University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA, LEGON DEPARTMENT OF PSYCHOLOGY POSTTRAUMATIC GROWTH AMONG BREAST CANCER SURVIVORS IN GHANA BY SAMUEL WIAFE AGYEI (10344486) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MPHIL CLINICAL PSYCHOLOGY DEGREE MAY 2018 University of Ghana http://ugspace.ug.edu.gh i Posttraumatic Growth among Breast Cancer Survivors in Ghana DECLARATION I hereby declare that this thesis is the result of my own research work and that no part of it has been presented for another degree by anyone for any academic award in this university or elsewhere. All references used in the work have been fully acknowledged. I bear sole responsibility for any shortcomings. ………………………. ………………… ……………………….. SAMUEL WIAFE AGYEI DATE (10344486) I hereby declare that the preparation and presentation of this thesis was supervised in accordance with the guidelines on the supervision of thesis laid down by the University of Ghana. …………………………………… Date:….../….…../.2018. DR. BENJAMIN AMPONSAH (Principal Supervisor) …………………………..……….. Date: …….../….…../.2018. DR. ADOTE ANUM (Second Supervisor) University of Ghana http://ugspace.ug.edu.gh ii Posttraumatic Growth among Breast Cancer Survivors in Ghana ACKNOWLEDGEMENT A good number of people have contributed in diverse ways to enable me to achieve success through my Postgraduate program and in carrying out my project work. I would like to express my heartfelt appreciation to my supervisors, Dr. Benjamin Amponsah and Dr. Adote Anum, who read, scrutinized and provided the necessary assistance, encouragement, and guidance which enlightened me to complete this research. I would like to show immense appreciation to the CEO of Peace and Love Hospitals, Dr. Beatrice Wiafe Addai as well as the management and the staff of Peace and Love Hospital for their co-operation and support. I also want to show appreciation to the executives of the Peace and Love Survivors Association (PALSA) especially the President, Mrs. Gyasi Safo; the organizer, Mrs. Rahima Quaye and the president of the Accra branch, Mrs. Eva Buatse for organizing their members for data collection. I also acknowledge the assistance of my research assistants, Frank Adu and Isaac Agyei Atuobi for aiding in collecting the data. I also want to say a big thank you to Gloria Nyame and Deborah Boateng who are both staff of Peace and Love Hospital for their support during the pilot phase of this. To all the survivors who availed themselves and committed their time, I say thank you and God richly bless you for devoting your time and energy to answer my questionnaires. I am grateful as well to all friends and loved ones who contributed their quota in diverse ways to my success in this program especially my course mates for their words of encouragement. Finally, my gratitude goes to my family for their prayers, support, love and inspirations throughout this program of study. University of Ghana http://ugspace.ug.edu.gh iii Posttraumatic Growth among Breast Cancer Survivors in Ghana DEDICATION This work is dedicated in memory of my late grandmother, Madam Juliana Oforiwaa Wiafe. May her soul continue to rest in perfect peace. University of Ghana http://ugspace.ug.edu.gh iv Posttraumatic Growth among Breast Cancer Survivors in Ghana TABLE OF CONTENT DECLARATION ............................................................................................................................. i ACKNOWLEDGEMENT .............................................................................................................. ii DEDICATION ............................................................................................................................... iii LIST OF TABLES ........................................................................................................................ vii LIST OF FIGURES ...................................................................................................................... vii ABSTRACT .................................................................................................................................... 1 CHAPTER 1 ................................................................................................................................... 2 INTRODUCTION .......................................................................................................................... 2 Background of the Study .......................................................................................................... 2 Breast Cancer and Trauma.................................................................................................. 5 Breast Cancer and Posttraumatic Growth ......................................................................... 7 Determinants of Posttraumatic Growth ............................................................................. 8 Statement of Problem ................................................................................................................ 11 Aims and Objectives ............................................................................................................... 12 Aim ....................................................................................................................................... 12 Objectives............................................................................................................................. 12 Relevance of the Study............................................................................................................ 12 CHAPTER 2 ................................................................................................................................. 14 LITERATURE REVIEW ............................................................................................................. 14 Theoretical Orientation .......................................................................................................... 14 Shattered Assumption Theory (Janoff-Bulman, 1992; 2006) ......................................... 14 Organismic Valuing Theory (Joseph & Linley, 2005) ..................................................... 15 The Meaning Making Model (Park, 2010) ....................................................................... 16 The Transformational Model of Positive Change (Tedeschi & Calhoun, 1995) ........... 17 Review of Related Studies ...................................................................................................... 19 Prevalence of Posttraumatic Growth in Chronic Diseases ............................................ 19 Socio-demographic and Disease/Treatment Related Variables and Posttraumatic Growth ................................................................................................................................. 22 Psychosocial factors and Posttraumatic Growth................................................................. 25 Coping and Posttraumatic Growth ................................................................................... 25 Optimism and Posttraumatic Growth .............................................................................. 27 Social Support and Posttraumatic Growth ...................................................................... 28 Cognitive Processing and Posttraumatic Growth ............................................................ 29 University of Ghana http://ugspace.ug.edu.gh v Posttraumatic Growth among Breast Cancer Survivors in Ghana Religiosity/ Spirituality and Posttraumatic growth ......................................................... 30 Gaps and Rationale for the Study ............................................................................................. 33 Statement of Hypotheses........................................................................................................... 34 The present study seeks to test the following hypotheses. ........................................................ 34 Conceptual Framework ............................................................................................................. 35 CHAPTER 3 ................................................................................................................................. 37 METHODOLOGY ....................................................................................................................... 37 Study Design ............................................................................................................................ 37 Population ................................................................................................................................ 37 Sampling and Sample Size ..................................................................................................... 38 Measures/Instruments ............................................................................................................ 39 Sociodemographic and Disease/Treatment Characteristics............................................ 39 Posttraumatic Growth Inventory (PTGI). ........................................................................ 39 Cognitive Processing of Trauma Scale (CPOTS) ............................................................. 40 Life Orientation Test- Revised (LOT-R) .......................................................................... 40 Santa Clara Strength of Religious Faith Questionnaire .................................................. 41 The Brief COPE .................................................................................................................. 41 The Multidimensional Scale of Perceived Social Support [MDSPSS] ........................... 42 Pilot Study ................................................................................................................................. 42 Reliability Analysis of Scales.............................................................................................. 42 Procedure ................................................................................................................................. 44 Ethical Consideration ............................................................................................................. 45 CHAPTER 4 ................................................................................................................................. 47 RESULTS ..................................................................................................................................... 47 Preliminary Analysis ..................................................................................................................... 47 Descriptive Statistics of the Variables ...................................................................................... 47 Validation of Scales .................................................................................................................. 49 Exploratory Factor Analysis of the Posttraumatic Growth Inventory .......................... 49 Exploratory Factor Analysis of the Cognitive Processing of Trauma Scale ................. 50 Exploratory Factor Analysis of the Life Orientation Test - Revised ............................. 51 EFA of the Santa Clara Strength of Religious Faith Questionnaire .............................. 52 Exploratory Factor Analysis of the Brief Cope ................................................................ 53 Exploratory Factor Analysis of the Multidimensional Scale of Perceived Social Support................................................................................................................................. 53 University of Ghana http://ugspace.ug.edu.gh vi Posttraumatic Growth among Breast Cancer Survivors in Ghana Descriptive Statistics of Variables and Test of Normality .................................................. 55 Intercorrelations among Predictor and Criterion Variables ...................................................... 56 Testing Hypotheses ....................................................................................................................... 58 Objective One ........................................................................................................................... 58 Prevalence of Posttraumatic Growth among Breast Cancer Survivors in Ghana ... 58 Objective Two and Three .......................................................................................................... 60 Association of Demographic and Disease/ Treatment Factors and Posttraumatic Growth ............................................................................................................................. 60 Objective Four .......................................................................................................................... 63 Predicting Posttraumatic Growth with Psychosocial Variables ..................................... 63 Mediation Analysis.............................................................................................................. 65 Optimism mediates the relationship between Cognitive Processing and Posttraumatic Growth. ................................................................................................................................ 66 Coping mediates the relationship between Cognitive Processing and Posttraumatic Growth. ................................................................................................................................ 68 Social Support mediates the relationship between Cognitive Processing and Posttraumatic Growth. ....................................................................................................... 69 Optimism mediates the relationship between Religiosity and Posttraumatic Growth. 71 Coping mediates the relationship between Religiosity and Posttraumatic Growth. .... 72 Social Support mediates the relationship between Religiosity and Posttraumatic Growth. ................................................................................................................................ 74 Summary of Findings ................................................................................................................ 75 Observed Model .................................................................................................................. 76 DISCUSSION .............................................................................................................................. 77 Limitations of this study ........................................................................................................... 86 Conclusion and Implications for Further Research .................................................................. 87 REFERENCES ............................................................................................................................. 88 APPENDICES ............................................................................................................................ 105 University of Ghana http://ugspace.ug.edu.gh vii Posttraumatic Growth among Breast Cancer Survivors in Ghana LIST OF TABLES Table 1: Internal Consistencies of the Scales ............................................................................... 43 Table 2: Demographic Characteristics of the Participants in the Study ....................................... 47 Table 3: Descriptive Statistics of the Predictors ........................................................................... 55 Table 4: Correlation Matrix representing the relationship between the variables ........................ 56 Table 5: Distribution of the prevalence of Posttraumatic growth experienced by the participants ....................................................................................................................................................... 58 Table 6: Chi-Square test assessing Association of Demographic and Disease/Treatment variables with Posttraumatic Growth ........................................................................................................... 61 Table 7: Summary of Hierarchical Regression Analysis for Variables Predicting Posttraumatic Growth among Breast Cancer Survivors. ..................................................................................... 63 Table 8: Mediation Analysis of Optimism on Cognitive Processing – Posttraumatic Growth relationship .................................................................................................................................... 66 Table 9: Mediation Analysis of Coping on Cognitive Processing – Posttraumatic Growth relationship .................................................................................................................................... 68 Table 10: Mediation Analysis of Social Support on Cognitive Processing – Posttraumatic Growth relationship .................................................................................................................................... 69 Table 11: Mediation Analysis of Optimism on Religiosity – Posttraumatic Growth relationship 71 Table 12: Mediation Analysis of Coping on Religiosity – Posttraumatic Growth relationship ... 72 Table 13: Mediation Analysis of Social Support on Religiosity – Posttraumatic Growth relationship .................................................................................................................................... 74 LIST OF FIGURES Figure 1 Conceptual Model Showing the Relationship between the Study Variables. ........ 36 Figure 2: Observed Model: Optimism, Coping and Social support mediates the relationship between Cognitive Processing and Religiosity on Posttraumatic Growth. ............................ 76 University of Ghana http://ugspace.ug.edu.gh 1 Posttraumatic Growth among Breast Cancer Survivors in Ghana ABSTRACT Cancer of the breast is one of the most diagnosed cancers in women and causes most deaths in women globally. While the diagnosis of breast cancer is increasing globally, due to early diagnosis and improved treatment, many women also survive from the disease. The breast cancer experience has been known to be a series of ongoing trauma that can last for a very long time even to survivorship. While the rate of survival is increasing globally and locally, there is scarcity of knowledge about the changes that have occurred in the lives of these women who experienced breast cancer. The aim of this study is to assess Posttraumatic Growth (PTG) in breast cancer survivors in Ghana and to investigate the factors that relate and impact on PTG. This study employed the cross-sectional survey where 150 breast cancer survivors were conveniently selected to respond to some validated questionnaires. The study found that Age, Years of survival and Marital status had a positive association with Posttraumatic Growth. It was also found that there was no association between educational level, employment status, religion and disease/treatment factors and Posttraumatic growth. Regression analysis shows that Optimism, Coping, and Social Support have a direct effect on Posttraumatic Growth. Also, an indirect effect was found between Religiosity and Posttraumatic Growth. Another indirect effect was found between cognitive processing and Posttraumatic Growth. Findings from this study together with the implications have been discussed. Keywords: Posttraumatic Growth, Breast Cancer, Breast Cancer Survivors, Optimism, Coping, Social Support, Cognitive Processing, Religiosity, Ghana, Positive Psychology. University of Ghana http://ugspace.ug.edu.gh 2 Posttraumatic Growth among Breast Cancer Survivors in Ghana CHAPTER 1 INTRODUCTION Background of the Study Breast cancer (BC) is a life-threatening and a chronic disease that originates from an abnormal growth of cells in the beast tissue and has both physical and mental consequences for the patients (Ozkal & Arıkan, 2014). According to the World Cancer Report (2014) breast cancer is the most widely known type of cancer found in women and globally about 1.67 million women are affected (McGuire, 2016). Globacan (2012) reported that in 2010, over 1.3 million women died from breast cancer globally, 2,062 (21.0%) women in Ghana were diagnosed with the disease and 1,137 (16.5%) women died from breast cancer in Ghana. It is well known that early detection with a positive response to treatment reduces psychological trauma (Baako, 1999). Different types of breast cancer have been identified by researchers. According to Sariego (2010), the most common among them include those that occur in the ducts: the invasive type and the noninvasive type which are “Invasive Ductal Carcinoma” and “Ductal Carcinoma In Situ” respectively. Invasive Ductal Carcinoma also have subtypes which include; “Medullary Carcinoma of the Breast”, “Papillary Carcinoma of the Breast”, “Mucinous Carcinoma of the Breast”, “Cribriform Carcinoma of the Breast” and “Tubular Carcinoma of the Breast” (Sariego, 2010). Other breast cancer types are those that occur in the lobule the noninvasive type – “Lobular Carcinoma In Situ” and the invasive type – “Invasive Lobular Carcinoma”. Also identified is the Molecular Subtypes of Breast Cancer: “Phyllodes Tumors of the Breast” and “Paget's Disease of the Nipple” (Sariego, 2010). In some cases, women may have “Recurrent and Metastatic Breast Cancer” (Sariego, 2010). University of Ghana http://ugspace.ug.edu.gh 3 Posttraumatic Growth among Breast Cancer Survivors in Ghana The staging of breast cancer after diagnosis is done based on information that is obtained from clinical, radiological and pathological findings and assists in predicting how an individual will progress over time. Stage 0, I and II constitute early breast cancer whiles stages III and IV are referred to as advanced breast cancer, the lower the stage, the better the prognosis (Cancer Research UK, 2004). Early stage breast cancer (stage I & II) has relatively small tumor sizes which have not yet spread to other sites and have a good prognosis (Cancer Research UK, 2004). In contrast, advanced stage cancer (stage III & IV) tumor size is large and has metastasized to the lymph nodes and other locations with poor prognosis. In Ghana, there is also an increase in BC which is mostly characterized by more advanced and aggressive forms of the cancer (Laryea, Awuah, Amoako, Osei-Bonsu, Dogbe et al., 2014; Ohene-Yeboah & Adjei, 2012). In one of the earliest studies in Ghana by Archampong (1977) on breast cancer, 75% of women with breast carcinoma presented with stage III and IV disease. Another study in Ghana on breast diseases at the surgical clinic of the Korle Bu teaching hospital indicated that among 300 women presenting with breast complaints, approximately 16% (47) had breast cancer, out of which 47% presented stage III and IV cancers (Asumanu, Vowotor, & Naaeder, 2000). A study in Ghana at the Korle Bu Teaching Hospital reported that 57.6% of patients presented with stage III-IV disease (Clegg-Lamptey & Hodasi, 2007). These results indicate that, patients in Ghana present at the late stage of their disease resulting in poor prognosis (Archampong, 1977; Asumanu et al., 2000; Clegg-Lamptey & Hodasi, 2007). These add to the findings by Abdulrahman and Rahman (2012) who found that Africans compared to Europeans present with advanced and invasive types of the disease and hence poor prognosis. Some of the recent treatments that women diagnosed of breast cancer include chemotherapy, surgery, radiation therapy and hormonal therapy. Given at the same time or in University of Ghana http://ugspace.ug.edu.gh 4 Posttraumatic Growth among Breast Cancer Survivors in Ghana succession depending on the disease severity, patients may receive a single treatment or a combination of therapies (NCI, 2006). Presently, according