Some women described that they are sent for investigation outside the hospital to private health institutions, and this created a huge impact on them financially, as private health institutions are expensive. One of the women stated that:

There are times we are required to go to a private health institution for some laboratory service since it is not available here … the service charge is expensive there … it will be very good if we receive the service here. (Participant 5)

The women also indicated that the financial burden is also associated with a long waiting period for receiving treatment by staying here in Addis Ababa. They strongly suggested that the government should avail the medical services in their nearby towns. This is indicated in one of the woman’s statements:

I believe that the government should have to open the service in other towns which are close to us, our suffering will be reduced. (Participant 2)

Most of the women believe that they had to provide for their families, and they could only do this when they are healthy. The fate of their family and their treatment was the main worry for some women because of the financial difficulties they are experiencing. Few of them expressed that they have a strong sense of responsibility to their families, as they are the primary breadwinner in the household.

Discussion

The findings of the qualitative study indicated that women experienced difficulties in psychosocial adjustment as suggested by “lack of satisfaction with health care”, “dealing with treatment side effects”, “struggle in work and daily life”, “having stress”, “disruption in the social relationship”, and “financial difficulties. Similar findings had been reported by other qualitative studies in Ethiopia,^19,20 in Zambia,¹³ and Nepal²¹ that reported patients experienced of physical ill consequences of the treatment, struggling with the socio-economic impact, distress associated with the side effects, and social stigma related to cervical cancer. As indicated by Earle et al, all patients” needs cannot be met by efforts done only on prolonging treatment and focusing only on survival.²² This suggests that integrating psychological and social services with medical care is essential to help women experience better psychosocial adjustment.

The qualitative finding also indicated that even though women hoped that the treatment they are receiving is helping them, most of them were not satisfied with their healthcare experiences, suggested by the subthemes “lack of satisfaction with health care” and “dealing with treatment side effects”. Participants describe that there was a long waiting period, they did not get appropriate information, inadequate counseling and emotional support regarding their illness, treatment, including side effects. In addition, it was also reported that the follow-up treatment lacked intimacy and proper communication from the health care personnel. Because of the aforementioned reasons, women could have a lack of satisfaction with the follow-up treatment that might lead to adjustment difficulties.

Previous studies conducted in TASH indicated that cancer patients are experiencing long waiting times to get curative treatment,^20,23 repeated service interruption,²⁴ and communication challenges between patients and health care professionals.^25–27 After the diagnosis, patients need information that is valuable in helping them to differentiate and clear out between rumors and reality regarding their illness and the treatment. Therefore, service providers should have empathy and openly communicate with patients in addressing their concerns, which may enhance the relationship between the two and satisfaction with the service.

The presence of higher adjustment difficulties was observed by the identification of the qualitative themes “struggle with daily life situation”, “struggle in work”, “disruption in the social relationships”, and “having stress” because of cancer and side effects of the treatment. Similar findings in Ethiopia had reported that treatment-related side effects could lead to such difficulties among cancer patients.^27–29 Studies abroad among cervical cancer patients also found similar findings.^30–32 Habinshuti et al indicated that such side effects and complications need proper care and follow-up.³³ This indicates that cervical cancer not only affects patients’ physical health but also the psychological and social health aspects. Thus, the follow-up treatment needs to focus on restoring the overall health of patients. The findings of this study give insight into the need for an interdisciplinary approach between health and psychosocial professionals in supporting the patient and family through the process of understanding the potential implications of cervical cancer diagnosis and treatment, creating and implementing systematic psychosocial support interventions based on women’s needs.

In the current study, “financial difficulties” are identified via theme analysis as adjustment difficulties experienced because of the illness and treatment. The cost of long-distance travel, accommodation and laboratory fees in private health institutions were reported as expensive. In Ethiopia, a study that calculated the cost of cervical cancer has documented that the mean outpatient cost per patient for cervical cancer was $407.2 and the mean inpatient cost for hospitalized patients was $404.4.³⁴ This has a huge financial burden when compared with the participants monthly mean household income of $67.73 and the mean distance of the patients’ residence from the Hospital of 351.36 km.

Similarly, studies conducted locally found out that cervical cancer resulted in a huge financial problem on patients resulting in an inability of bearing costs related to treatment and accommodation.^20,34 Similar studies conducted among another type of cancer patients showed that numerous patients are exposed to a high level of healthcare spending with considerable medical and transportation costs.^15,35,36 This might result because of limited physical access to cervical cancer treatment facilities and impaired productivity of patients as a result of their illness. This calls for expansion of service to regional towns, provision of support services such as transportation reimbursement, and health insurance scheme to the poorest patients may address the financial burden.

Psychosocial services are provided as one of the components of cancer care in high income countries.³⁷ Evidences revealed that psychosocial services including cognitive and behavioral coping, relaxation training, group social support, and cancer education session had significant effect in improving the adaptation, wellbeing, and survival of cancer patients.^37,38

The Ethiopian Ministry of Health had taken up its accountability to ensure a better access to cancer treatment for people living with cancer.³⁹ It has making efforts to expand the services through establishing five regional oncology centers located in different parts of the country. In addition, there is ongoing training of health professionals like Oncologist, Oncology Nurses and Radiotherapists. There is also a plan to expand chemotherapy services for cancer patients in general and tertiary hospitals in the country.⁴⁰ These efforts will improve access to cancer treatment in the country.

Strength/Limitation of the Study

This study is one of a few qualitative studies to explore women’s experience during follow-up treatment for cervical cancer. The limitation of this study was that we only conducted in-depth interviews, and it might be helpful if other data collection techniques, such as focus group discussion were used in order to triangulate our findings.

Conclusion

In conclusion, this study revealed various insights into the experiences of women receiving follow-up treatment for cervical cancer. Overall, women were found to have experienced a variety of physical and psychosocial difficulties. They have undergone difficulties indicated in health care orientation, lack of satisfaction with the health care experience, dealing with treatment side effects, struggle in work and daily life, having stress, disruption in social relationships, and financial difficulties incurred because of their illness and treatment. The findings of the present study depict that cervical cancer patient’s experiences are the outcome of a complex interplay by personal, clinical, psychological, and social spheres. Therefore, holistic care intervention strategies that integrate psychosocial services with medical treatment should be considered to help women experience better psychosocial adjustment. In addition, expansion of diagnostic and treatment facilities should be considered to help women access timely and cost-effective care. Further studies could examine psychosocial adjustment experiences in a different sample including women during post-diagnosis waiting for treatment or among women who completed treatment.