to the Global Cancer Statistics (2012), with improved treatment options and early diagnosis for breast cancer, survival rates are increasing and disclosure of survivor‟s experience after treatment is gaining importance (Torre, Bray, Siegel, Ferlay, Lortet-Tieulent, Jemal et al., 2015). Findings from the NCI (2006) indicate that 5-year survival rates for early - stage breast cancers (stage I & II) are 96% -75% and that of breast cancers that have metastasized (stage III & IV cancers) is 20%. It is therefore not surprising that 47.9% has been reported as the cumulative 5- year overall survival of rate of breast cancer in Ghana and 91.94% and 15.09% for Stage I and Stage IV respectively (Mensah, Yarney, Nokoe, Opoku & Clegg-Lamptey, 2016). In the psychosocial definition, survival is accepted as a process that begins with the time the patient is diagnosed and is defined in three stages (Mullan, 1985). According to Mullan (1985) the first stage of survival is the “Acute survival stage” which is the period beginning at the time the patient is diagnosed. The second stage is the “Extended survival stage” which is also the period beginning after termination of treatment when the patient enters the healing process and experience the fear of recurrence. The final stage is the Permanent survival stage which represents the period when a possible risk of recurrence is minimized (Mullan, 1985). In this current study, women who have gone through the second and third stage of survival proposed by Mullan (1985) are considered as breast cancer survivors. University of Ghana http://ugspace.ug.edu.gh 5 Posttraumatic Growth among Breast Cancer Survivors in Ghana Breast Cancer and Trauma Breast cancer like other Oncological illnesses epitomizes an ongoing trauma that can last for a very long time possibly for as long as the person lives (Aitken-Swan & Easson, 1959; Cordova, Giese-Davis, Golant, Kronenwetter, Chang & Spiegel, 2007). Even with developments in technology and medicine together with many preventive and medical treatment procedures, breast cancer to date is perceived as a disease which impacts many areas of the patient‟s life such as self-care, family life, sexuality and work life (Gumus, 2006; Ozkal & Arıkan, 2014). In most non-western cultures like cultures in Africa, breast is viewed as a representation of maternity, ferminity and motherhood (Baglama & Atak, 2015; Brinton, Figueroa, Awuah, Yarney, Wiafe et al., 2014). Along these lines, it can be demonstrated that breast cancer may threaten the women‟s ferminity, sexuality, maternal identity and their relationships with the environment such as self- esteem, self-confidence and body image (Brinton et al., 2014; Lantz & Booth, 1998). For people who experience breast cancer, the traumatic experience starts from the first day of detecting a lump, through diagnosis and treatment and continues through to survivorship (Cordova et al., 2007). One's life may be threatened by the disease together with its treatment and the experience may evoke feelings of helplessness and intense emotional reaction of fear due to an abrupt or unexpected diagnosis (Cordova et al., 2007; Sawyer, Ayers & Field, 2010; Stanton, Revenson & Tennen, 2007). Effects of treatment are not limited to only cancer cells; other healthy cells and tissues are damaged during treatment causing unpleasant side effects. The type and extent of the treatment mainly determines the side effects of cancer and it varies from each person (Merck Manual of Diagnosis and Therapy [MMDT], 2003). “Physical side effects of cancer treatments documented include pain, lymphedema, changes in body image, anemia, muscle ache, tiredness, skin reactions, loss of appetite, nausea, vomiting, diarrhea or constipation and risk of developing University of Ghana http://ugspace.ug.edu.gh 6 Posttraumatic Growth among Breast Cancer Survivors in Ghana a secondary cancer. Other side effects are immune suppression leading to opportunistic infections, delayed blood clotting time, hair loss, tiredness, mouth sore, hot flashes, vaginal dryness, peripheral neuropathy, weight gain, insomnia and interrupted menstrual periods” (Eure, 2006; MMDT, 2003). Coupled with the possibility of losing the breast, anxiety about the disease due to the radical and stressful medical and surgical procedures may worsen the traumatic experience of these women (Cordova et al., 2007). The experience of breast cancer like other extremely unpleasant life event can result in a range of behavioral, psychological and emotional outcomes (Ramos & Leal, 2013; Taku, Cann, Tedeschi, & Calhoun, 2009). Negative adjustment to circumstances concerning the cancer diagnosis and its treatment, such as symptoms of anxiety, depression and post-traumatic stress disorder may arise as a result of the trauma from breast cancer (Bostock, Sheikh, & Barton, 2009; Calhoun & Tedeschi, 2001; Linley, Joseph & Goodfellow, 2008; Taku et al., 2009). Patients must also deal with several negative experiences, including side effects of medical treatments such as “fatigue, pain, and hair loss; temporary and permanent changes in physical appearance; alterations in future life plans; and the threat of future disease recurrence” (Eure, 2006; MMDT, 2003). These negative experiences with breast cancer indicate that suffering from a life-threatening illness like breast cancer is a series of recounting threats and stressors but rather not an acute, extraordinary stressful experience (Cordova, 2008; Stanton et al., 2007). Other traumatic stressors parallel breast cancer in many ways. As a result, cancer has been included in the 5th edition of Diagnostic and Statistical Manual of Mental Disorders as one of the events that can trigger elicits cancer-related posttraumatic symptoms of depression, anxiety and posttraumatic stress disorder (PTSD) (American Psychiatric Association, 2013). Kangas, Henry and Bryant (2002) in their review found that a range of 5% to 35% is the global PTSD rates found in breast cancer patients. University of Ghana http://ugspace.ug.edu.gh 7 Posttraumatic Growth among Breast Cancer Survivors in Ghana Koutrouli, Anagnostopoulos, and Potamianos (2012) also found that the global PTSD rates in breast cancer patients and survivors vary from 2.4% and 19% globally. This indicates that the rate of having a negative psychological outcome after surviving from breast cancer is low. Breast Cancer and Posttraumatic Growth Some researchers believe that the negative impact of life-threatening and chronic diseases is not only seen as a loss or threat, but also create opportunities for positive changes and growth (Cordova et al., 2007; Fallah, Keshmir, Kashani, Azargalib &Akbari, 2012; Frazier & Kaler, 2006; Linley & Joseph, 2004). Studies on breast cancer survivors have confimed that, amidst the trauma, people experience positive changes as well (Kolokotroni, Anagnostopoulos & Tsikkinis, 2014). Tedeschi and Calhoun (1995) introduced the term “posttraumatic growth” (PTG) which they described as “the positive psychological change experienced as a result of the struggle with highly challenging life circumstances” (Tedeschi & Calhoun, 2004). Janoff-Bulman (2004) has indicated that during challenging life events like breast cancer, what the individual knows and beliefs about life and its existence are crashed and needs to be reconstructed to decrease psychological burden. According to Park (2010), to reduce the psychological distress associated with ones encounter with breast cancer and any other life threating situation, the patient will have to resolve the discrepancy between what he/she knows, believes and desire about the world (global meaning) against what he/she has experienced or perceived about breast cancer. This is achieved either through the process of assimilation (the very meaning of the stressor is changed) or through the process of accommodation (global beliefs and goals are altered) to improve the balance between the appraised meaning and global meaning of breast cancer (Park, 2013). Thus, PTG is therefore viewed as a potential consequence of the cognitive effort to redefine those University of Ghana http://ugspace.ug.edu.gh 8 Posttraumatic Growth among Breast Cancer Survivors in Ghana beliefs and to reconstruct the assumptive world (Tedeschi & Calhoun, 2004; Janoff-Bulman, 1992, 2006). Globally, between 60-98% of people who experience breast cancer have been reported to experience some perceived growth due to a breast cancer diagnosis, treatment and survivorship (Parikh, De Ieso, Garvey, Thachil, Ramamoorthi, Penniment & Jayaraj, 2015; Kolokotroni et al., 2014; Sears, Stanton & Danoff-Burg, 2003; Stanton, Bower & Low, 2006; Weiss, 2002). According to Tedeschi and Calhoun (2004), in the process of rebuilding the assumptive world, individuals may reexamine many aspects of their lives and might recognize growth in five vital domains of their life including: “changes in priorities”; “an increased appreciation for life”; “a sense of increased personal strength”; “an essential relationship with others” and “existential/spiritual thrive” (Tedeschi & Calhoun, 2004). Determinants of Posttraumatic Growth Most theories and models of growth have come to the consensus that, growth from trauma starts through the individual‟s appraisal or meaning ascribed to the event or situation (Janoff-Bulman, 1992; 2006; Joseph & Linley, 2004; Park, 2010; Tedeschi & Calhoun, 1995; 2004). According to Linley and Joseph (2004), the development of PTG is mainly influenced by the perception one holds due to their subjective traumatic experience of the event. In the framework of illnesses like breast cancer, being diagnosed can cause disruption in important global views, including the kindness, fairness, one‟s ability to predict the world, sense of control and one‟s sense of immunity (Jim & Jacobsen, 2008). Additionally, serious illnesses like breast cancer almost inherently interrupt the individuals' strategies for the future and their goals for their current lives (Carver, 2005). The breast cancer survivor then begins to make sense of their new experiences and attempt to rebuild their previous assumptions by drawing from different and competing University of Ghana http://ugspace.ug.edu.gh 9 Posttraumatic Growth among Breast Cancer Survivors in Ghana sources of knowledge available to them (Park, 2013). According to Park (2013) information exist that suggest that for situational meaning, knowledge is created with evidence from information individuals obtain from sources such as their healthcare providers, the anticipated impact of the illness on their future, appraisal of their ability to manage the illness, and generally, the sense of control they have over their lives (Leventhal, Weinman, Leventhal & Phillips, 2008; Weinstein & Quigley, 2006). Making meaning of the self, the future and the world based on information derived uniquely from the experience of cancer is what has been termed as cognitive processing of cancer. Spirituality/Religiosity has been identified as one of the variables that appear to be central of many individuals‟ “meaning systems” especially for those in Africa (Park, 2013). At diagnosis, the situational meaning they assign to their illness may be influenced by individuals‟ pre-illness spirituality. For instance, survivors may come to see God‟s purpose in their illness or try to reevaluate it as a chance for spiritual growth. They may also vigorously interrogate even the existence of God or whether their lives are determined by God (Cummings & Pargament, 2010). Park (2010) found that the effect between any of the meaning-making processes (situational cognitive processing and spirituality) and health outcomes are indirect and many different pathways are reported to influence these effects. Based on the “functional-descriptive model of PTG” that was proposed by Tedeschi and Calhoun (2004), several factors including environmental characteristics like sociocultural influences, social support, level of distress from the trauma as well as individual characteristics like coping style and personality characteristics have been identified to influence the individual‟s confrontation with trauma (Calhoun & Tedeschi, 2006). Tedeschi and Calhoun (2004) pointed out that one of the variables that significantly influence the development of PTG is the Coping process. According to Lazarus and Folkman (1984), Coping is conceptualized as “cognitive and University of Ghana http://ugspace.ug.edu.gh 10 Posttraumatic Growth among Breast Cancer Survivors in Ghana behavioral mechanisms that people use to deal with the distress caused by a demanding experience”. Associated with cognitive processing, the type of coping style used in close succession to the trauma may determine the level of growth. In fact, both emotion-focused and problem-focused coping are noted for having a positive association with PTG (Linley & Joseph, 2004). In the PTG model, Social support plays a major role. Not only does it provide reassurance, comfort and assistance and confidence, but an avenue for empathic listening is provided which offers a companion for cognitive and emotion processing and promotes emotional expression which is essential for coping with difficult life experiences. A supportive social environment plays an important role in the PTG process because it grants individuals with information and enables the cognitive processing and permits them to talk about the trauma (Tedeschi & Calhoun, 2004). Aiding in the successful adjustment for traumatic experiences, Social support becomes a predictor for PTG through its influences on the Coping process (Nolen-Hoeksema & Davis, 1999). New contacts and friendships, more compassionate behaviors and opportunity for closest relationships may be created through the positive changes that occur in many areas of the survivor‟s life due to the support they receive in the phase of difficult times (Prati & Pietrantoni, 2009). Also, the functional descriptive model of PTG has included personality characteristics such as optimism (Tedeschi & Calhoun, 2004). It has been proposed that optimists emphasize the positive aspects of their situation, allowing them to take an active, problem-focused style of dealing with stressors (Tedeschi & Calhoun, 1995). University of Ghana http://ugspace.ug.edu.gh 11 Posttraumatic Growth among Breast Cancer Survivors in Ghana Statement of Problem There is a high prevalence rate of breast cancer globally (World Cancer Report, 2014). In Ghana, the diagnosis of breast cancer is also on the rise (Laryea et al, 2014; Ohene-Yeboah & Adjei, 2012). For women in sub-Saharan Africa, the mortality rate of breast cancer is high compared to women in other developed countries since breast cancer is characterized by late presentation, advanced and aggressive forms of the disease as well as negative attitudes such as late presentation and non-adherence to treatment (Opoku, Benwell & Yarney, 2012). However, due to advances in screening and educational programs which have led to early detection coupled with improved treatment, the global rate of survival is on the rise (Coleman et al., 2008). Today, the incidence of surviving cancer for more than 5 years globally is 2 in 3 adults diagnosed (Ries et al., 2006). Though breast cancer mortality in Africa is high compared to rates in other Western countries, Ghana‟s overall survival rate of breast cancer is reported as 47.91% (Mensah et al., 2016). This shows that at least a close to a half of women who experience breast cancer in Ghana is expected to survive the disease. There exist a great number of women who experience the long-lasting costs of the breast cancer since the rate of survival for breast cancer patients is improving. Therefore, there is a rising concern to look at how these survivors are adjusting to life after cancer. However, the majority of the studies in Ghana on breast cancer have neglected the survivors as well as their posttraumatic experiences or how they are adjusting after cancer. Primarily, epidemiological trends (Boyle, 2012; Ohene-Yeboah & Adjei, 2012); awareness and its screening policies (Clegg-Lamptey & Hodasi, 2007; Opoku, Benwell & Yarney, 2007); genetic correlates and its prognosis of breast cancer types (Owiredu et al., 2009; Stark et al., 2010); ways of improving on medical treatments (Clegg-Lamptey, Dakubo & Attobra, 2009); well-being, help-seeking behaviors and quality of University of Ghana http://ugspace.ug.edu.gh 12 Posttraumatic Growth among Breast Cancer Survivors in Ghana life of the patients (Clegg-Lamptey et al., 2009). There is limited knowledge about how these women adjust to life after their treatment within the Ghanaian setting. Hence the need to study how breast cancer survivors in Ghana are adjusting positively after cancer as well as the variables that are aiding them in this growth process. Aims and Objectives Aim The aim of the study is to assess Posttraumatic Growth in breast cancer survivors in Ghana and the factors that relate and impact on Posttraumatic Growth. Objectives  To assess the prevalence of Posttraumatic Growth and its domains (“New Possibilities”, “Spiritual Change”, “Appreciation of Life”, “Personal Strength” and “Relationship with Others”) in BCS in Ghana.  To assess the association of socio-demographic variables with Posttraumatic Growth To assess the association disease/treatment variables with Posttraumatic Growth  To assess whether psychosocial variables (Optimism, Social Support, Coping, Cognitive Processing and Religiosity) predict Posttraumatic Growth Relevance of the Study The purpose of this study is to investigate posttraumatic growth among survivors of breast cancer in Ghana and to examine the factors that impact on this construct. By understanding the adaptation process after diagnosis and post-treatment, finding from this study could be of many benefits to professionals who work with cancer patients in clinical settings since they can focus University of Ghana http://ugspace.ug.edu.gh 13 Posttraumatic Growth among Breast Cancer Survivors in Ghana on the possible positive consequences of cancer. In planning future rehabilitation programs for breast cancer patients, knowledge about PTG can be very helpful. With the understanding of the factors that may account for PTG in breast cancer survivors, healthcare providers and caregivers will know what to consider especially encouraging growth. In addition, knowledge about PTG after breast cancer together with its associated factors can be very helpful for the education of health care professionals. Furthermore, this study will further add to the scientific literature on Posttraumatic Growth in Africa and Positive Psychology. University of Ghana http://ugspace.ug.edu.gh 14 Posttraumatic Growth among Breast Cancer Survivors in Ghana CHAPTER 2 LITERATURE REVIEW Theoretical Orientation Shattered Assumption Theory (Janoff-Bulman, 1992; 2006) Shattered assumption theory by Janoff-Bulman (1992; 2006) emphasizes assumptions about the world and how traumatic events can “shatter” such assumptions. According to Janoff-Bulman (2006), there are three fundamental assumptions individuals hold which are: “the world is benevolent; the world is meaningful, and the self is worthy”. Such assumptions afford individuals with a sense of security and safety. According to Janoff-Bulman (2006), assumptions are broader and encompass schemas (which are narrower in scope and are largely influenced by daily interactions with the world) and can be challenged by significant life crises like serious illnesses such as Cancer (Janoff-Bulman, 2006). Janoff-Bulman (1992) proposes that before experiencing a traumatic or life changing event in this case breast cancer, the world is considered a safe and just place. One‟s sense of meaning in life including comprehensibility, meaningfulness of one‟s assumptive world and self-concept is called into question due the diagnosis and treatment of life-threating illnesses like breast cancer (Janoff-Bulman, 2006). It is assumed that following the diagnosis of cancer, instead of assuming the world is predictive and controllable, the world becomes dangerous, unsafe, and unpredictable; one‟s inner world becomes fragile and summons with uncertainty leading to feelings of vulnerability (Janoff- Bulman, 2006). Following treatment of cancer, subsequently, individuals attempt to rebuild their devastated assumptions and their shattered beliefs about the world and the reconstructed assumptions may be different than their pre-event assumptions about the world (Janoff-Bulman, University of Ghana http://ugspace.ug.edu.gh 15 Posttraumatic Growth among Breast Cancer Survivors in Ghana 2006). With processes such as coping and social support, Janoff-Bulman (1992) further hypothesized that individuals rebuild and reconstruct their assumptions to adjust to life after trauma and this brings about growth (Janoff-Bulman, 1992; 2006). Organismic Valuing Theory (Joseph & Linley, 2005) Their theory is emphasized within a positive psychology framework and assumes that individuals are inherently motivated to achieve growth (Joseph & Linley, 2005; 2008). Organismic Valuing Theory focuses on the integration between appraisal processes and personality/assumptive world. Organismic Valuing Theory assumes that individuals following traumatic events such as surviving cancer, the individual navigates through a series of appraisals, coping styles and emotional states to either assimilate or accommodate trauma-related information (Joseph & Linley, 2005; 2008). The theory further suggests that there are three means by which individuals process and cognitively interpret information. First, breast cancer survivor may use maladaptive coping strategies to maintain a presence in their current assumptive world. These individual returns to pre-levels of event functioning. He/she then develops strict defense mechanisms that may make them more vulnerable to future stressful or traumatic events (Joseph & Linley, 2005; 2008). Secondly, survivors who can accommodate trauma-related information, or change their worldviews, can either achieve positive or negative value direction. Those who positively accommodate may use adaptive coping strategies, by appraising and accepting the new trauma information. Positive accommodation may lead to PTG (e.g., increased personal strength, change in life perspective, improved interpersonal relationships with others). Experiences that are accommodated in a negative direction, by use of maladaptive coping strategies, lead to negative outcomes and increased psychopathology (Joseph & Linley, 2005; 2008). Finally, Organismic University of Ghana http://ugspace.ug.edu.gh 16 Posttraumatic Growth among Breast Cancer Survivors in Ghana Valuing Theory also stresses that supportive others and social support are important in the aftermath of trauma. Specifically, the process of assimilation and accommodation are influenced by the individuals in one‟s environment. Joseph and Linley (2008) theorized outcomes to be contingent upon the degree in which individuals are open to changing their pre-existing schemas about life. The Meaning Making Model (Park, 2010) The Meaning Making Model distinguishes between “global and situational” meaning making (Park & Folkman, 1997). The general way an individual has been oriented and how he/she generally views many situations has been referred to as Global meaning, while situational meaning on the contrary refers to meaning one derives concerning a specific instance or situation in this case breast cancer. The Meaning Making Model suggests that the awareness of incompatibilities between people‟s global meaning they hold about the world and their appraised meaning of a situation due to discrepancy-based nature creates distress (Park, 2010), which in turn increases their efforts to decrease the subsequent distress or discomfort. Both emotion- focused and problem-focused coping strategies are some of the many ways these discrepancies can be decreased (Aldwin, 2007). Nevertheless, Park, Folkman, and Bostrom (2001) have stated that in situations which are not responsive to direct repair or problem-solving, such as serious illness and loss, meaning-making is often the most adaptive. Involved with meaning making is the survivors‟ search for a more favorable understanding of the situation and its implications as well as reexamining global beliefs and revising goals together with question or revise one‟s sense of purpose in life (Park, 2010; Wrosch, 2010). Predominantly if the adequate meaning is created or found, the outcome of a successful rebuilding process may lead to better adjustment, whereas the result of unproductive and protracted meaning-making efforts may be maladaptive University of Ghana http://ugspace.ug.edu.gh 17 Posttraumatic Growth among Breast Cancer Survivors in Ghana rumination of the event (Segerstrom, Stanton, Alden, & Shortridge, 2003). Together with changes in global meaning, changes in the way one appraises a situation such as growth, revised identity and views of the world are results of the meaning made (Park, 2010). Park (2013) has indicated that the subsequent adjustment and coping survivors experience are predicted by the meanings that survivors assign to their illness. The Transformational Model of Positive Change (Tedeschi & Calhoun, 1995) The transformational model proposed by (Tedeschi & Calhoun, 1995) is one of the most complete and widely used models of growth. According to Tedeschi and Calhoun (1995, 2003), the outcome of excessive rumination (or cognitive processing) following the life-threating event is posttraumatic growth. Following such a life-threating event such as cancer diagnosis, the individual is presented with various challenges including the management of emotional distress and the person then goes through three stages in managing the excessive rumination. At the Initial stage, the survivors learn to manage intrusive and automatic thoughts which they experience over time until they engage in “deliberate rumination” (Tedeschi & Calhoun, 2008; Hefferon & Boniwell, 2011). Next, in attempt to reduce emotional distress, they engage in self- disclosure while dealing with these thoughts. Finally, they begin disengaging from previous goals which results to changed narrative and schemas (Tedeschi & Calhoun, 2008). According to Tedeschi and Calhoun (2008), in addition to wisdom or preparedness, the person can achieve posttraumatic growth once these processes have been completed. University of Ghana http://ugspace.ug.edu.gh 18 Posttraumatic Growth among Breast Cancer Survivors in Ghana Model of Life Crisis and Personal Growth (Schaefer & Moos, 1992) This model posits that in the aftermath of trauma both personal and environment factors impact life crises. All the components in their model are linked by feedback loops, which have the potential to influence one another. Their model considers such individual characteristics as socio-demographic, socioeconomic, prior crisis experience and health status and environmental factors include social support (e.g. family, friends, and co-workers). Factors related to the event, including the timing of the event, duration, severity and whether the event affects an individual or group of people are also relevant to this model (Schaefer & Moos, 1992). Schaefer and Moos (1992) proposed that after experiencing traumatic events like breast cancer, there are three primary outcomes can result from it: increases in social resources (e.g., better relationships with members of the family and friends), increases in personal resources (e.g., self-understanding, cognitive differentiation, empathy, assertiveness, altruism and maturity); and the development and increase of coping skills (e.g., ability to think through problems, regulate affect and seek help when needed) (Schaefer & Moos, 1992). The coping style appears to play an important role in experiencing PTG, as well as positive and negative health outcomes in general (Schaefer & Moos, 1992). University of Ghana http://ugspace.ug.edu.gh 19 Posttraumatic Growth among Breast Cancer Survivors in Ghana Review of Related Studies Prevalence of Posttraumatic Growth in Chronic Diseases Studies on posttraumatic growth have been conducted on several populations in the health sector including people with chronic diseases such as diabetes and HIV ; other cancer populations such as survivors of stomach cancer, survivors of colorectal cancer , survivors of childhood cancers; survivors with mixed cancer diagnosis; breast cancer patients and Breast Cancer Survivors have noted that individuals experienced positive growth from their illness experience (Arpawong et al., 2013; Barthakur et al., 2016; Brix et al 2013; Danhauer et al., 2015; Danhauer et al., 2013; Dirik et al., 2016; Kolokotroni et al., 2014; Liu et al., 2014; McDonough et al., 2014; Mehrabi et al., 2015; Parikh et al., 2015; Ruini et al., 2013; Shand et al., 2015; Sim et al., 2015; Wang et al., 2014). However, different levels and domains of posttraumatic growth have been reported for different populations. For example, in a study by Romeo, Ghiggia, Tesio, Di Tella, Torta and Castelli (2017) with the aim of evaluating the level of PTG and its relationship with socio- demographic, clinical, and psychological variables in a sample of Italian BC survivor using a cross-sectional survey method, they found that a moderate positive psychological change after BC with the most changes in the “Appreciation of life” category and the least positive in “spiritual changes” were presented by the participants. In another study with the purposed of investigating the correlates and prevalence of PTG as well as the relationship between health-related quality of life and PTG among Korean stomach cancer survivors, Sim et al., (2015) in a cross-sectional study found that majority of the participants reported experiencing moderate to high levels of PTG. The authors reported that the most common domain of growth reported were “Change of self-perception”, followed by “new possibilities”, “spiritual change” and “relating to others”. University of Ghana http://ugspace.ug.edu.gh 20 Posttraumatic Growth among Breast Cancer Survivors in Ghana In a comparative study, Brix, Bidstrup, Christensen et al. (2013) also found that significantly higher PTG in the domains of “appreciation of life” and “relating to others” were experienced by women with breast cancer compared to BC-free women. Schroevers and Teo (2008) investigated the prevalence of posttraumatic growth in Malaysian cancer patients using a cross-sectional survey. They found that “appreciation of life” was the most reported domain of posttraumatic growth reported by many patients in Malaysia. In a qualitative study, Fallah, Keshmir, Kashani, Azargashb, and Akbari (2012) explored posttraumatic growth in Iranian breast cancer survivors. They found that overall posttraumatic growth occurred in the Iranian breast cancer survivors and these happened in three domains of their life which are “spiritual growth”, “appreciation of life”, and “increasing personal strength”. In another qualitative study, Mehrabi et al. (2015) investigated experiences of Iranian women Iranian women with breast cancer relating to PTG. Results show that “stability”, appreciate of life”, “effective interaction” and “spiritual prosperity” were the four prominent themes that came out of the participant's statements that demonstrated that the experiences of women with breast cancer in Iran induced psychological growth and maturity. Using a mixed method, Barthakur et al. (2016) conducted a study which aimed to understand from an Indian perspective the occurrence of PTG in women who have survived breast cancer. Results indicate that in varying forms, PTG was evident through changes in “a better understanding of self”, “perspective toward life”, “and richer spiritual dimension of life” and “closer/warmer relationships with others.” Findings from these studies cannot be generalized to Ghanaian women who have also survived breast cancer because these studies did not include or consider African or Ghanaian population. University of Ghana http://ugspace.ug.edu.gh 21 Posttraumatic Growth among Breast Cancer Survivors in Ghana In Ghana, there has been very limited studies that have focused on the psychosocial outcomes of breast cancer. For example, in a review of studies on breast cancer done in Ghana between 1956 and 2012 by Atobrah (2013) showed that 32.4% of cancer researches done in Ghana are done on breast cancer. In her review, she found that in Ghana, most of these researches have focused on the prevalence of breast cancer, the nature of the disease including the surgical material of the lump and the clinic-pathological features of the female breast, the biomedical treatments options, risks, presentation, diagnosis, and pattern and profiling of the disease. Very few studies had paid attention to the impact of psychosocial factors. Even these few studies that focused on psychosocial factors have been trying to answer the question about patients‟ non-compliance to treatment (late presentation and discontinuation of biomedical treatment) (Opoku, Benwell & Yarney, 2012). As a result, most of these studies have documented negative sequel of breast cancer such as fear, guilt, stigma, pain, financial challenges and much more. These psychosocial reactions are mostly influenced by their sociocultural norms, beliefs, and expectations of the breast cancer experience which then affects their health behavior (Atobrah, 2013). Studies in this reviewed work have totally failed to pay attention to the life after breast cancer and how patients who successfully go through the treatment are adjusting to their new life. Bonsu, Azito, and Clegg-Lamptey (2014) used a qualitative exploratory method to explore the psychological and emotional experiences of women in Ghana who live with advanced breast cancer in the Kumasi metropolis. Findings from this study reveal that in addition to the negative psychological outcomes such as Sadness, Fear, Anxiety, pain, loss of hope in marriage parenting that women with breast cancer face, the women showed a strong desire to live which was mainly influenced by their high reliance on religiosity as a meaning-making process which helps them to come into a state of acceptance and subsequently have a strong will to live. University of Ghana http://ugspace.ug.edu.gh 22 Posttraumatic Growth among Breast Cancer Survivors in Ghana In a recent study done by Boateng (in press) to assess the psychological distress and quality of life of women at various stages of breast cancer treatment journey in Ghana compared to their healthy controls, using both quantitative and qualitative method, she found that, generally the psychological distress is very high among breast cancer patients whereas their physical health, quality of life and psychological wellbeing were very poor compared to the control group. From the qualitative data, results indicate that in the midst of psychological distress mainly due to the breast cancer diagnosis and treatment those patients receive, women especially those in their later stage of the treatment reported to have hope and regain confidence that they will survive. Being religious about their cancer experience was identified as the main coping strategy which helps the women to deal with the distress from breast cancer and allows them to use other coping mechanisms. Though these two studies have reported some positive trends in the life of breast cancer patients undergoing treatment in Ghana, no study was found that has documented how patients who have successfully gone through the treatment are adjusting to life positively. Socio-demographic and Disease/Treatment Related Variables and Posttraumatic Growth Some socio-demographic variables have been observed to be associated with PTG in some studies done. Age, education, socioeconomic and marital status (Sim et al., 2015; Shand et al., 2015; Yi et al., 2015; Wang et al., 2014; Kolokotroni et al., 2014; Brix et al., 2013; Jansen et al., 2011). Some have also found weak correlations between demographic and PTG (Arpawong et al., 2013; Svetina et al., 2012). The time since diagnosis, the type of treatment and the stage of disease are some disease/treatment related factors that have been known by some researchers to have an University of Ghana http://ugspace.ug.edu.gh 23 Posttraumatic Growth among Breast Cancer Survivors in Ghana association with PTG (Brix et al., 2013; Dirik et al., 2016; Jansen et al., 2011; Kolokotroni et al., 2014; Tomich & Helgeson, 2012). The weak relationship has also been found concerning disease/treatment-related characteristics and PTG (Arpawong et al, 2013; Sim et al., 2015; Svetina et al., 2012). For example, as far as the relationships between the PTGI scores and socio- demographic variables are concerned, Romeo et al (2017) found that there was a significant negative correlation between Age and the “New possibilities” subscale scores and “Appreciation of life” subscales scores of PTGI. It was also reported that Years of education was not correlated with PTGI scores. In addition, a significant differences in the PTGI levels between patients who had a partner (married, cohabiting) and those who did not (single or separated) was found. Specifically, women with a partner presented significantly higher scores on “recognition of new possibilities”, “interpersonal relationships”, and “a greater appreciation of life” than patients without a partner. As for the clinical variables, Romeo et al. (2017) found that years since diagnosis significantly positively correlated with the “Personal strength” and “Appreciation of life” subscale scores. In addition, women with malignant breast cancer showed a significantly greater “appreciation of life” than women with benign cancer. Women who underwent Chemotherapy Therapy showed higher levels of PTG compared to women who underwent Hormone Therapy. Rahmani et al. (2012) adopted descriptive-correlational design to examine the level together with the determinants of posttraumatic growth in cancer patients in Iran. Outcomes indicated that a significant association was observed between age, educational level and radiotherapy treatment history and experience of posttraumatic growth. In a study to determine the level of PTG, Wang, Liu, Wang, Chen and Li (2014) used a descriptive research design to identify associated socio-demographic and clinical factors among University of Ghana http://ugspace.ug.edu.gh 24 Posttraumatic Growth among Breast Cancer Survivors in Ghana breast cancer survivors in China. Results showed an average PTGI-SC score among Chinese breast cancer survivors. This is an indication that PTG is present in breast cancer survivors in China. It was found that educational level and household income have positive influence on PTG. PTG was highest for survivors who were retired, those who were working had moderate PTG, and PTG was lowest for women on sick leave. Also, Survivors with comorbid chronic diseases had lower PTG. Sim et al. (2015) found that among Korean stomach cancer survivors, Age, Socioeconomic status and Religion were associated with PTG. Cormio et al. (2017) found that higher PTGI average score was observed for long-term disease-free cancer survivors in Italy who were more educated, employed and with longer time from diagnosis as well as those with no comorbidities. Brix et al. (2013) also found that Age was negatively associated with overall PTG and time since the surgery was positively related with overall PTG. They also found that the size of the tumor was associated positively with overall PTG and the domains of “personal strength”, “appreciation of life” and “relating to others”. Also, associated positively with overall PTG was the number of positive lymph nodes which impacted the domains of “spiritual change” and “relating to others”. Compared to patients who had undergone lumpectomy, having undergone mastectomy was positively associated with overall PTG and with the domains of “personal strength” and “relating to others”. Again, positively associated with the domain of “appreciation of life” was going through endocrine treatment. This implies that the development of PTG is influenced by the severity of disease. Tanyi, Szluha, Nemes, Kovács, and Bugán (2015) used cross-sectional study to examine how cancer-related factors and sociodemographic predict PTG following a cancer diagnosis among breast or prostate cancer patients immediately before undergoing radiotherapy. Results show that University of Ghana http://ugspace.ug.edu.gh 25 Posttraumatic Growth among Breast Cancer Survivors in Ghana younger age significantly predicted PTG total score and “New Possibilities” subscale score. Also, subjective severity of cancer was associated positively with the PTG total score and subscales scores on the “Appreciation of Life” and “New Possibilities” domains. The authors, therefore, concluded that sociodemographic and cancer-related variables may contribute significantly to growth. Sim et al. (2015) found no relationship between disease-related variable and PTG among Korean stomach cancer survivors. Svetina and Nastran (2012) found a weak relationship between demographic and illness-related variables and PTG among breast cancer patients in Croatia. Lelorain et al. (2010) also found that demographic and medical variables poorly predict PTG. Psychosocial factors and Posttraumatic Growth Coping and Posttraumatic Growth Pat-Horenczyk, Perry, Hamama-Raz, Ziv, Schramm-Yavin, and Stemmer (2015) conducted a case-control study on breast cancer survivors to investigate the impact a building-resilience intervention has on coping and posttraumatic growth (PTG). Results from this study show that, more than half of the participants reported increased PTG at 6 months. The participants in the intervention group reported increase in both positive coping and PTG which was significantly greater than what the control group reported. Additionally, as compared to those in the control group, participants in the intervention group reported higher proportion of PTG. Therefore, they concluded that interventions should not center on only building cancer survivor‟s PTG but along with building their coping skills. Reviews and studies by (Park et al., 2016; Dirik et al., 2016; Shand et al., 2015; Danhauer et al., 2015; Kolokotroni, et al., 2014; Brix et al 2013; Danhauer et al., 2013; Svetina et al., 2012; Koutrouli et al., 2012; Schmidt et al., 2012) showed a positive University of Ghana http://ugspace.ug.edu.gh 26 Posttraumatic Growth among Breast Cancer Survivors in Ghana association between Coping and PTG. For instance, Schroevers and Teo (2008) in a cross- sectional study using the PTGI and Brief Cope found that among Malaysian cancer survivors, the coping strategies that were associated with more posttraumatic growth were humor, instrumental support and positive reframing. In another cross-sectional study to assess the role of coping and goal reengagement on posttraumatic growth, Schroevers, Kraaij and Garnefski (2011) investigated how positive and negative changes are related and how they are associated with positive and negative affect. Findings from this study indicate that variables associated with more positive changes were the patient‟s use of approach coping (goal reengagement and positive reappraisal) whereas use of avoidant coping (self-distraction) was associated with more negative changes. Oginska-Bulik and Kobylarczyk (2015) also performed a study in a group of paramedics with the purpose of investigating the mediating role of coping strategies for stress in the relationship between resilience and post-traumatic growth. Denial and Venting of negative emotions appeared as suppressors in the analyses of the relationship, while planning plays mediating role between resilience and post-traumatic growth. The authors concluded that in the process of post- traumatic growth, both problem-focused strategies and avoidance are important. Büyükaşik-Çolak, Gündoğdu-Aktürk and Bozo (2012) performed a study to examine the relationship between posttraumatic growth and dispositional optimism and also assess whether coping strategies mediated this relationship in postoperative breast cancer patients. Results revealed that problem-focused coping fully mediated the relationship between dispositional posttraumatic growth and optimism, but emotion-focused coping could not mediate the relationship between optimism and PTG. Thus, postoperative breast cancer patients who were University of Ghana http://ugspace.ug.edu.gh 27 Posttraumatic Growth among Breast Cancer Survivors in Ghana more likely to use problem-focused coping strategies and were optimistic led to the development of posttraumatic growth. In another study, Turner-Sack et al. (2012) examined associations between coping strategies, posttraumatic growth and psychological distress in adolescent survivors of cancer. Results showed less use of avoidant coping strategies and younger age at diagnosis predicted higher levels of posttraumatic growth. Also, the use of more acceptance coping strategies and adolescents' beliefs that they were more likely to relapse predicted higher levels of posttraumatic growth. Yeung et al. (2016) did a study which was aimed to apply the stress and coping model and the self-determination theory to further understand the psychological factors (including basic psychological needs satisfaction and coping variables) that promote PTG in a sample of 454 college students who are an ethnically diverse. Results show that after controlling for gender, the level of current distress due to the most traumatic event and the number of types of traumatic events the satisfaction of relatedness need, challenge appraisal, emotional expression, positive reframing and acceptance were associated with higher PTG. Lelorain et al. (2010) estimated the prevalence and predictors of PTG after breast cancer and how it relates with psychological health among women who are disease-free 5-15 years after diagnosis. They found that, the variables: “active coping, dispositional positive affectivity and adaptative coping, religious coping, relational coping and to some extent denial coping” have an influence on PTG. Optimism and Posttraumatic Growth Optimism has been known to be positively related to PTG (Arpawong et al., 2013; Büyükaşik- Colak et al., 2012; Dirik et al., 2016; Kolokotroni et al., 2014; Koutrouli et al., 2012; Park et al., University of Ghana http://ugspace.ug.edu.gh 28 Posttraumatic Growth among Breast Cancer Survivors in Ghana 2016; Shand et al., 2015; Yi et al., 2015). For example, Ho et al. (2011) conducted a cross- sectional study to investigate the association of Optimism, the positive Coping Strategies and Hope on PTG in oral cavity cancer patients in China, where they found that Optimism and Hope have significant positive correlation with PTG and accounted for 25% variance of Posttraumatic Growth. Married patients showed high levels of PTG when compared to unmarried patients. Social Support and Posttraumatic Growth Some reviews and studies have shown that, social support was positively related to PTG (Danhauer et al., 2015; Danhauer et al., 2013; Dirik et al., 2016; Kolokotroni et al., 2014; Koutrouli et al., 2012; McDonough et al., 2014; Park et al., 2016; Shand et al.,2015; Svetina et al., 2012; Yi et al., 2015). For example, Schroevers, Helgeson, Sanderman and Ranchor (2010), in a longitudinal study examined the relationship between emotional support after diagnosis of cancer and the experience of posttraumatic growth, at 8 years after diagnosis of cancer in a study which centered on three distinct types of emotional support: actually received support, dissatisfaction with emotional support received and perceived availability of support. Characterized by problem-solving comforting and reassuring, the findings suggest that getting support from friends and family in the period following diagnosis help cancer survivors to find positive meaning in the cancer experience (Schroevers et al, 2010). In other to examine the role perceived social support play in enhancing PTG in cancer patients Tanriverd et al. (2012) used a cross-sectional study which involved 105 cancer patients. Relatively high levels of PTG and social support were reported by participants. Variables that were significantly positively associated with the development of PTG among cancer patients include total perceived social support, support from family, and friends. University of Ghana http://ugspace.ug.edu.gh 29 Posttraumatic Growth among Breast Cancer Survivors in Ghana In a cross-sectional study performed Zhou et al. (2017) which aimed to increase our understanding the relationship between PTSD and PTG by examining simultaneously the role of social support and emotion regulation in PTSD and PTG among Ya'an earthquake survivors who were adolescents. Results indicate that Social support had a significant direct association with PTG and a positive indirect prediction on PTG through cognitive reappraisal. Baglama and Atak (2015) conducted a cross-sectional survey to examine the relationship between locus of control, social support, dispositional hope and posttraumatic growth among breast cancer postoperative patients in North Cyprus. Results from this study showed a significant positive relationship between social support and posttraumatic growth. Cormio et al. (2017) in a cross-sectional study assessed the existence of PTG in long-term disease-free cancer survivors in Italy. They also explore the association between the dimensions of PTG and demographic variables, clinical, various agents of perceived social support and psychological distress. In their findings, it was indicated that PTG was not found to be correlated with distress, nonetheless it correlated with perceived social support. However, another study by Hill and Watkins (2017) which used a cross-sectional survey to examine the role of social support and rumination in psychological distress, psychological well- being and posttraumatic growth among women with ovarian cancer in USA found that social support did not predict PTG. However, Social support positively correlated with the “Relating to Others” domain of PTG. Cognitive Processing and Posttraumatic Growth Some studies have identified a positive relationship between cognitive processing and PTG (Bussell et al., 2010; Chan et al., 2011; Cohen & Numa, 2011; Gall et al., 2011; Kolokotroni et University of Ghana http://ugspace.ug.edu.gh 30 Posttraumatic Growth among Breast Cancer Survivors in Ghana al., 2014). For example, Cohen and Numa (2011) performed a study to assess the relationship between PTG and emotional expressing, emotional and cognitive processing, and social support in volunteer and non-volunteer breast cancer survivors. Relatively, participants in both groups reported similar high levels of PTG. The study variables accounted for 31% of PTG variance, with cognitive and emotional processing being significant predictors. Gangstad, Norman, and Barton (2009) examined whether PTG is associated with psychological distress and cognitive processing in stroke patients. They also explored whether the time since stroke moderate relationships between these variables. Findings indicate that four indicators of cognitive processing (i.e., positive cognitive restructuring, downward comparison, resolution, and denial) correlated positively with PTG and negatively with depression. therefore, they concluded that PTG is possible after stroke and cognitive processing plays an important role in this process for promoting such growth Religiosity/ Spirituality and Posttraumatic growth Religiosity or spirituality have been known to be positively related to PTG among non-western cultures such as India and China (Danhauer et al., 2013; Park et al., 2016; Shand et al., 2015). For example, Bellizzi et al. (2010) in a comparative study examined the relationship between religiosity, race and PTG. They also assessed the association between PTG and health-related quality of life in African American and White breast cancer survivors. Results revealed that higher levels of PTG were reported by African American breast cancer survivors compared to White women. Findings also show that the relationship between one‟s ethnicity and posttraumatic growth was mediated by religiosity. Again, Gesselman, et al. (2016) conducted a study which intended to assess how emotional distress, spirituality and PTG are associated for University of Ghana http://ugspace.ug.edu.gh 31 Posttraumatic Growth among Breast Cancer Survivors in Ghana BCS and their partners. They found that greater levels of spirituality were associated with increases in PTG for BC survivors and their partners. They also found no association between BCS and partner spirituality and emotional distress. They therefore concluded that spirituality is associated with growth in BCS and their partners following diagnosis and treatment of breast cancer. Ai et al. (2013) used a cross-sectional survey method to explore the impact preoperative religious coping has on long-term postoperative personal growth as well as its potential mediators in this effect in patients undergoing cardiac surgery. Positive religious coping and a living status without a partner predicted PTG. Results further showed that social support, optimistic expectations, other religious factors and Medical indices were unrelated to PTG. they also found that, spiritual support mediates the role of positive religious coping and PTG. These results suggest that after surviving a life-altering operation, spirituality may play an important role in cardiac patients' PTG. Other studies considering more than two psychosocial variables and Posttraumatic Growth In a recent study which aimed to explore PTG level and how it‟s related to spirituality, social support and coping strategies among Polish rheumatoid arthritis patients, Rzeszutek et al. (2017) found that spirituality; coping strategies such as acceptance and return to religion and need for social support were significantly related to PTG levels among the participants. Kim (2017) conducted a research aimed to test the variables of PTG based on an existing theoretical model of PTG in mothers of children with cancer. The variables of optimism, disruption of core beliefs, social support, and deliberate rumination accounted for 41.4% of the variance in the mothers' PTG. Social support and deliberate rumination are important factors directly affecting PTG. University of Ghana http://ugspace.ug.edu.gh 32 Posttraumatic Growth among Breast Cancer Survivors in Ghana Park et al. (2016) did a study to identify the level of PTG and its correlates in patients with breast cancer in Korea. Findings show that a total score for the PTG was moderate in patients surviving breast cancer and this score was positively associated with having a religion, greater optimism, perceived social support, illness intrusiveness and cancer coping. Regression analysis showed that illness intrusiveness, cancer coping and optimism were statistically significant in patients' PTG. A systematic review of studies by Casellas-Grau et al. (2016) show that being young, undergoing chemotherapy, and having social support were the sociodemographic, medical, and psychosocial characteristics associated with PTG. The findings further indicted that positive dispositional characteristics like optimism, socioeconomic status like level of education, the women's coping styles and the culture of the different samples were also associated with positive psychological functioning. In conclusion, they proposed that patient‟s perceived impact of breast cancer and their perceived support from significant others, can result in better functioning in women with breast cancer (Casellas-Grau, et al., 2016). Koutrouli et al. (2016) through a cross-sectional study examined the levels of posttraumatic growth by exploring the relationships between medical, demographic, psychosocial variables and posttraumatic growth. The study also assessed the role social constraints plays in the relationship between automatic and deliberate cognitive processing of the trauma. The results showed that age at diagnosis and psychological distress was inversely associated with PTG while time since diagnosis was directly associated with PTG and indirectly associated with intrusions and psychological distress, through reflective rumination. Also, the relationship between intrusions and reflective rumination was moderated by Social constraints in the PTG process. University of Ghana http://ugspace.ug.edu.gh 33 Posttraumatic Growth among Breast Cancer Survivors in Ghana Danhauer, Case, Tedeschi, Russell et al., (2013) used a longitudinal study to examined change in PTG over 2 years following breast cancer diagnosis. They also examined the role of multiple variables (sociodemographic, cancer-related, and psychosocial) associated with a change in PTG using Linear mixed effects models. Results indicate that mostly within the first few months following diagnosis, the total PTGI score had increased over time. Longer time since diagnosis, education level, and increases in social support greater baseline level of illness intrusiveness, spirituality, mental health and use of active-adaptive coping strategies were associated with greater PTGI in the longitudinal model. Lelorain et al., (2012) explored how women who have survived cancer between 5- to 15-year integrate PTG in their overall cancer experience in a qualitative method (28 open interviews concerning changes). The analysis of results revealed women with high coping and social support and active cognitive processing reported statements which was specific to one thematic class of PTG. Kolokotroni et al. (2014) reviewed quantitative studies concerning how PTG is associated with psychosocial factors in patients with breast cancer. They found that perceived the threat of the disease, Personality traits such as optimism and openness, cognitive processing of cancer like the use of deliberate rumination, social support, coping strategies such as problem-focused were identified to be related to PTG in women with breast cancer. Demographic characteristics such as age at cancer diagnosis were also found to play a key significant role in PTG. Gaps and Rationale for the Study Though several studies on PTG in Cancer survivors have been done among Breast Cancer patients and survivors and with different methods, varying and inconsistent results have been reported. Moreover, most studies on PTG in Cancer survivors have been conducted in western University of Ghana http://ugspace.ug.edu.gh 34 Posttraumatic Growth among Breast Cancer Survivors in Ghana countries. Studies that explored posttraumatic experiences in breast cancer survivors within the Ghanaian context were extremely rare. It is well known fact that attitudes towards cancer differ between Western Cultures and African Cultures as well as their adjustment to the cancer and therefore factors that predict PTG in Ghanaians may also differ. Most studies on breast cancer in Ghana have focused primarily on the epidemiological trends (Boyle, 2012; Ohene-Yeboah & Adjei, 2012); awareness and its screening policies (Clegg-Lamptey & Hodasi, 2007; Opoku, Benwell & Yarney, 2007); genetic correlates of kinds of breast cancer and its prognosis (Owiredu et al., 2009; Stark et al., 2010); medical treatments and ways of improving on it (Clegg-Lamptey, Dakubo & Attobra, 2009); quality of life issues; well-being and help-seeking behaviors (Clegg-Lamptey et al., 2009). The majority of these studies on Breast Cancer in Ghana have neglected Survivors and more especially their positive experiences (Attobra, 2013). Statement of Hypotheses The present study seeks to test the following hypotheses. Hypothesis 1: Demographic variables will be associated with Posttraumatic Growth A. Age will be negatively associated with Posttraumatic Growth B. Years of survival will be positively associated with Posttraumatic Growth C. Women‟s marital status will be positively associated with their level of Posttraumatic Growth Hypothesis 2: Disease/Treatment variables will be associated with Posttraumatic Growth A. Type of Breast Cancer will be positively associated with Posttraumatic Growth D. The Stage of Breast Cancer will be associated with Posttraumatic Growth E. Type of treatment will be associated with Posttraumatic Growth University of Ghana http://ugspace.ug.edu.gh 35 Posttraumatic Growth among Breast Cancer Survivors in Ghana Hypothesis 3: After controlling for demographic and disease/treatment factors, psychosocial variables will predict PTG. i. Religiosity will predict Posttraumatic Growth ii. Cognitive processing will predict Posttraumatic Growth iii. Optimism will predict Posttraumatic Growth iv. Social support will predict Posttraumatic Growth v. Coping will predict Posttraumatic Growth Conceptual Framework The model below represents the relationships that were predicted for testing in this study. First of all, some demographic variable (Age, Years of survival, Marital status, type of breast cancer, Stage of breast cancer, Type of treatment) was perceived to have a positive association with PTG. Secondly, Psychosocial variables (Religiosity, Cognitive Processing, Optimism, Coping and Social support) were also expected to positively predict PTG. University of Ghana http://ugspace.ug.edu.gh 36 Posttraumatic Growth among Breast Cancer Survivors in Ghana Demographic and Disease variables Age, Years of survival, Marital status, type of breast cancer, Stage of breast cancer, Type of treatment R eligiosity H3a HI & H2 Cognitive Processing H3b Posttraumatic Optimism H3c Growth H3d Coping Social H3e Support Figure 1 Conceptual Model Showing the Relationship between the Study Variables. University of Ghana http://ugspace.ug.edu.gh 37 Posttraumatic Growth among Breast Cancer Survivors in Ghana CHAPTER 3 METHODOLOGY This chapter discusses the process of data collection in terms of the research setting/population, sample and sampling technique, the design, measures as well as the procedures involved in the data collection process. This section discusses the steps that were taken in gathering evidence to test the stated hypotheses. Study Design Since the study sought to obtain self-report information about breast cancer survivors‟ opinions concerning their post cancer experiences, the most appropriate design for this study is the cross- sectional survey. According to Rubin (2005), the cross-sectional survey is a type of research design that enables the researcher to collect a large amount of data across a wide range of people in a relatively short time using standardized questionnaires (Rubin, 2005). Cross-sectional surveys are used to gather information on a population at a single point in time. The advantages of using this method are that it is an efficient way of collecting information from a large number of respondents, less expensive, relatively easy to administer, permits anonymity and may result in more honest responses (Rubin, 2005). Population The population for this study was breast cancer survivors in Ghana (women who have been diagnosed and treated for breast cancer). Participants were selected from the OPDs of Peace and Love Hospital in both Accra and Kumasi. These settings were chosen because it is one of the private centers known for providing comprehensive breast cancer care. In addition, Peace and University of Ghana http://ugspace.ug.edu.gh 38 Posttraumatic Growth among Breast Cancer Survivors in Ghana Love Hospital in Kumasi has a well-structured and organized support group for breast cancer survivors which is called Peace and Love Survivors Association (PALSA). PALSA was established in 2013 and it has a membership of more than 500 members. For convenience, participants were selected from members of this group who came for a check-up at Peace and Love Hospital the study. Participants who were included in this study met the following criteria:  Must be 18 years and above  Was diagnosed with breast cancer  At least 6 months after chemotherapy courses and surgery have been done.  Be willing to participate voluntarily Exclusion Criteria  Males  women currently in active treatment (undergoing chemotherapy or surgery) Sampling and Sample Size The sample size for this study was a total of 105 breast cancer survivors who met the inclusion criteria. This sample size selection was based on the minimum sample size determination offered by Tabachnick and Fidell (2013; N > 50 + 8m where m=number of variables) for regression analysis. Therefore, a study with 6 variables will need a minimum sample of 98 participants. Hence, a sample size of 105 was adequate for this study. In selecting the actual sample for the study, different sampling techniques were used. Initially, the researcher adopted the purposive sampling technique to identify the participants who met the inclusion criteria. Purposive sampling technique helps in identifying the specific individuals that bare the most relevant data considering the topic of a study (Yin, 2011). Convenient sampling University of Ghana http://ugspace.ug.edu.gh 39 Posttraumatic Growth among Breast Cancer Survivors in Ghana technique was used for selecting the participants for the study (i.e., survivors who were available at the OPD as at the time of data collection and consented to be part of the study). Measures/Instruments Sociodemographic and Disease/Treatment Characteristics Self-report questionnaires were used to obtain Sociodemographic information such (e.g. age, marital status, level of education, years of survival) (see Appendix 1, section A). Disease and treatment information (e.g. disease type and severity, type of treatment etc.) were obtained from medical charts using a checklist (see Appendix 2). Posttraumatic Growth Inventory (PTGI). The Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996) was used to assess Posttraumatic Growth. The PTGI is a 21-item self-report measure assessing five separate domains of posttraumatic growth: “New Possibilities” (5items, sample item: “I established a new path for my life”), “Relating to Others” (7items, sample item, “Putting effort into my relationships”), “Personal Strengths” (4items, sample item, “I discovered that I am stronger than I thought I was”), “Spiritual Change” (2items, sample item, “A better understanding of spiritual matters”), and “Appreciation of Life” (3items, sample item, “Appreciating each day”). Respondents were asked to indicate the degree to which they have experienced positive changes in their lives following the breast cancer diagnosis. The items were rated on a 6-point Likert-type scale ranging from 1 (not at all) to 6 (a very great degree), with higher scores indicating higher growth. A total PTGI was used as a measure of PTG. The highest score that one can obtain on PTGI is 126 and the least score one can obtain is 21. Scores from 21- 83 indicate low levels of growth, 84-104 indicate moderate levels of growth and scores from 105- 126 indicate higher University of Ghana http://ugspace.ug.edu.gh 40 Posttraumatic Growth among Breast Cancer Survivors in Ghana levels of growth. Internal consistency reliability (Cronbach‟s alpha) ranged from .90 to .95 for the total scale (Brunet, McDonough, Hadd, Crocker & Sabiston, 2010; Tedeschi & Calhoun, 1996). Test–retest reliability for PTGI has been reported as r =.71 (Tedeschi & Calhoun, 1996) (see Appendix 1, Section B). Cognitive Processing of Trauma Scale (CPOTS) Cognitive processing was measured with Cognitive Processing of Trauma Scale (Williams et al., 2002). The Cognitive Processing of Trauma Scale (CPOTS) measures five aspects of cognitive processing: “Positive Cognitive Restructuring”, “Downward Comparison”, “Resolution”, “Denial”, and “Regrets” (Williams et al., 2002). The scale consists of the 17-item test in which statements are rated on a 7 point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). The scale was scored and a total score of the scale was used. Scores ranged from 17 to 119. A higher score indicates higher Cognitive Processing. The entire scale has a Cronbach‟s alpha of .80 to .85 (Williams et al., 2002) (see Appendix 1, Section C). Life Orientation Test- Revised (LOT-R) The Life Orientation Test-Revised (LOT-R) by Scheier, Carver, and Bridges (1994) was used as a self-report measure of Optimism. It is comprised 10 items measuring Optimism versus Pessimism: 3 items for Optimism, 3 items for Pessimism, and 4 filler items. Each item is rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Items 3, 7, and 9 are reverse scored. Items 2, 5, 6, and 8 are fillers and are not to be scored. Scoring is kept continuous. The total scores of the LOT range from 6 to 30 with higher scores indicating higher levels of Optimism. Internal consistency of the LOT has been reported to be acceptable with α = .85 (Scheier et al., 1994) (see Appendix 1, Section D). University of Ghana http://ugspace.ug.edu.gh 41 Posttraumatic Growth among Breast Cancer Survivors in Ghana Santa Clara Strength of Religious Faith Questionnaire The Santa Clara Strength of Religious Faith Questionnaire assesses a person‟s strength and dedication to his/her spiritual conviction, irrespective of his/her religion (Plante & Boccaccini, 1997). It is suitable for individuals from diverse religious traditions since it is not restricted to a particular religion including no religious tradition. Respondents were asked to reply to 10 items regarding the extent to which they respect, depend and are dynamically drawn to their faith. The response format is a four-point Likert scale varying from 1 (Strongly Disagree) to 4 (Strongly Agree). Examples of items on the scale are: "I pray every day" and "My faith influences several of my choices." The scale has internal reliability (Cronbach Alpha = .94 - .97) (Plante & Boccaccini, 1997) (see Appendix 1, Section E). The Brief COPE The Brief COPE (Carver, 1997) was used to assess the participants‟ coping strategies. The Brief COPE is a 28-item self-report measure which is a measure of both maladaptive and adaptive coping skills. Participants rate their degree of use of these strategies on a 4-point scale ranging from 1 (not at all) to 4 (doing a lot). This tool has been developed to assess 14 different ways people respond to stress which is: “Self-distraction” (e.g. “taking mind off things”); “Active Coping” (e.g. “concentrating efforts on doing something”); “Denial”; “Substance Abuse” (“including prescriptive medications for mood disorders”); “use of Emotional Support”; “use of Instrumental Support” ( e.g. “getting advice from others”); “Behavioral Disengagement” (e.g. “giving up”); “Venting”; “Positive Reframing” ; “Planning” (e.g. “coming up with a strategy”); “Humor”; “Acceptance”; “Religion”; and “Self-blame” (Carver, 1997). Every dimension has two items. A score that ranges from 28 to 56 means the least use of psychological coping; 57 to 84 University of Ghana http://ugspace.ug.edu.gh 42 Posttraumatic Growth among Breast Cancer Survivors in Ghana means the moderate use of psychological coping and 85 to 112 means greater use of psychological coping. The internal consistencies for the fourteen domains range between .54 and .90 (Carver, 1997) (see Appendix 1, Section F). The Multidimensional Scale of Perceived Social Support [MDSPSS] The Multidimensional Scale of Perceived Social Support [MDSPSS] (Zimet et al., 1988) was used to measure Social support. The MDSPSS measures perceived sufficiency of support from three different sources: family, friends, and significant other. The MDSPSS consists of 12 items with 7-point Likert-type scales ranging from “very strongly disagree” to “very strongly agree”. Four items are dedicated to measuring perceived social support from a particular source and the MSPSS measures the adequacy of support from three sources: family (items 3, 4, 8, 11), friends (items 6, 7, 9, 12) and significant other (item 1, 2, 5, 10). The scale is self-administered and a score of 69 to 84 is indicative of high social support, 49 to 68 indicate moderate social support and 12 to 48 indicates low social support. Reliability coefficient alphas for the scale and the subscales range from .85 to .91 (see Appendix 1, Section G). Pilot Study Reliability Analysis of Scales One of the assumptions considered in this study has to do with reliability of the measures used in data collection. Reliability of a measure is defined as the stability or consistency of the measure (Gravetter, 2006). According to Gravetter, (2006) when the same people are measured at the same or similar conditions, a reliable measure should produce the same or similar results. A pilot study was conducted prior to the main study to determine the reliability of the scales employed in the study. This pilot study was conducted by administering the scales to 20 breast University of Ghana http://ugspace.ug.edu.gh 43 Posttraumatic Growth among Breast Cancer Survivors in Ghana cancer survivors receiving an out-patient care at the Peace and Love Hospital. In this study, the internal consistency (Cronbach‟s Alpha) was used to assess the reliability of the scales and subscale and results are presented in Table 1 below. Table 1: Internal Consistencies of the Scales SCALE Cronbach Alpha (α) Posttraumatic Growth Inventory (PTGI) .90 Subscales of PTGI Appreciation of Life .71 Spiritual Change .52 Personal Strength .79 New Possibilities .57 Relating to Others .75 Cognitive Processing of Trauma Scale (CPOTS) .74 Subscales of CPOTS Denial .50 Positive Cognitive Reconstruction .84 Resolution .62 Regret .55 Downward Comparison .66 Life Orientation Test-Revised (LOT-R) .89 Santa Clara Strength of Religiosity Questionnaire .91 Brief COPE .98 Subscales of Brief COPE Self-Distraction .95 Active Coping .92 Denial .89 Substance Use .80 Emotional Support .84 Instrumental Support .87 Behavior Disengagement .84 Venting .77 Positive Reframing .74 Planning .75 Humor .72 Acceptance .88 Religion .85 Self-Blame .74 Multidimensional Scale of Perceived Social Support (MSPSS) .87 N= 20 University of Ghana http://ugspace.ug.edu.gh 44 Posttraumatic Growth among Breast Cancer Survivors in Ghana From Table 1 above, the overall Posttraumatic Growth Inventory (PTGI) has a Cronbach alpha value of .90 and the Cronbach alphas of the subscales range from .52 to.79. Apart from Spiritual Change and New Possibility subdomain of the PTGI which yielded relatively lower Cronbach alphas (.52 and .57 respectively), all the other scales were higher. The overall Cognitive Processing of Trauma Scale (CPOTS) has a Cronbach alpha value of .74 and the Cronbach alpha of its subscales range from .50 to .84. Most of the subscales yielded high Cronbach alphas except for Denial and Regret subscales which yielded lower Cronbach alphas (.50 and .55 respectively). The overall Life Orientation Test has a Cronbach alpha value of .89. The Santa Clara Strength of Religiosity Questionnaire has a Cronbach alpha value of .91. The overall Brief Cope has a Cronbach alpha value of .98 and the Cronbach alpha of the subscales range from .72 to .95. The overall Multidimensional Scale of Perceived Social Support has a Cronbach alpha value of .87. These alphas are appropriate as described by Nunnally (1978). This indicated that most of the instruments in the study were reliable to be used. Therefore, no revision was made to the items on the scales. Procedure Ethical clearance was obtained from the Ethics Committee for Humanities (ECH), University of Ghana, Legon. After the approval was granted by ECH, an introductory letter was acquired from the Department of Psychology of the University of Ghana. The letter of introduction from the Department of Psychology, a copy of Research Proposal and the Ethical clearance certificates were sent to the management of Peace and Love Hospital for permission to conduct the study in the facility. After the permission was granted at Peace and Love Hospitals, a date was fixed for University of Ghana http://ugspace.ug.edu.gh 45 Posttraumatic Growth among Breast Cancer Survivors in Ghana the commencement of the data collection. Two research assistants were recruited for the data collection and were given training on the administration of the questionnaires. The out- patient‟s departments of the hospitals were used for the data collection. On the days of the data collection, the researchers were introduced to the patients waiting to see their doctors. The participants who meet the inclusion criteria were identified and the researcher and the two assistants engaged the patients individually. Details of the study were thoroughly explained in writing and orally by either the researcher or the research assistants to the participants and those who were willing to partake were giving an informed consent form to either sign or thumbprint. After obtaining consent from the participants, the questionnaires were given to the participants to fill. The respondents who could read and write were administered the questionnaires in a pen-and-paper form. Those who could not read and write were interviewed by following the questions on the questionnaires. During the data collection, those who could not finish were given the chance to go and their questionnaires were not included in the analysis. The data collection lasted for 4 weeks. The completed questionnaires were then sorted out for analysis. Ethical Consideration Research using human participants requires high ethical standards. Hence an ethical clearance was sought from the Ethical Committee for Humanities of the University of Ghana. The nature and purpose of the study were well explained to participants who were approached for the study and those who agreed to participate were given the informed consent form to sign before taking part in the study. University of Ghana http://ugspace.ug.edu.gh 46 Posttraumatic Growth among Breast Cancer Survivors in Ghana Again, they were made aware of the voluntary nature of the study, their right to withdraw at any point in time without explanation or penalty and were also assured of privacy and confidentiality. After the study, the researcher also addressed any other concerns that participants had about the study in the form of debriefing. University of Ghana http://ugspace.ug.edu.gh 47 Posttraumatic Growth among Breast Cancer Survivors in Ghana CHAPTER 4 RESULTS This chapter presents the results of the analyses of the data by summarizing the key findings in appropriate tables. The SPSS version 22 was used in analyzing the data and series of statistical tests were used including descriptive statistics to summarize the data. The main inferential statistical tests that were used to analyze each hypothesis are discussed with reasons. The discussion of the tests is followed by detailed presentations of Tables with their interpretations. The key findings are summarized below. Preliminary Analysis Descriptive Statistics of the Variables The characteristics of the respondents in the study are summarized in Table 2 below: Table 2: Demographic Characteristics of the Participants in the Study N = 150 % Variable Minimum Maximum M SD Age 28 78 52.93 10.39 Years of Survival 6 months 14 years 5.01 3.30 Marital Status Single 8 7.6 Married 46 43.8 Divorced 29 27.6 Widow 22 21.0 Educational Level No School 16 15.2 Primary/JHS 42 40.0 Secondary/Vocational 18 17.1 Tertiary 29 27.6 University of Ghana http://ugspace.ug.edu.gh 48 Posttraumatic Growth among Breast Cancer Survivors in Ghana Continuation of Table 2: Demographic Characteristics of the Participants in the study Variable N = 150 % Employment Status Not employed 31 29.5 Employed Full-time 21 20.0 Employed Part-Time 3 2.9 Self-Employed 50 47.6 Religion Christianity 90 85.7 Islam 13 12.4 No Religion 2 1.9 Type of Breast Cancer Unknown 6 5.7 Ductal Carcinoma In Situ 12 11.4 Invasive Ductal Carcinoma 75 71.4 Mucinous Carcinoma of the Breast 5 4.8 Invasive Lobular Carcinoma 3 2.9 Recurrent & Metastatic Breast Cancer 4 3.8 Stage of Breast Cancer Unknown 9 8.6 Stage I 25 23.8 Stage II 40 38.1 Stage III 27 25.7 Stage IV 4 3.8 Type of Surgery Lumpectomy 26 24.8 Mastectomy 79 75.2 Chemotherapy Yes 105 100.0 Radiotherapy No 29 27.6 Yes 76 72.4 Hormone Therapy No 6 5.7 Yes 99 94.3 Summarized descriptive results are presented in Table 2. The respondents‟ age ranges from 28 to 78 years (M= 52.93, SD = 10.39). The Years of survival of the respondents range from 6 months to 14 years (M = 5.0, SD = 3.30). In terms of their marital status, 46 (43.8%) of the women were University of Ghana http://ugspace.ug.edu.gh 49 Posttraumatic Growth among Breast Cancer Survivors in Ghana married. For the level of education, 42 (40%) of the participants were primary/JHS leavers. 50 (47.6%) were self-employed and 90 (85.7%) of the participants were Christians. For the Disease/Treatment factors, 75 (71.4%) of participants were diagnosed with Invasive Ductal Carcinoma and 40 (38.1%) of the respondents were diagnosed with Stage II breast cancer. For the type of surgery done, 79 respondents underwent Mastectomy. All the respondents had gone through Chemotherapy and 72.4% had gone through Radiotherapy while 94.3% of them were undergoing Hormone Therapy. Validation of Scales All the scales measuring the study variables were validated in order to ensure that, they could actually measure what they are supposed to measure. The Exploratory Factor Analysis (EFA) was done with the aim of verifying whether the foreign measures are able measure the same constructs in the African setting. With this methodology, the individual items on the scales were analyzed in relation to the subthemes to establish the amount of variance that each component of the scale is able to account for in the overall variations. The EFA helped to ascertain whether the items of the corresponding scales would yield factor loadings that could be considered to be part of a single construct (Field, 2009). Exploratory Factor Analysis of the Posttraumatic Growth Inventory An EFA was performed on the PTGI items using Principal Components Analysis with Varimax rotation. Principal components analysis was used because the primary purpose was to identify and compute composite scores for the PTGI. The factorability of the 21 PTGI items which measures Posttraumatic Growth was examined. All the 21 items correlated with at least one other University of Ghana http://ugspace.ug.edu.gh 50 Posttraumatic Growth among Breast Cancer Survivors in Ghana item (at least .3), which suggests reasons for factorability. The Bartlett‟s test of sphericity was significant (χ2 (210) = 1383.647, p < .001). The Kaiser-Meyer-Olkin measure of sampling adequacy was .847 which was above the commonly recommended value of .6 and the communalities were all above .3, additionally confirming that each item shared some common variance with other items. Given these overall indicators, factor analysis was deemed to be suitable with all 21items. Only the first four components yielded eigenvalues greater than 1.0. Initial eigenvalues indicated that the first four factors explained 41.70%, 10.19%, 8.11% and 5.48% of the variance respectively. Solutions for first, second, third and fourth factors were each examined using varimax of the factor loading matrix. In each of the four components, more than 3 items loaded eigenvalues above .30. The four-factor solution, which explained 65.48% of the variance were maintained. Results are presented in Appendix 3. Exploratory Factor Analysis of the Cognitive Processing of Trauma Scale An EFA was performed on the CPOTS items using Principal Components Analysis with Varimax rotation. Principal components analysis was used because the primary purpose was to identify and compute composite scores for the CPOTS which was used as a measure for Cognitive Processing. The factorability of the 17 CPOTS items which measures was examined. All the 17 items correlated with at least one other item (at least .3) which suggests reasons for factorability. The Bartlett‟s test of sphericity was significant (χ2 (136) = 630.474, p < .001). The Kaiser-Meyer-Olkin measure of sampling adequacy was .79, above the commonly recommended value of .60 and the communalities were all above .30 further confirming that each item shared University of Ghana http://ugspace.ug.edu.gh 51 Posttraumatic Growth among Breast Cancer Survivors in Ghana some common variance with other items. Given these overall indicators, factor analysis was deemed to be suitable for all 17 items. Only the first four components yielded eigenvalues greater than 1.0. Initial eigenvalues indicated that the first four factors explained 30.37%, 11.43%, 8.53% and 8.17% of the variance respectively. Solutions for first, second, third and fourth factors were each examined using varimax of the factor loading matrix. In each of the four components, more than 3 items loaded eigenvalues above .30. The four-factor solution, which explained 58.50% of the variance were maintained. Results are presented in Appendix 4. Exploratory Factor Analysis of the Life Orientation Test - Revised An EFA was performed on the LOT-R items using Principal Components Analysis with Varimax rotation. Principal components analysis was used because the primary purpose was to identify and compute composite scores for the Life Orientation Test-Revised (LOT-R) which was used as a measure of Optimism. The factorability of the 10 LOT-R items was examined. All the 10 items correlated with at least one other item (at least .3) which suggests reasons for factorability. The Bartlett‟s test of sphericity was significant (χ2 (45) = 265.096, p < .001). The Kaiser-Meyer-Olkin measure of sampling adequacy was .71, above the commonly recommended value of .60 and the communalities were all above .30, further confirming that each item shared some common variance with other items. Given these overall indicators, factor analysis was deemed to be suitable for all 10 items. Only the first three components yielded eigenvalues greater than 1.0. Initial eigenvalues indicated that the first four factors explained 33.76%, 13.56% and 13.42% of the variance respectively. Solutions for first, second and third factors were each examined using varimax of the factor loading matrix. In each of the three components, more than 3 items loaded eigenvalues University of Ghana http://ugspace.ug.edu.gh 52 Posttraumatic Growth among Breast Cancer Survivors in Ghana above .30. The three-factor solution, which explained 60.74% of the variance were maintained. See appendix 5 for results. EFA of the Santa Clara Strength of Religious Faith Questionnaire An EFA was performed on the Santa Clara Strength of Religious Faith Questionnaire items using Principal Components Analysis with Varimax rotation. Principal components analysis was used because the primary purpose was to identify and compute composite scores for the Santa Clara Strength of Religious Faith Questionnaire (SCSRFQ) which was used as a measure for Religiosity. The factorability of the 10 SCSRFQ items was examined. All the 10 items correlated with at least one other item (at least .3) which suggests reasons for factorability. The Bartlett‟s test of sphericity was significant (χ2 (45) = 366.203, p < .001). The Kaiser-Meyer-Olkin measure of sampling adequacy was .81, above the commonly recommended value of .60 and the communalities were all above .30, further confirming that each item shared some common variance with other items. Given these overall indicators, factor analysis was deemed to be suitable for all 10 items. Only the first two components yielded eigenvalues greater than 1.0. Initial eigenvalues indicated that the first two factors explained 40.12% and 14.77% of the variance respectively. Solutions for first and second factors were each examined using varimax of the factor loading matrix. In each of the two components, more than 3 items loaded eigenvalues above .30. The two-factor solution, which explained 54.89% of the variance were maintained. Results are presented in Appendix 6. University of Ghana http://ugspace.ug.edu.gh 53 Posttraumatic Growth among Breast Cancer Survivors in Ghana Exploratory Factor Analysis of the Brief Cope An EFA was performed on the Brief Cope items using Principal Components Analysis with Varimax rotation. Principal components analysis was used because the primary purpose was to identify and compute composite scores for the Brief Cope which was used as a measure of Coping. The factorability of the 28 Brief Cope items was examined. All the 28 items correlated with at least one other item (at least .3) which suggests reasons for factorability. The Bartlett‟s test of sphericity was significant (χ2 (378) = 1821.771, p < .001). The Kaiser-Meyer-Olkin measure of sampling adequacy was .73, above the commonly recommended value of .60 and the Communalities were all above .30, further confirming that each item shared some common variance with other items. Given these overall indicators, factor analysis was deemed to be suitable for all 28 items. Only the first eight components yielded eigenvalues greater than 1.0. Initial eigenvalues indicated that the first eight factors explained 28.37%, 13.84%,6.38%, 5.46%,5.31%,4.71%, 4% and 3.81% of the variance respectively. Solutions for all the eight factors were each examined using varimax of the factor loading matrix. In the first seven components, more than 3 items loaded eigenvalues above .30. Only two items in the eighth component yielded eigenvalues greater than .30. Therefore, items in the first seven-factor solution, which explained 68.072% of the variance were maintained. Results are presented in Appendix 7. Exploratory Factor Analysis of the Multidimensional Scale of Perceived Social Support An EFA was performed on the Multidimensional Scale of Perceived Social Support items using Principal Components Analysis with Varimax rotation. Principal components analysis was used University of Ghana http://ugspace.ug.edu.gh 54 Posttraumatic Growth among Breast Cancer Survivors in Ghana because the primary purpose was to identify and compute composite scores for the Multidimensional Scale of Perceived Social Support [MDSPSS] which was used as a measure for Social Support. The factorability of the 12 MDSPSS items which measures Social Support was examined. All the 12 items correlated with at least one other item (at least .3) which suggests reasons for factorability. The Bartlett‟s test of sphericity was significant (χ2 (66) = 366.203, p < .001). The Kaiser-Meyer-Olkin measure of sampling adequacy was .897, above the commonly recommended value of .60 and the communalities were all above .30, further confirming that each item shared some common variance with other items. Given these overall indicators, factor analysis was deemed to be suitable for all 12 items. Only the first two components yielded eigenvalues greater than 1.0. Initial eigenvalues indicated that the first two factors explained 61.37% and 16.445% of the variance respectively. Solutions for first and second factors were each examined using varimax of the factor loading matrix. In each of the two components, more than 3 items loaded eigenvalues above .30. The two-factor solution, which explained 54.89% of the variance were maintained. Results are presented in Appendix 8. University of Ghana http://ugspace.ug.edu.gh 55 Posttraumatic Growth among Breast Cancer Survivors in Ghana Descriptive Statistics of Variables and Test of Normality Table 3: Descriptive Statistics of the Predictors Minimum Maximum M SD Skewness Kurtosis Cognitive Processing 71.00 109.0 89.95 7.65 .24 .29 Religiosity 31.00 40.00 37.91 2.42 -1.21 .70 Posttraumatic Growth 66.00 124.00 104.07 14.59 -.78 -.26 Optimism 22.00 30.00 27.93 2.15 -.90 -.18 Coping 47.00 95.00 79.50 9.88 -1.64 2.50 Social Support 18.00 84.00 57.21 16.85 -.66 -.63 N=105, S.E of Skewness=.236 Descriptive statistics are presented in Table 3. For the variable Cognitive Processing, the scores obtained by respondents ranges from 71 to 109 (M =89.95, SD =7.65). For the variable Religiosity, the scores obtained by respondents range from 31 to 40 (M = 37.90, SD =2.42). For the variable PTG, the scores obtained by respondents range from 66 to 124 (M = 104.07, SD = 14.59. The scores obtained by the respondents on the variable Optimism were between 22 and 30 (M = 27.93, SD = 2.15). On the variable Coping, the scores obtained by respondents range from 47 and 95 (M = 79.50, SD = 9.90). For the variable Social Support, the scores obtained by the respondents were between 18 and 84 (M = 4.77, SD = 1.40). The skewness and kurtosis for all the variables fall into the accepted range of skewness (−1.96, +1.96) and kurtosis (-2, +2) (Tabachnick & Fidell, 2013; George & Mallery, 2010). This indicates that the distributions of all variables were approximately univariately normal. University of Ghana http://ugspace.ug.edu.gh 56 Posttraumatic Growth among Breast Cancer Survivors in Ghana Intercorrelations among Predictor and Criterion Variables To assess for linearity between the variables to be used in the regression model, correlation was performed using the Pearson Product-moment Correlations to access the relationship among variables. The Table 4 below represents the correlation matrix. Table 4: Correlation Matrix representing the relationship between the variables 1 2 3 4 5 6 7 8 1 Age 2 Years of * .17 Survival 3 Optimism *-.04 -.22 4 Cognitive * -.11 -.06 .20 Processing 5 Religiosity * ** *.03 -.20 .53 .21 6 Coping * ** ** **.06 -.21 .47 .55 .47 7 Social ** ** ** ** -.03 -.03 .49 .29 .36 .56 Support 8 Posttraumatic * * ** * ** ** ** .20 .20 .53 .22 .34 .48 .53 Growth *** p<0.001; ** p< 0.01; * p< 0.05 Table 4 above shows the results for exploring the relationship between the variables using Pearson Product-moment Correlation coefficient. Of the potential covariates, there was a weak significant positive relationship between Age (r=.20); Years of survival (r= .20) and PTG (p<.05) and PTG. Of the hypothesized predictors of change in PTG, there was a weak positive relationship between Cognitive Processing and PTG (r=.22, p<.05). There was also a significant moderate relationship between Religiosity and PTG (r=.34, p<.01) and between Coping and PTG (r= .48, p<.01). There was also a strong significant positive relationship between optimism and posttraumatic growth (r=.53, p<.01) and between social support and posttraumatic growth (r=.53, p<.01). This correlation coefficient was adequate for a regression analysis since it is below the .7 University of Ghana http://ugspace.ug.edu.gh 57 Posttraumatic Growth among Breast Cancer Survivors in Ghana threshold which is too high and hence considered to be violating the assumption of multicollinearity (Field, 2009). University of Ghana http://ugspace.ug.edu.gh 58 Posttraumatic Growth among Breast Cancer Survivors in Ghana Testing Hypotheses Objective One Prevalence of Posttraumatic Growth among Breast Cancer Survivors in Ghana To assess the prevalence of overall PTG and its domains, the proportions were estimated. PTG has five domains (Spiritual Change, Appreciation of Life, Personal Strength, New Possibilities and Relationships with others) and each was measured on three levels or categories (Low, Moderate, and High). The Table 5 below is a summary of the findings. Table 5: Distribution of the prevalence of Posttraumatic growth experienced by the participants [95% Conf. Interval] n = 105 % Posttraumatic Growth Low 13 12.4 7.3–20.3 Moderate 32 30.5 22.3 – 40.1 High 60 57.1 47.4 – 66.4 Spiritual Change Low 3 2.9 0.9 – 8.6 Moderate 15 14.3 8.7 – 22.5 High 87 82.9 74.3 – 89.0 Appreciation of Life Low 5 4.8 2.0 – 11.1 Moderate 26 24.8 17.3 – 34.1 High 74 70.5 60.9 – 78.5 Personal Strength Low 7 6.7 3.2 – 13.5 Moderate 29 27.6 19.8 – 37.1 High 69 65.7 60.1 – 74.3 New Possibilities Low 26 24.8 17.3 – 34.1 Moderate 43 41.0 31.8 – 50.7 High 36 34.3 25.7 – 44.0 Relationships with Low 14 13.3 8.0 – 21.4 others Moderate 22 21.0 14.1 – 30.0 High 69 65.7 56.0 – 74.3 University of Ghana http://ugspace.ug.edu.gh 59 Posttraumatic Growth among Breast Cancer Survivors in Ghana From the Table 5, 57% of the women experienced high levels of overall PTG [95% CI = 47.4 – 66.4] and 30.5% of the women also experienced moderate levels of PTG [95% CI = 22.3 – 40.1]. This means that more than half of the participants experienced high PTG. Put together, 87.5% of the participants experienced moderate to high levels of PTG. In the domains of PTG, 83% of the participants reported high scores in the Spiritual Change domain of PTG [95% CI = 74.3 – 89.0]. Again, 71% of the participants reported high scores in the Appreciation of Life domain of PTG [95% CI = 60.9 – 78.5].in addition, 66% of the participants reported high scores in Personal Strength [95% CI = 60.1 – 74.3]. Also, 66% of the participants reported high scores in Improved relationship [95% CI = 56.0 – 74.3] and finally, 34% of the participants reported high scores in New Possibilities [95% CI = 25.7 – 44.0]. This shows that, the domain to experience the highest level of PTG was “Spiritual Change”, followed by “Appreciation of life”, then “Personal Strength” and “Relating with others”. The domain to receive the least growth was “New possibilities”. University of Ghana http://ugspace.ug.edu.gh 60 Posttraumatic Growth among Breast Cancer Survivors in Ghana Objective Two and Three Association of Demographic and Disease/ Treatment Factors and Posttraumatic Growth Hypothesis 1: Demographic variables will be associated with Posttraumatic Growth Hypothesis 1a: Age will be negatively associated with Posttraumatic Growth Hypothesis 1b: Years of survival will be positively associated with Posttraumatic Growth Hypothesis 1c: Women‟s marital status will be positively associated with their level of Posttraumatic Growth Hypothesis 2: Disease/Treatment variables will be associated with Posttraumatic Growth Hypothesis 2a: Type of Breast Cancer will be positively associated with Posttraumatic Growth Hypothesis 2b: The Stage of Breast Cancer will be positively associated with Posttraumatic Growth Hypothesis 2c: Type of treatment will be positively associated with Posttraumatic Growth To examine which Demographic and Disease/Treatment variables are associated with PTG, series of Pearson Chi-square tests were performed. All the demographic and Disease/Treatment variables were categorical and PTG was also in 3 categories (Low, Moderate, and High). Chi- Square tests are used to test the association of two categorical variables. Table 6 below shows the results from the Chi-square tests. University of Ghana http://ugspace.ug.edu.gh 61 Posttraumatic Growth among Breast Cancer Survivors in Ghana Table 6: Chi-Square test assessing Association of Demographic and Disease/Treatment variables with Posttraumatic Growth Posttraumatic Growth, n (%) Variable χ2 Low Moderate High P-Value Demographic Variables Age Below 50 Years 10(62.5) 16(50.0) 15(26.3) ** 9.192 Above 50 Years 6 (37.5) 16(50.0) 42(73.7) Years of Survival < 5 years 10(62.5) 25(78.1) 22(38.6) 13.417*** ≥ 5 Years 6 (37.5) 7 (21.9) 35(61.4) Marital Status Single 4 (25.0) 1 (3.1) 3 (5.3) Married 0 (0.0) 11(34.4) 35(61.4) *** 31.865 Divorced 10(62.5) 10(31.3) 9 (15.8) Widow 2(12.5) 10(31.3) 10(17.5) Educational Level No School 1 (6.3) 4 (12.5) 11(19.3) Primary/JHS 5 (31.3) 17 53.1) 19(33.3) 9.422 Secondary/Vocational 6(37.5) 3(9.4) 9(15.8) Tertiary 4 (25.0) 8 (25.0) 18(31.6) Employment Status Not employed 5 (31.3) 9 (28.1) 17(29.8) Employed Full-time 3 (18.8) 5 (15.6) 13(22.8) 7.839 Employed Part-Time 2 (12.5) 0 (0.0) 1(1.8) Self-Employed 6 (37.5) 18(56.3) 26(45.6) Religion Christianity 15(93.8) 25(78.1) 50(87.7) Islam 1 (6.3) 7 (21.9) 5 (8.8) 5.462 No Religion 0 (0.0) 0 (0.0) 2 (3.5) Disease and Treatment Variables Type of Breast Cancer Unknown 2 (12.5) 0 (0.0) 4 (7.0) 17.878 Ductal Carcinoma In Situ 4 (25.0) 1 (3.1) 7 (12.3) Invasive Ductal Carcinoma 8 (50.0) 24(75.0) 43(75.4) Mucinous Carcinoma of the 1 (6.3) 4 (12.5) 0 (0.0) breast Invasive Lobular 1(6.3) 1(3.1) 1(1.8) Carcinoma Recurrent & Metastatic 0(0.0) 2 (6.3) 2 (3.5) Breast Cancer Stage of Breast Cancer Unknown 2 (12.5) 1(3.1) 6 (10.5) 7.655 Stage I 6(37.5) 8 (25.0) 11(19.3) Stage II 5 (31.3) 14(43.8) 21(36.8) Stage III 3 (18.8) 9 (28.1) 15(26.3) Stage IV 0(0.0) 0(0.0) 4 (7.0) Type of Surgery Lumpectomy 6 (37.5) 5 (15.6) 15(26.3) 2.901 Mastectomy 10(62.5) 27(84.4) 42(73.7) Radiotherapy No 6 (37.5) 10(31.3) 13(22.8) 1.653 Yes 10(62.5) 22(68.8) 44(77.2) *** p<0.001; **p< 0.01; *p< 0.05 University of Ghana http://ugspace.ug.edu.gh 62 Posttraumatic Growth among Breast Cancer Survivors in Ghana From the Table 6 above, there was a significant positive association age (χ2 (2) = 9.192, p <.01) and PTG. This indicates that, older women are more likely to experience PTG relative to younger women. Therefore, the hypothesis that Age will have a negative association with PTG was not supported. There was also a significant positive association between Years of Survival (χ2 (2) = 13.417, p <.001) and PTG. This means that, the longer a woman survives from breast cancer, the higher the chances of her developing PTG. This supports the hypothesis that Years of Survival will have a positive association with PTG. In addition, there was a significant Positive association between marital status (χ2 (2) = 31.865, p <.001) and PTG. This also shows that married women are more likely to experience PTG relative to women who are not married. Therefore, the hypothesis that Women‟s marital status will be positively associated with their level of PTG was supported. Type of Breast Cancer (χ2 (10) = 17.878, p>.05), Stage of Breast Cancer (χ2 (8) = 7.655, p>.05), Type of Surgery (χ2 (2) = 2.901, p>.05) and Radiotherapy (χ2 (2) = 1.653, p>.05) were not associate with PTG. Therefore, the hypotheses that Type of Breast Cancer will be positively associated with PTG, Stage of Breast Cancer will be associated with PTG and Type of treatment will be associated with PTG were not supported. University of Ghana http://ugspace.ug.edu.gh 63 Posttraumatic Growth among Breast Cancer Survivors in Ghana Objective Four Predicting Posttraumatic Growth with Psychosocial Variables Hypothesis 3: After controlling for demographic and disease/treatment factors, psychosocial variables will predict Posttraumatic Growth Hypothesis 3a: Religiosity will predict Posttraumatic Growth Hypothesis 3b: Cognitive processing will predict Posttraumatic Growth Hypothesis 3c: Optimism will predict Posttraumatic Growth Hypothesis 3d: Social support will predict Posttraumatic Growth Hypothesis 3e: Coping will predict Posttraumatic Growth A 2-step Hierarchical Multiple Regression was performed to test the hypothesis that psychosocial factors (Optimism, Coping, Cognitive Processing, Social Support, and Religiosity) will predict PTG after controlling for the demographic and the clinical variables (Age and Years of survival). Normality and linearity, the basic assumptions that need to be satisfied before running a regression analysis were all adequate. Results are presented in Table 7 below. Table 7: Summary of Hierarchical Regression Analysis for Variables Predicting Posttraumatic Growth among Breast Cancer Survivors. Model Predictor B Std. Error β t Sig. Step 1 Age .240 .136 .171 1.761 .081 Years of Survival .743 .429 .168 1.730 .087 Step 2 Age .208 .103 .148 2.022 .046 Year of Survival 1.386 .333 .313 4.166 .000 Optimism 2.603 .617 .383 4.220 .000 Cognitive -.049 .164 -.026 -.301 .764 Processing Religiosity -.022 .523 -.004 -.042 .966 Coping .367 .159 .248 2.300 .024 Social Support 2.350 .938 .226 2.506 .014 For Step 1, , F= 3.651; step 2, , Δ .457, F= 18.649, ΔF = 15.266 University of Ghana http://ugspace.ug.edu.gh 64 Posttraumatic Growth among Breast Cancer Survivors in Ghana Demographic variables (Age and years of survival) are entered at Step 1 and psychosocial variables (Optimism, Cognitive Processing, Religiosity, Coping and Social Support) were added at Step 2. Age, and Years of survival when entered at Step 1, explained 6.7% of the variance in 2 PTG (R =.067, F (2,102) = 3.651, p<.01). Psychosocial variables entered in step 2 explained an 2 additional 45.7% of the variance in PTG after controlling for Age and Years of survival (∆R 2 =.457, ∆F (5, 97) = 18.649, p <.001). The total variance explained by the model was 52.4%, (R =.524, F (7, 97) = 15.266, p<.001). The result in the Table 7 above indicate that, Optimism (B= 2.6) was a significant predictor of PTG (β= .383, p< .001). This indicates that as Optimism increase by one unit, PTG also increases by 2.6 units. Also, as Optimism increase by one standard deviation (SD=2.15), PTG increases by 0.38 standard deviations. The standard deviation of PTG is 14.59 and so this constitutes a change of 37.934 (2.6 x 14.59) of PTG. Therefore, for every 2.15 increase in terms of Optimism felt by the women, there is a corresponding increase of 37.934 in terms of PTG. This means that Optimism as a psychosocial factor leads to an increased level of PTG. Therefore, the hypothesis that Optimism will predict PTG was supported. Also, Coping (B=.37) significantly predict PTG (β=.248, p<.05). This indicates that as coping increase by one unit, PTG also increases by .37 units. Also, as Coping increase by one standard deviation (SD=9.88), PTG increases by 0.25 standard deviations. The standard deviation of PTG is 14.59 and so this constitutes a change of 5.40 (.37 x 14.59) of PTG. Therefore, for every 9.88 increase in coping felt by the women, there is a corresponding increase of 5.40 in terms of PTG. This means that Coping as a psychosocial factor leads to an increased level of PTG. Therefore, the hypothesis that Coping will predict PTG was supported. University of Ghana http://ugspace.ug.edu.gh 65 Posttraumatic Growth among Breast Cancer Survivors in Ghana Social Support (B= 2.35) was a significant predictor of PTG (β=.23, p<.01). This indicates that as Social Support increase by one unit, PTG also increases by 2.35 units. Also, as Social Support increase by one standard deviation (SD=1.40), PTG increases by 0.23 standard deviations. The standard deviation of PTG is 14.59 and so this constitutes a change of 34.29 (2.35 x 14.59) of PTG. Therefore, for every 1.40 increase in Social Support received by the women, there is a corresponding increase of 34.29 in terms of PTG. This means that Social Support as a psychosocial factor leads to an increased level of PTG. Therefore, the hypothesis that Social Support will predict PTG was supported. In the Table 7, the result showed that Cognitive Processing and Religiosity could not predict PTG with beta scores of -.045 and -.02 respectively. Therefore, the results do not support the hypothesis that Cognitive Processing will predict PTG. Also, results do not support the hypothesis that Religiosity will predict PTG. This indicates that survivors who were optimistic, use more coping strategies and receive social support are more likely to experience PTG relative to survivors‟ cognitive processing or religiosity level. Mediation Analysis A series of regression analyses were run to test the mediating role Optimism, Coping and Social Support plays on the Cognitive Processing, Religiosity and PTG relationship. Specifically, the Sobel‟s test of significance was determined by the method proposed by Preacher and Hayes (2004). Baron and Kenny‟s (1986) suggestion for testing mediation analysis was used to test for mediation role of psychosocial variables (Optimism, Coping and Social support) on the Religiosity, Cognitive Processing and PTG relationship. For a variable to play a mediating role according to Baron and Kenny (1986), first of all, variations in the predictor variable (X) should significantly account for variation in the mediating variable (M). Secondly, changes in the University of Ghana http://ugspace.ug.edu.gh 66 Posttraumatic Growth among Breast Cancer Survivors in Ghana mediating variable should significantly account for a variance in the criterion (Y). Thirdly, when the relationship between the predictor and the mediator and that of the mediator and criterion are controlled, an earlier significant association between the predictor and criterion should no longer be significant. In other words, for Baron et al (1986), there should always be a relationship between the independent and dependent variable before a third variable which renders this relationship insignificant will be said to be a mediator. However, Bollen (1989) argued that the nonexistence of relationship between a predictor and a criterion does not refute causality. He is noted to have said that establishing relationship is neither a necessary nor an adequate prerequisite for causality. Recent researchers interested in mediation analysis have taken on this perspective (Hayes, 2009). Optimism mediates the relationship between Cognitive Processing and Posttraumatic Growth. Table 8: Mediation Analysis of Optimism on Cognitive Processing – Posttraumatic Growth relationship Model Predictor Criterion B S. E. β Model 1 Optimism Age .004 .020 .020 Years of Survival -.136 .063 -.209* Cognitive .054 .027 .191* Processing Model 2 Posttraumatic Growth Age .259 .108 .184* Years of Survival 1.320 .348 .298*** Cognitive .266 .148 .140 Processing Optimism 3.882 .538 .571*** Sobel’s test for significant mediation displayed Z= 1.93, ***P<.001, **P<.01, *p<.05 University of Ghana http://ugspace.ug.edu.gh 67 Posttraumatic Growth among Breast Cancer Survivors in Ghana From Table 7 above, it was observed that Cognitive Processing which is the independent variable could not predict PTG when the personal variables were controlled. However, based on the argument by Bollen (1989) and Hayes (2009; 2013) it is possible to test for mediation (M) even if the predictor (X) and the criterion (Y) aren‟t associated. For this study, there was a significant relationship between the predictor and the criterion (see Table 4). As presented in Table 8 above, in the first model, Optimism (the mediator) was regressed on Cognitive Processing (the predictor) while controlling for Age and Years of survival which were the personal variables that had a significant effect on PTG. All other personal variables were not considered because they could not account for a significant variance in the criterion. Results indicated that there was a significant relationship between Cognitive Processing and Optimism (β = .191, ρ <.05). A positive significant relationship was found to exist between Optimism and PTG (see Table 7). For the second model, PTG was regressed on both Cognitive Processing and Optimism. It resulted that, while Cognitive Processing could not predict PTG (β = .140, ρ >.05), Optimism significantly predicted PTG (β = .571, ρ < .001) which suggests the presence of a mediating effect. Finally, using the method proposed by Preacher and Hayes (2004), Sobel‟s test for mediating effect was conducted. Results indicated that the mediator (Optimism) did not significantly explain the influence of Cognitive Processing on PTG (Z= 1.93, p >.05). The above result suggests the presence of a full mediating effect of Optimism on the relationship between Cognitive Processing and PTG. University of Ghana http://ugspace.ug.edu.gh 68 Posttraumatic Growth among Breast Cancer Survivors in Ghana Coping mediates the relationship between Cognitive Processing and Posttraumatic Growth. Table 9: Mediation Analysis of Coping on Cognitive Processing – Posttraumatic Growth relationship Model Predictor Criterion B S. E. β Model 1 Coping Age .150 .077 .157 Years of -.617 .242 -.206* Survival Cognitive .716 .104 .554** Processing Model 2 Posttraumatic Growth Age .148 .118 .105 Years of 1.316 .377 .297** Survival Cognitive -.133 .189 -.070 Processing Coping .849 .150 .575*** Sobel’s test for significant mediation displayed Z= 4.37, ***P<.001, **P<.01, *p<.05 With reference to Table 7 above, it was observed that Cognitive Processing which is the independent variable could not predict PTG when the personal variables were controlled. However, based on the argument by Bollen (1989) and Hayes (2009; 2013) it is possible to test for mediation (M) even if the predictor (X) and the criterion (Y) aren‟t associated. For this study, there was a significant relationship between the predictor and the criterion (see Table 4). As presented in Table 9 above, in the first model, Coping (the mediator) was regressed on Cognitive Processing (the predictor) whiles controlling for Age and Years of survival which were the personal variables that had a significant effect on PTG. All other personal variables were not considered because they could not account for a significant variance in the criterion. Results indicated that there was a significant relationship between Cognitive Processing and Coping (β = .554, ρ <.01). A positive significant relationship was found to exist between Coping and PTG (see Table 7). University of Ghana http://ugspace.ug.edu.gh 69 Posttraumatic Growth among Breast Cancer Survivors in Ghana For the second model, PTG was regressed on both Cognitive Processing and Coping. It resulted that, while Cognitive Processing could not predict PTG (β = -.070, ρ >.05), Coping significantly predicted PTG (β = .575, ρ < .001) which suggests the presence of a mediating effect. Finally, using the method proposed by Preacher and Hayes (2004), Sobel‟s test for mediating effect was conducted. Results indicated that the mediator (Coping) significantly explained the influence of Cognitive Processing on PTG (Z= 4.37, p <.001). The above result suggests the presence of a full mediating effect of Coping on the relationship between Cognitive Processing and PTG. Social Support mediates the relationship between Cognitive Processing and Posttraumatic Growth. Table 10: Mediation Analysis of Social Support on Cognitive Processing – Posttraumatic Growth relationship Model Predictor Criterion B S. E. β Model 1 Social Support Age .001 .013 .006 Years of -.007 .041 -.017 Survival Cognitive .052 .018 .285** Processing Model 2 Posttraumatic Growth Age .271 .114 .193* Years of .829 .358 .187* Survival Cognitive .197 .159 .103 Processing Social Support 5.293 .864 .509*** Sobel’s test for significant mediation displayed Z=2.61, *** p<0.001; **. p< 0.01,*. p< 0.05 With reference to Table 7 above, it was observed that Cognitive Processing which is the independent variable could not predict PTG when the personal variables were controlled. University of Ghana http://ugspace.ug.edu.gh 70 Posttraumatic Growth among Breast Cancer Survivors in Ghana However, based on the argument by Bollen (1989) and Hayes (2009; 2013) it is possible to test for mediation (M) even if the predictor (X) and the criterion (Y) aren‟t associated. For this study, there was a significant relationship between the predictor and the criterion (see Table 4). As presented in Table 10 above, in the first model, Social Support (the mediator) was regressed on Cognitive Processing (the predictor) while controlling for Age and Years of survival which were the personal variables that had a significant effect on PTG. All other personal variables were not considered because they could not account for a significant variance in the criterion. Results indicated that there was a significant relationship between Cognitive Processing and Social Support (β = .285, ρ <.01). A positive significant relationship was found to exist between Social Support and PTG (see Table 7). For the second model, PTG was regressed on both Cognitive Processing and Social Support. It resulted that, while Cognitive Processing could not predict PTG (β = .103, ρ >.05), Social Support significantly predicted PTG (β = .509, ρ < .001) which suggests the presence of a mediating effect. Finally, using the method proposed by Preacher and Hayes (2004), Sobel‟s test for mediating effect was conducted. Results indicated that the mediator (Social Support) significantly explained the influence of Cognitive Processing on PTG (Z= 2.61, p <.01). The above result suggests the presence of a full mediating effect of Social Support on the relationship between Cognitive Processing and PTG. University of Ghana http://ugspace.ug.edu.gh 71 Posttraumatic Growth among Breast Cancer Survivors in Ghana Optimism mediates the relationship between Religiosity and Posttraumatic Growth. Table 11: Mediation Analysis of Optimism on Religiosity – Posttraumatic Growth relationship Model Predictor Criterion B S. E. β Model 1 Optimism Age -.006 .018 -.030 Years of -.074 .056 -.113 Survival Religiosity .448 .076 .506*** Model 2 Posttraumatic Growth Age .230 .109 .164* Years of 1.363 .353 .308*** Survival Religiosity .623 .546 .103 Optimism 3.712 .618 .546*** Sobel’s test for significant mediation displayed Z=4.21, **P<.01, *p<.05 With reference to Table 7 above, it was observed that Religiosity which is the independent variable could not predict PTG when the personal variables were controlled. However, based on the argument by Bollen (1989) and Hayes (2009; 2013) it is possible to test for mediation (M) even if the predictor (X) and the criterion (Y) aren‟t associated. For this study, there was a significant relationship between the predictor and the criterion (see Table 4). As presented in Table 11 above, in the first model, Optimism (the mediator) was regressed on Religiosity (the predictor) while controlling for Age and Years of survival which were the personal variables that had a significant effect on PTG. All other personal variables were not considered because they could not account for a significant variance in the criterion. Results indicated that there was a significant relationship between Religiosity and Optimism (β = .506, ρ <.001). A positive significant relationship was found to exist between Optimism and PTG (see Table 7). University of Ghana http://ugspace.ug.edu.gh 72 Posttraumatic Growth among Breast Cancer Survivors in Ghana For the second model, PTG was regressed on both Religiosity and Optimism. It resulted that, while Religiosity could not predict PTG (β = .103, ρ >.05), Optimism significantly predicted PTG (β = .546, ρ < .001) which suggests the presence of a mediating effect. Finally, using the method proposed by Preacher and Hayes (2004), Sobel‟s test for mediating effect was conducted. Results indicated that the mediator (Optimism) significantly explained the influence of Religiosity on PTG (Z= 4.21, p <.001). The above result suggests the presence of a full mediating effect of Optimism on the relationship between Religiosity and PTG. Coping mediates the relationship between Religiosity and Posttraumatic Growth. Table 12: Mediation Analysis of Coping on Religiosity – Posttraumatic Growth relationship Model Predictor Criterion B S. E. β Model 1 Coping Age .071 .084 .075 Years of -.417 .269 -.139 Survival Religiosity 1.811 .360 .444*** Model 2 Posttraumatic Growth Age .160 .114 .114 Years of 1.369 .371 .309*** Survival Religiosity 1.072 .550 .178 Coping .671 .136 .454*** Sobel’s test for significant mediation displayed Z=3.52, **P<.01, *p<.05 With reference to Table 7 above, it was observed that Religiosity which is the independent variable could not predict PTG when the personal variables were controlled. However, based on the argument by Bollen (1989) and Hayes (2009; 2013) it is possible to test for mediation (M) University of Ghana http://ugspace.ug.edu.gh 73 Posttraumatic Growth among Breast Cancer Survivors in Ghana even if the predictor (X) and the criterion (Y) aren‟t associated. For this study, there was a significant relationship between the predictor and the criterion (see Table 4). As presented in Table 12 above, in the first model, Coping (the mediator) was regressed on Religiosity (the predictor) while controlling for Age and Years of survival which were the personal variables that had a significant effect on PTG. All other personal variables were not considered because they could not account for a significant variance in the criterion. Results indicated that there was a significant relationship between Religiosity and Coping (β = .444, ρ <.001). A positive significant relationship was found to exist between Coping and PTG (see Table 7). For the second model, PTG was regressed on both Religiosity and Coping. It resulted that, while Religiosity could not predict PTG (β =.178, ρ >.05), Coping significantly predicted PTG (β = .454, ρ < .001) which suggests the presence of a mediating effect. Finally, using the method proposed by Preacher and Hayes (2004), Sobel‟s test for mediating effect was conducted. Results indicated that the mediator (Coping) significantly explained the influence of Religiosity on PTG (Z= 3.52, p <.001). The above result suggests the presence of a full mediating effect of Coping on the relationship between Religiosity and PTG. University of Ghana http://ugspace.ug.edu.gh 74 Posttraumatic Growth among Breast Cancer Survivors in Ghana Social Support mediates the relationship between Religiosity and Posttraumatic Growth. Table 13: Mediation Analysis of Social Support on Religiosity – Posttraumatic Growth relationship Model Predictor Criterion B S. E. β Model 1 Social Support Age -.006 .013 -.046 Years of .020 .041 .048 Survival Religiosity .217 .055 .375*** Model 2 Posttraumatic Growth Age .237 .111 .169* Years of .991 .358 .224* Survival Religiosity 1.238 .516 .206* Social Support 4.828 .872 .465*** Sobel’s test for significant mediation displayed Z=3.21, **P<.01, *p<.05 With reference to Table 13 above, it was observed that Religiosity which is the independent variable could not predict PTG when the personal variables were controlled. However, based on the argument by Bollen (1989) and Hayes (2009; 2013) it is possible to test for mediation (M) even if the predictor (X) and the criterion (Y) aren‟t associated. For this study, there was a significant relationship between the predictor and the criterion (see Table 4). As presented in Table 13 above, in the first model, Social Support (the mediator) was regressed on Religiosity (the predictor) while controlling for Age and Years of survival which were the personal variables that had a significant effect on PTG. All other personal variables were not considered because they could not account for a significant variance in the criterion. Results indicated that there was a significant relationship between Religiosity and Coping (β = .375, ρ <.001). A positive significant relationship was found to exist between Coping and PTG (see Table 7). University of Ghana http://ugspace.ug.edu.gh 75 Posttraumatic Growth among Breast Cancer Survivors in Ghana For the second model, PTG was regressed on both Religiosity and Social Support. It resulted that, Religiosity could predict PTG (β = .206, ρ <.05) while Social Support also significantly predicted PTG (β = .465, ρ < .001) which suggests the presence of a partial mediating effect. Finally, using the method proposed by Preacher and Hayes (2004), Sobel‟s test for mediating effect was conducted. Results indicated that the mediator (Social Support) significantly explained the influence of Religiosity on PTG (Z= 3.21, p <.01). The above result suggests the presence of a partial mediating effect of Social Support on the relationship between Religiosity and PTG. Summary of Findings The results presented in the tables above indicate that breast cancer survivors in Ghana reported moderate to high levels of PTG. The women in this study showed significant high growth in Spiritual Growth, Appreciation of Life, Improved relationship with others and Personal Strength. Least change was observed in New Possibilities. It was also found that Age was associated with PTG. In addition, Marital status was associated with PTG and Years of survival was associated with PTG. No Disease/Treatment factors were found to be associated with PTG. Again, it was found that, Optimism predicts PTG. Also, Coping predicted PTG and Social Support also predicted PTG. Further analysis showed that Optimism fully mediated the relationship between Religiosity and PTG. A full mediation was also found for Coping on the relationship between Religiosity and Posttraumatic Growth. It was also found that Coping fully mediates the relationship between Cognitive processing and PTG. Social Support fully mediated the relationship between Cognitive Processing and PTG. It was found that Optimism fully mediated the relationship between Cognitive Processing and PTG. Finally, it was found that Social Support partially mediates the relationship between Religiosity and PTG. University of Ghana http://ugspace.ug.edu.gh 76 Posttraumatic Growth among Breast Cancer Survivors in Ghana Observed Model The diagram below represents the observed model from the data analysis based on the study hypotheses that were developed from the study objectives. It was found that Optimism, Coping and Social Support have a significant direct relationship with PTG. However, Religiosity and Cognitive Processing had an indirect relationship with PTG. Also, Optimism, Coping and Social Support fully mediated the relationship between Cognitive Processing and PTG. Again, Optimism and Coping had a full mediating effect on the relationship between Religiosity and PTG and a partial mediation effect of Social Support was found on the relationship between Religiosity and PTG. The model below therefore holds that, Optimism, Coping and Social Support are mediators for the relationship between Cognitive Processing and Religiosity on PTG. Cognitive * β =.191 Optimism Processing *** *** β = .554 β = .383 ** β =.285 Coping Posttraumatic * β =.248 Growth *** β =.506 *** ** β =.444 β =.226 Social Religiosity *** β =.375 Support Figure 2: Observed Model: Optimism, Coping and Social support mediates the relationship between Cognitive Processing and Religiosity on Posttraumatic Growth. University of Ghana http://ugspace.ug.edu.gh 77 Posttraumatic Growth among Breast Cancer Survivors in Ghana CHAPTER 5 DISCUSSION The aim of the study is to assess Posttraumatic Growth in breast cancer survivors in Ghana and to investigate the factors that relate and impact on PTG. There is paucity of data on the posttraumatic experiences of breast cancer survivors within the Ghanaian setting; this will set the baseline for other future studies. The objectives were first to assess the prevalence of PTG and to assess the prevalence of the domains of the PTGI (spiritual growth, appreciation of life, personal strength, new possibilities and relationship with others) in BCS in Ghana. Secondly, the study sought to examine the association of socio-demographic and disease/treatment variables with PTG. Finally, the study further examined how psychosocial variables (Optimism, Coping, Social support, Religiosity and cognitive processing) predict PTG. Prevalence of Posttraumatic Growth in Ghanaian Breast Cancer Survivors Results show that about eighty eight percent (88%) of the women reported moderate to high levels of Posttraumatic Growth. Results from this study support previous findings by other researchers who found that PTG is evident at varying degrees in breast cancer survivors (Barthakur et al., 2016; Cheng et al., 2016; Danhauer et al., 2015; Kolokotroni et al., 2014; Liu et al., 2014; Mehrabi et al., 2015; McDonough et al., 2014; Parikh et al., 2015; Park et al., 2016; Romeo et al., 2017; Shand et al., 2015; Wang et al., 2014). Findings from this study is higher than findings by Sim et al (2015) who found that 53.3% of the participants experienced moderate to high levels of PTG among Korean stomach cancer survivors and also higher than what was reported by Jansen et al. (2011) among colorectal cancer survivors (46.0%). This means that University of Ghana http://ugspace.ug.edu.gh 78 Posttraumatic Growth among Breast Cancer Survivors in Ghana positive posttraumatic experience is not limited to cancer survivors in other part of the world but also it is largely evident in breast cancer survivors in Ghana too. According to Tedesch and Calhoun (2004), PTG may be attained if the event is sufficiently distressing to change the individual‟s assumption about self, the world, and the future. The high mortality rate and the stigma associated with breast cancer in Ghana makes its experience more traumatic hence leading to this recorded high PTG rate after surviving it. This confirms that breast cancer is indeed a traumatic experience, especially within the Ghanaian context. As found by Bonsu et al. (2014), women who are almost through with their treatment of breast cancer begin to show positive trends such as the desire to live and regaining hope and confidence in life, this study shows that these positive trends progress through to survivorship and affect other areas of their lives. Results by an individual subscale of PTG show that breast cancer survivors in Ghana reported higher growth in Spiritual Growth, Appreciation of Life, Improved relationship with others and Personal Strength. Least change was observed in New Possibilities. Findings are consistent with previous studies (Barthakur et al., 2016; Brix et al., 2013; Mehrabi et al., 2015; Moore et al., 2017; Romeo et al.,2017; Sim et al., 2015). Since breast cancer on the average affects older people, growth in the domain of new possibilities may be less prevalent. High levels of Spiritual Growth maybe as a result of the strong sociocultural beliefs most Ghanaians hold about illness. Some people believe that suffering from a disease like breast cancer is a curse or punishment from God or the Spirits so therefore surviving from the disease might mean a repaired relationship between themselves and their object of worship. Given the chance to live again after encountering such a life threatening disease may indicate that whoever they worship has forgiven them any offense and has given them another chance to make things right. They may be University of Ghana http://ugspace.ug.edu.gh 79 Posttraumatic Growth among Breast Cancer Survivors in Ghana therefore grateful and appreciate this new life better and may be extra careful with how they live their lives now. Due to the collective nature of Africans and Ghanaians particularly, the kind of support the women received from their relatives and friends as well as other support groups such as their church or fellowships while they were going through the treatment might have improved their interpersonal relationship. Based on the support received, the women might value and the benefits of having close relationship and therefore, they may spend some time building and strengthening these interpersonal relationships. They may also strengthen their relationship with others as an indication of how much they appreciate the help they offered them when they were undergoing treatment. Demographic Variables and Posttraumatic Growth in Ghanaian Breast Cancer Survivors Regarding the association of the sociodemographic variables, three variables (age, marital status and years of survival) are positively associated with PTG. This means that survivors who were older, married and had survived for longer reported significantly higher PTG. Age was positively associated with PTG. This finding contradicts what has been reported by previous studies (Brix et al., 2013; Jansen et al., 2011; Romeo et al., 2017; Sim et al., 2015). The reason may be that younger woman who are diagnosed and treated for breast cancer may have other problems associated with sexuality, body image, loss of job, finding a partner etc. to contend with. This study confirms analysis by Atobrah (2012) who found that young patients diagnosed with cancer or other chronic diseases experience prolonged periods of denial because of fear. This in effect can prolong their grief process (Kubler-Ross, 1969) and delay their posttraumatic growth. This finding also supports findings by Boateng (in press) who showed that young cancer patients experience more psychological distress than older counterparts and older women have a higher University of Ghana http://ugspace.ug.edu.gh 80 Posttraumatic Growth among Breast Cancer Survivors in Ghana quality of life than younger ones in among breast cancer patients in Ghana. This confirms that younger women who experience breast cancer in Ghana have poor psychological outcomes compared to older women. Also, Marital status is positively associated with PTG. Those who are married reported higher PTG than those who were not married. Findings confirm other findings by previous researchers (Brix et al., 2013; Jansen et al., 2011; Kolokotroni et al., 2014; Romeo et al., 2017; Shand et al., 2015; Wang et al., 2014; Yi et al., 2015). This may be due to the fact that married women may get some sort of support (social, emotional and financial) from their husbands. Years of survival was also found to be associated with PTG. Women who have survived for more than five (5) years showed higher PTG than women who have survived below five (5) years. This finding supports findings from previous studies (Brix et al., 2013; Dirik et al., 2016; Jansen et al., 2011; Kolokotroni et al., 2014; Tomich & Helgeson, 2012). This may be because women who survive for long may become more confident about the future. In addition, since the development of PTG is time oriented, the more years one survives, the higher their PTG. Disease/Treatment Variables and Posttraumatic Growth in Ghanaian Breast Cancer Survivors No disease and treatment variable was found to be associated with posttraumatic growth. Though the type and severity of the cancer diagnosis as well as the treatments have been known to be a traumatic one, surprisingly, results from this study found no association between these factors and the positive changes women survivors of breast cancer in Ghana experience as reported in other studies in other countries (Dirik et al., 2016; Kolokotroni et al., 2014; Brix et al., 2013; Tomich & Helgeson, 2012; Jansen et al., 2011). The findings violate the assertion that the University of Ghana http://ugspace.ug.edu.gh 81 Posttraumatic Growth among Breast Cancer Survivors in Ghana severity of the disease influences PTG. It contradicts findings from Romeo et al. (2017) who found that having malignant breast cancer and undergoing Chemotherapy Therapy relate to some extent to PTG among Italian BC survivors. Also, findings from this study contradict that of Brix et al. (2013) who found that among breast cancer survivors, Tumor size, the number of positive lymph nodes, having undergone mastectomy versus lumpectomy and Endocrine treatment were positively related to PTG. It however supports finds by other researchers (Sim et al., 2015; Arpawong et al, 2013; Svetina et al., 2012) who found no association between disease characteristics and PTG. For example, the study supports findings by Sim et al. (2015) who found that no disease-related variable related to PTG among stomach cancer survivors. Several reasons may have accounted for this outcome. First, due to the myth and stigma associated with the diagnosis of breast cancer within the Ghanaian setting, being diagnosed with breast cancer may be enough to trigger some traumatic symptoms such as fear, feeling worried and grief. Hence the specific nature of the disease, as well as its treatment, may not necessarily be associated with growth. Often after people have successfully gone through the treatment, they may show growth mainly because they have been able to overcome the stigma associated with breast cancer. In addition to the reason stated above, another possible explanation as to why disease and treatment variables may not be related to PTG was the fact that in most developing countries like Ghana, patient‟s knowledge about their health condition as well as their treatment is very low (de-Graft Aikins, 2005). In most cases, medical professionals do not communicate the details of their condition as well as details of their treatment to the patients. So, most patients may finish the treatment without knowing the specific type of breast cancer they were diagnosed of, the stage of cancer and even the chemotherapy course they were taking. In this study, the severity of the disease and treatment were assessed directly from the patient‟s folder and not University of Ghana http://ugspace.ug.edu.gh 82 Posttraumatic Growth among Breast Cancer Survivors in Ghana from how the patient perceives it. However, a number of studies have demonstrated that perceived stressfulness has an association with PTG. So, an assessment of their subjective experiences and perception of the stressfulness of the treatment would have brought more understanding on how their disease and treatment factors affect their PTG. Psychosocial Variables and Posttraumatic Growth in Ghanaian Breast Cancer Survivors In terms of the role of the psychosocial factors in predicting growth, this study found that optimism predicts PTG. Some studies have also found that optimism influence the PTG process (Arpawong et al., 2013; Dirik et al., 2016; Kolokotroni et al., 2014; Park et al., 2016; Shand et al., 2015; Yi et al., 2015). This may be to the fact that optimistic people often show some positive qualities such as the expression of positive feelings, a positive understanding of threatening situations, the use of adaptive coping and seeking for social support and that may facilitate the perception of positive changes following trauma (Prati & Pietrantoni, 2009). Also, results from this study indicate that Coping is a significant predictor of PTG. In line with prior research (Brix et al., 2013; Büyükaşik-Colak et al., 2012; Danhauer et al., 2015; Dirik et al., 2016; Park et al., 2016; Kolokotroni, et al., 2014; Oginska-Bulik & Kobylarczyk, 2015; Shand et al., 2015), individuals who employed active coping, planning, positive reframing, and acceptance techniques in dealing with their diagnosis of cancer reported greater PTG. This demonstrates that coping foster PTG in cancer survivors. In fact, according to Schaefer and Moos (1992 PTG is positively influenced by both problem and emotion -focused coping. Popularly, a coping style characterized by denial, repression and emotion suppression is associated with worse health outcomes (Linley & Joseph, 2004). Results are in accordance with the functional descriptive transformational model of positive change (Tedeschi & Calhoun, 1995; University of Ghana http://ugspace.ug.edu.gh 83 Posttraumatic Growth among Breast Cancer Survivors in Ghana 2004) and model of life crisis and personal growth (Schaefer & Moos, 1992) which suggests that coping is an important predictor of PTG. In addition, this study shows that Social support predicts PTG. This finding is consistent with some results of the studies in the literature (Danhauer et al., 2015; Dirik et al., 2016; Hasson- Ohayon et al., 2016; Kolokotroni et al., 2014; McDonough et al., 2014; Park et al., 2016; Shand et al., 2015; Yi et al., 2015). As found by Prati and Pietrantoni (2009) in their meta - analysis emphasized that social support is an important contributor to the development of PTG in breast cancer survivors. Bozo et al. (2009) also showed that breast cancer survivors with high social support are more likely to develop PTG. Then again, the perception of positive changes in several domains of the survivor‟s life may create the opportunity for closest relationships, more compassionate behaviors, and new contacts and friendships, which turn social support into an outcome (Prati & Pietrantoni, 2009). This study also found an indirect effect between Religiosity and PTG. This indirect effect is mediated by optimism and coping. This indirect relationship has not been found by any of the reviewed literatures (Ai et al., 2013; Casellas-Grau et al., 2017; Danhauer et al., 2013; Gesselman et al., 2016; Park et al., 2016; Rzeszutek et al., 2017; Shand et al., 2015). According to Park (2013), spirituality is a global source of knowledge that people rely on in meaning making and that will not necessarily predict good health outcome unless it goes through different pathways. In the case of breast cancer survivors in Ghana, the pathway between spirituality and PTG may include optimism and coping. Making religious or spiritual meaning to the cancer event may increase the person‟s sense of hope in a higher power or about life which may lead to developing PTG. In addition, making religious connotation to the cancer experience can lead to University of Ghana http://ugspace.ug.edu.gh 84 Posttraumatic Growth among Breast Cancer Survivors in Ghana one using more coping skills such as religious coping and positive reframing which has been found to be greatly linked to the development of PTG. There was also an indirect effect between Cognitive processing and PTG. This indirect effect is mediated by optimism, coping and social support. This result contradicts previous findings (Kolokotroni et al., 2014; Chan et al., 2011; Cohen & Numa, 2011; Gall et al., 2011; Bussell et al., 2010) who found that cognitive processing predicts PTG directly. Processing information that was acquired from the traumatic experience (breast cancer) has been identified as a situational source of meaning making and it may not per say predict health outcomes unless it goes through different pathways (Park, 2013). In this study, the use of optimism, coping and social support has been identified as the pathway that mediates the effect of cognitive processing of breast cancer and PTG. The ability to assimilate the new experience with the old information the women have about breast cancer can increase their level of optimism and hope about their self, their life and the world at large and this can lead to PTG. Also, a successful appraisal of the new information experienced by the women as a result of breast cancer may lead to the use of more coping strategies like acceptance, positive reframing, humor, planning etc. which may also facilitate them developing PTG. In addition, social support has been found to be a significant contextual factor that facilitates the cognitive processing of breast cancer and offer an alternative perspective about the condition which may lead to PTG (Kolokotroni et al., 2014). To explain the final model, Religiosity/Spirituality is operationalized as a person‟s strong urges to rely on and use resources in his or her religion to make meaning and representation and for that matter use religious themes as a process to rebuild his or her views about the world after an encounter with a cancer event. In other words, religiosity is viewed in this study as a sense of meaning making to challenging events in one‟s life which are mainly based on one‟s religious University of Ghana http://ugspace.ug.edu.gh 85 Posttraumatic Growth among Breast Cancer Survivors in Ghana beliefs. In contrast, cognitive processing is operationalized as an individual‟s ability to critically and analytically appraise a cancer event based on the information he/she has come to know through experiencing breast cancer; especially, information received from health professionals and other sources. Religiosity/Spirituality and Cognitive processing of the cancer are two sources of knowledge that have been identified by the meaning making model as global and situational meaning respectively (Park, 2013). As proposed by Janoff-Bulman (1992; 2006) in the Shattered assumption theory, after one encounters a breast cancer, his/her global view about is called into question. This causes what is termed as a cognitive dissonance (Festinger, 1957) which refers to the feelings of discomfort that result from holding two conflicting beliefs about a situation. In attempts to resolve this dissonance, according to the Organismic Valuing Theory (Joseph & Linley,2005; 2008), the individual engages in processes to accommodate and assimilate the new information they have acquired through their experience with breast cancer about life (situational meaning of breast cancer) to their already existing schemas (global meaning of breast cancer) (Park, 2013). Spirituality has been reported as one of the global source of knowledge that most people in most African societies use in making sense of their illnesses experiences (de-Graft Akins et al., 2012). Park (2013) also identified spirituality as a global source of meaning people make in the adverse situation. Situational sources of knowledge are obtained mainly based on information they obtain from sources such as their healthcare providers their appraisals of their ability to manage the illness and its anticipated impact on their future and their general sense of control over their lives (Park, 2013). The effects these sources have on health outcomes have been thought to be exerted through many different pathways. The model from this study supports the theory by Tedeschi and Calhoun (1995) which suggested that several psychosocial variables such as personality characteristics like optimism; coping and social support influence the University of Ghana http://ugspace.ug.edu.gh 86 Posttraumatic Growth among Breast Cancer Survivors in Ghana appraisal process through a complex relationship between these variables. This model is consistent with Schaefer and Moos‟ (1992) coping theory which suggested that individual characteristics, Environmental factors, and socioeconomic factors affect the appraisal processes and lead to health outcomes through a feedback loop that is linked with each other and have the potential to influence one another. Limitations of this study Several limitations to this study must be noted. First, the study included self-report data only and no observational or interview data so the responses might be socially desirable ones. Similarly, although regression analysis typically permits the inference of causality, this is not a controlled, experimentally manipulated study, and results must, therefore, be interpreted in this light. The findings from this study should be interpreted with care. Findings from this study reflect the views of a section of breast cancer survivors seeking care in a private hospital in Accra and Kumasi in Ghana and not the entire Ghanaian breast cancer survivors thus potentially limiting the generalizability of these results. Due in part to the small sample size and in part to a lack of theoretical basis, potential moderators of the relations explored in this study were not tested. Finally, in the model, the study did not examine the different types of cognitive processing as well different types of coping strategies and how they affect PTG. In addition, this study did not also take into account the subdomains of posttraumatic growth in the model. University of Ghana http://ugspace.ug.edu.gh 87 Posttraumatic Growth among Breast Cancer Survivors in Ghana Conclusion and Implications for Further Research Based on the findings from this study, it can be concluded that PTG is evident breast cancer survivors in Ghana and it happens in many domains in their lives. This is more evident in people who are Optimistic, use social support and have more coping skills. People who process their illness experience from religious perspective show PTG through being Optimistic and using more coping skills. On the other hand, people who process their illness experience from information unique to their illness experience show PTG through being Optimistic, using more coping skills and making use of social support. This confirms that positive cancer experience is greatly affected by both internal (optimism and coping abilities) as well as external (social support) factors. This is important information that clinicians taking care of breast cancer patients and survivors should take into consideration when planning both short-term and long- term intervention for rehabilitation. These findings are also essential for example in providing psychoeducation to the public. Findings from this study add additional information that can be included in training of healthcare professionals who will be caring for breast cancer patients. Future researchers should consider using other methods such as qualitative or mixed-methods to bring a clear understanding of the construct of Posttraumatic Growth within the Ghanaian context. Also, other psychosocial and cultural variables should be examined by future research. Since PTG is time bound, it is recommended that a longitudinal study should be employed by future researchers for a better understanding of the growth process. Future studies can explore other cancer and breast cancer populations to help throw more light on the construct of Posttraumatic Growth. Other studies can compare both the positive and negative outcomes of experiencing breast cancer to help give a holistic understanding of the posttraumatic experiences of breast cancer survivors. University of Ghana http://ugspace.ug.edu.gh 88 Posttraumatic Growth among Breast Cancer Survivors in Ghana REFERENCES Abdulrahman Jr., G.O., and Rahman, G.A. (2012) Epidemiology of Breast Cancer in Europe and Africa. Journal of Cancer Epidemiology, 2012, Article ID: 915610. http://dx.doi.org/10.1155/2012/915610 Aflakseir, A., et al. (2016). "The Role of Psychological Hardiness and Marital Satisfaction in Predicting Posttraumatic Growth in a Sample of Women With Breast Cancer in Isfahan." Iran J Cancer Prev 9(4): e4080. Ai, A. L., et al. (2013). "Posttraumatic growth in patients who survived cardiac surgery: the predictive and mediating roles of faith-based factors." J Behav Med 36(2): 186-198. Aikins, A. d.-G. (2005). "Healer shopping in Africa: new evidence from a rural-urban qualitative study of Ghanaian diabetes experiences." BMJ 331(7519): 737. Aitken-Swan, J. and E. C. Easson (1959). "Reactions of cancer patients on being told their diagnosis." Br Med J 1(5124): 779-783. Aldwin, C. M. (2007). Stress, coping, and development: An integrative Approach, 2nd Edition. New York: Guilford. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Archampong, E.Q. (1977). Breast Cancer. Ghana Med. J. 16(2): 63. Arpawong, T. E., et al. (2013). "Post-traumatic growth among an ethnically diverse sample of adolescent and young adult cancer survivors." Psychooncology 22(10): 2235-2244. Asumanu E, Vowotor R, Naaeder S.B. (2000). The pattern of breast diseases in Ghana. Ghana Med. J. 34:206-209 Atobrah, Deborah. (2013). “Breast Cancer Research in Ghana: a Focus on Social Science University of Ghana http://ugspace.ug.edu.gh 89 Posttraumatic Growth among Breast Cancer Survivors in Ghana Perspectives” In Aikins de-Graft Ama, et al. (Eds.) Chronic Non-Communicable Diseases in Ghana: Multidisciplinary Perspectives. University of Ghana Reader. Sub- Saharan Publishers: Accra Baako B. N. (1999). “Breast Cancer Screening in Ghana: Is There a Need?” Ghana Med J. Mar;33(1):9–12 Baglama, B. and I. E. Atak (2015). "Posttraumatic Growth and Related Factors among Postoperative Breast Cancer Patients." Procedia - Social and Behavioral Sciences 190: 448-454. Barthakur, M. S., et al. (2016). "Posttraumatic Growth in Women Survivors of Breast Cancer." Indian J Palliat Care 22(2): 157-162. Bellizzi, K. M. and T. O. Blank (2006). "Predicting posttraumatic growth in breast cancer survivors." Health Psychol 25(1): 47-56. Bellizzi, K. M., et al. (2010). "Posttraumatic growth and health-related quality of life in a racially diverse cohort of breast cancer survivors." J Health Psychol 15(4): 615-626. Boateng, R. (in press). Mental health, quality of life and life experiences Of ghanaian women living with breast cancer. Global Health, McMaster University. Bonsu, A. B., et al. (2014). "Living with Advanced Breast Cancer among Ghanaian Women: Emotional and Psychosocial Experiences." International Journal of Palliative Care 2014: 9. Bostock, L., et al. (2009). "Posttraumatic growth and optimism in health-related trauma: a systematic review." J Clin Psychol Med Settings 16(4): 281-296. Boyle, C. C., et al. (2016). "Posttraumatic growth in breast cancer survivors: does age matter?" Psychooncology. University of Ghana http://ugspace.ug.edu.gh 90 Posttraumatic Growth among Breast Cancer Survivors in Ghana Boyle, P. (2012). "Triple-negative breast cancer: epidemiological considerations and recommendations." Ann Oncol 23 Suppl 6: vi7-12. Bozo, O., et al. (2009). "The moderating role of different sources of perceived social support on the dispositional optimism-- posttraumatic growth relationship in postoperative breast cancer patients." J Health Psychol 14(7): 1009-1020. Brinton, L. A., et al. (2014). "Breast Cancer in Sub-Saharan Africa: Opportunities for Prevention." Breast cancer research and treatment 144(3): 467-478. Brix, S. A., et al. (2013). "Post-traumatic growth among elderly women with breast cancer compared to breast cancer-free women." Acta Oncol 52(2): 345-354. Brunet, J., et al. (2010). "The Posttraumatic Growth Inventory: an examination of the factor structure and invariance among breast cancer survivors." Psychooncology 19(8): 830- 838. Bussell, V. A. and M. J. Naus (2010). "A longitudinal investigation of coping and posttraumatic growth in breast cancer survivors." J Psychosoc Oncol 28(1): 61-78. Buyukasik-Colak, C., et al. (2012). "Mediating role of coping in the dispositional optimism- posttraumatic growth relation in breast cancer patients." J Psychol 146(5): 471-483. Byra, S. (2015). "Posttraumatic growth in people with traumatic long-term spinal cord injury: predictive role of basic hope and coping." Spinal Cord. Calhoun, L. G., & Tedeschi, R. G. (2001). Posttraumatic growth: The positive lessons of loss. In R. A. Neimeyer (Ed.), Meaning reconstruction and the experience of loss. Washington, DC: American Psychological Association. Cao, W., et al. (2017). "Modeling posttraumatic growth among cancer patients: The roles of University of Ghana http://ugspace.ug.edu.gh 91 Posttraumatic Growth among Breast Cancer Survivors in Ghana social support, appraisals, and adaptive coping." Psychooncology. Carver, C. S. (2005). Enhancing adaptation during treatment and the role of individual differences. Cancer, 104, 2602-2607. doi: 10.1002/cncr.21247 Carver, C. S. (1997). "You want to measure coping but your protocol‟ too long: Consider the Brief cope." Int J Behav Med 4(1): 92. Casellas-Grau, A., et al. (2017). "Psychological and Clinical Correlates of Posttraumatic Growth in Cancer. A Systematic and Critical Review." Psychooncology. Clegg-Lamptey, J. & W. Hodasi (2007). "A study of breast cancer in Korle Bu teaching hospital: Assessing the impact of health education." Ghana Med J 41. Clegg-Lamptey, J., et al. (2009). "Why Do Breast Cancer Patients Report Late or Abscond During Treatment in Ghana? A Pilot Study." Ghana Medical Journal 43(3): 127-131. Cohen, M. and M. Numa (2011). "Posttraumatic growth in breast cancer survivors: a comparison of volunteers and non-volunteers." Psychooncology 20(1): 69-76. Coleman, M. P., et al. (2008). "Cancer survival in five continents: a worldwide population-based study (CONCORD)." Lancet Oncol 9(8): 730-756. Cordova, M. J. (2008). Facilitating Posttraumatic Growth Following Cancer. Trauma, Recovery, and Growth, John Wiley & Sons, Inc.: 183-205. Cordova, M. J., et al. (2007). "Breast Cancer as Trauma: Posttraumatic Stress and Posttraumatic Growth." J Clin Psychol Med Settings 14(4): 308-319. Cormio, C., et al. (2017). "Posttraumatic growth and cancer: a study 5 years after treatment end." Supportive Care in Cancer 25(4): 1087-1096. Cummings, J. P. and K. I. Pargament (2010). "Medicine for the Spirit: Religious Coping in Individuals with Medical Conditions." Religions 1(1). University of Ghana http://ugspace.ug.edu.gh 92 Posttraumatic Growth among Breast Cancer Survivors in Ghana Cummings, J. P., et al. (2015). "Santa Clara Strength of Religious Faith Questionnaire: Psychometric analysis in older adults." Aging Ment Health 19(1): 86-97 Danhauer, S. C., et al. (2013). "Predictors of posttraumatic growth in women with breast cancer." Psychooncology 22(12): 2676-2683. Danhauer, S. C., et al. (2015). "Trajectories of Posttraumatic Growth and Associated Characteristics in Women with Breast Cancer." Ann Behav Med 49(5): 650-659. Davis, C. G., et al. (1998). "Making sense of loss and benefiting from the experience: two construals of meaning." J Pers Soc Psychol 75(2): 561-574 de Graft Aikins, A., et al. (2012). "Lay Representations of Chronic Diseases in Ghana: Implications for Primary Prevention." Ghana Medical Journal 46(2 Suppl): 59-68. Dirik, G. and A. N. Karanci (2008). "Variables related to posttraumatic growth in Turkish rheumatoid arthritis patients." J Clin Psychol Med Settings 15(3): 193-203. Dirik, G. and E. G. Yorulmaz (2016). "Positive Sides of the Disease: Posttraumatic Growth in Adults with Type 2 Diabetes." Behav Med: 1-10. Fallah R, Keshmir F, Kashani FL, Azargashb E, Akbari ME. (2012) “Post-traumatic growth in breast cancer patients: A qualitative phenomenological study”. MEJC.;3:35–44. Feder, A., et al. (2008). "Posttraumatic Growth in Former Vietnam Prisoners of War." Psychiatry: Interpersonal and Biological Processes 71(4): 359-370. Ferlay, J., et al. (2010). "Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008." Int J Cancer 127(12): 2893-2917. Festinger, L. (1962). "Cognitive dissonance." Scientific American 207(4): 93-107. Frazier, P. A. and M. E. Kaler (2006). "Assessing the validity of self-reported stress-related growth." J Consult Clin Psychol 74(5): 859-869. University of Ghana http://ugspace.ug.edu.gh 93 Posttraumatic Growth among Breast Cancer Survivors in Ghana Gall, T. L., et al. (2011). "The relationship between religious/spiritual factors and perceived growth following a diagnosis of breast cancer." Psychol Health 26(3): 287-305. Gangstad, B., et al. (2009). "Cognitive processing and posttraumatic growth after stroke." Rehabil Psychol 54(1): 69-75. George, D. and Mallery, P. (2010) SPSS for Windows Step by Step: A Simple Guide and Reference 17.0 Update. 10th Edition, Pearson, Boston. Gesselman, A. N., et al. (2016). "Spirituality, emotional distress, and post-traumatic growth in breast cancer survivors and their partners: an actor-partner interdependence modeling approach." Psychooncology. Gumus, A. B. and O. Cam (2008)."Effects of emotional support-focused nursing interventions on the psychosocial adjustment of breast cancer patients." Asian Pac J Cancer Prev 9: 691- 697. Rzeszutek, M., et al. (2017). "Stress coping strategies, spirituality, social support and posttraumatic growth in a Polish sample of rheumatoid arthritis patients." Psychol Health Med: 1-7. Hasson-Ohayon, I., et al. (2016). "The need for friendships and information: Dimensions of social support and posttraumatic growth among women with breast cancer." Palliat Support Care 14(4): 387-392. Hefferon, K., & Boniwell, I. (2011). Positive psychology: Theory, research and applications. London: McGraw-Hill. Hill, E. M. and K. Watkins (2017). "Women with Ovarian Cancer: Examining the Role of Social Support and Rumination in Posttraumatic Growth, Psychological Distress, and Psychological Well-being." J Clin Psychol Med Settings 24(1): 47-58. University of Ghana http://ugspace.ug.edu.gh 94 Posttraumatic Growth among Breast Cancer Survivors in Ghana Ho, S. M., et al. (2011). "Relationships between explanatory style, posttraumatic growth and posttraumatic stress disorder symptoms among Chinese breast cancer patients." Psychol Health 26(3): 269-285. İnan, F. Ş. and B. Üstün (2014). "Breast Cancer and Posttraumatic Growth." The Journal of Breast Health 10(2): 75-78. Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York: Free Press Janoff-Bulman, R. (2004). "Posttraumatic Growth: Three Explanatory Models." Psychological Inquiry 15(1): 30-34. Jansen, L., et al. (2011). "Benefit finding and post-traumatic growth in long-term colorectal cancer survivors: prevalence, determinants, and associations with quality of life." Br J Cancer 105(8): 1158-1165. Jeon, M., et al. (2015). "Post-traumatic growth in survivors of allogeneic hematopoietic stem cell transplantation." Psychooncology 24(8): 871-877. Jim, H. S. and P. B. Jacobsen (2008). "Posttraumatic stress and posttraumatic growth in cancer survivorship: a review." Cancer J 14(6): 414-419. Joseph, S. and P. A. Linley (2008). Positive Psychological Perspectives on Posttraumatic Stress: An Integrative Psychosocial Framework. Trauma, Recovery, and Growth, John Wiley & Sons, Inc.: 1-20. Joseph, S. and P. A. Linley (2005). "Positive Adjustment to Threatening Events: An Organismic Valuing Theory of Growth Through Adversity." Review of General Psychology 9(3): 262-280. Kangas, M., et al. (2002). "Posttraumatic stress disorder following cancer: A conceptual and University of Ghana http://ugspace.ug.edu.gh 95 Posttraumatic Growth among Breast Cancer Survivors in Ghana empirical review." Clin Psychol Rev 22(4): 499-524. Kim, M. Y. (2017). "Factors Influencing Posttraumatic Growth in Mothers of Children With Cancer." J Pediatr Oncol Nurs: 1043454217697021. Kolokotroni, P., et al. (2014). "Psychosocial factors related to posttraumatic growth in breast cancer survivors: a review." Women Health 54(6): 569-592. Koutrouli, N., et al. (2012). "Posttraumatic stress disorder and posttraumatic growth in breast cancer patients: a systematic review." Women Health 52(5): 503-516. Kyei, K. A., Oppong, S., D., Opoku, S. Y., Antwi, W. K. & Tagoe, S. (2014). Assessment on the quality of life of breast cancer patients undergoing radiation treatment in Ghana, World Journal of Psycho-Social Oncology, 3(2):13-19, Varanasi, India. Kubler-Ross, E. (1969) On Death and Dying. Macmillan, New York. Laryea, D. O., et al. (2014). "Cancer incidence in Ghana, 2012: evidence from a population- based cancer registry." BMC Cancer 14(1): 362. Lantz, P. M. and K. M. Booth (1998). "The social construction of the breast cancer epidemic." Soc Sci Med 46(7): 907-918. Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer. Lechner, S. C., Stoelb, B. L., & Antoni, M. H. (2008). Group-based therapies for benefit finding in cancer. In S. Joseph & A. Linley (Eds.), Trauma, recovery, and growth: Positive psychological perspectives on posttraumatic stress (pp. 207-231). Hoboken, NJ: Wiley Lelorain, S., et al. (2010). "Long term posttraumatic growth after breast cancer: prevalence, predictors and relationships with psychological health." J Clin Psychol Med Settings 17(1): 14-22. Lelorain, S., et al. (2012). "Posttraumatic growth in long term breast cancer survivors: relation to University of Ghana http://ugspace.ug.edu.gh 96 Posttraumatic Growth among Breast Cancer Survivors in Ghana coping, social support and cognitive processing." J Health Psychol 17(5): 627-639. Leventhal, H., et al. (2008). "Health Psychology: the Search for Pathways between Behavior and Health." Annu Rev Psychol 59: 477-505. Lindstrom, C. M., Cann, A., Calhoun, L. G., & Tedeschi, R. G. (2013). The relationship pf core belief challenge, rumination, disclosure, and socio-cultural elements to posttraumatic growth. Psychological Trauma: Theory, Research, Practice, and Policy, 5, 50–55 Linley, P. A. and S. Joseph (2004). "Positive change following trauma and adversity: a review." J Trauma Stress 17(1): 11-21. Linley, P. A., Joseph, S., & Goodfellow, B. (2008). Positive changes in outlook following trauma and their relationship to subsequent posttraumatic stress, depression, and anxiety. Journal of Social and Clinical Psychology, 27, 877-891. Liu, J. E., et al. (2014). "Posttraumatic growth and psychological distress in Chinese early-stage breast cancer survivors: a longitudinal study." Psychooncology 23(4): 437-443. Manne, S., et al. (2004). "Posttraumatic growth after breast cancer: patient, partner, and couple perspectives." Psychosom Med 66(3): 442-454. McDonough, M. H., et al. (2014). "Predicting changes in posttraumatic growth and subjective well-being among breast cancer survivors: the role of social support and stress." Psychooncology 23(1): 114-120. McGuire, S. (2016). "World Cancer Report 2014. Geneva, Switzerland: World Health Organization, International Agency for Research on Cancer, WHO Press, 2015." Adv Nutr 7(2): 418-419. Mehrabi, E., et al. (2015). "Post-traumatic growth: a qualitative analysis of experiences regarding University of Ghana http://ugspace.ug.edu.gh 97 Posttraumatic Growth among Breast Cancer Survivors in Ghana positive psychological changes among Iranian women with breast cancer." Electron Physician 7(5): 1239-1246. Mensah, A.C., Yarney, J., Nokoe, S.K., Opoku, S. and Clegg-Lamptey, J.N. (2016) Survival Outcomes of Breast Cancer in Ghana: An Analysis of Clinicopathological Features. Open Access Library Journal, 3: e2145. http://dx.doi.org/10.4236/oalib.1102145 Merck Manual of Diagnosis and Therapy (2003) Breast Disorders: Breast Cancer. Retrieved 5 February 2017. Moore, M., Davis, C., & Cadet, T. (2017). Growth through trauma: Posttraumatic growth in African American breast cancer survivors. Poster to be presented at the 21st Annual Conference of the Society of Social Work and Research (SSWR), New Orleans, LA., January 11-15, 2017 Mullan, F. (1985). "Seasons of survival: reflections of a physician with cancer." N Engl J Med 313(4): 270-273. Nenova, M., et al. (2013). "Posttraumatic growth, social support, and social constraint in hematopoietic stem cell transplant survivors." Psychooncology 22(1): 195-202. Nolen-Hoeksema, S. and C. G. Davis (1999). ""Thanks for sharing that": ruminators and their social support networks." J Pers Soc Psychol 77(4): 801-814. Oginska-Bulik, N. (2014). "[The role of coping strategies in posttraumatic growth in medical rescue workers]." Med Pr 65(2): 209-217. Oginska-Bulik, N. (2015). "Social support and negative and positive outcomes of experienced traumatic events in a group of male emergency service workers." Int J Occup Saf Ergon 21(2): 119-127. Oginska-Bulik, N. and M. Kobylarczyk (2015). "Relation between resiliency and post-traumatic University of Ghana http://ugspace.ug.edu.gh 98 Posttraumatic Growth among Breast Cancer Survivors in Ghana growth in a group of paramedics: The mediating role of coping strategies." Int J Occup Med Environ Health 28(4): 707-719. Oginska-Bulik, N. and M. Kobylarczyk (2015). "Relation between resiliency and post-traumatic growth in a group of paramedics: The mediating role of coping strategies." Int J Occup Med Environ Health 28(4): 707-719. Ohene-Yeboah, M. and E. Adjei (2012). "Breast Cancer in Kumasi, Ghana." Ghana Med J 46. Opoku, S. Y., et al. (2012). "Knowledge, attitudes, beliefs, behaviour and breast cancer screening practices in Ghana, West Africa." The Pan African Medical Journal 11: 28. Owiredu, W. K., et al. (2009). "Serum lipid profile of breast cancer patients." Pak J Biol Sci 12(4): 332-338. Ozkal, F. and Y. Arikan (2014). "The opinions of patients and patients relatives on announcement of the cancer diagnosis to the patient." Global Journal on Advances in Pure & Applied Sciences [Online] 4: 179-183. Pargament, K. I., et al. (2006). Spirituality: A Pathway to Posttraumatic Growth or Decline? Handbook of posttraumatic growth: Research & practice. Mahwah, NJ, US, Lawrence Erlbaum Associates Publishers: 121-137. Parikh, D., et al. (2015). "Post-traumatic stress disorder and post-traumatic growth in breast cancer patients--a systematic review." Asian Pac J Cancer Prev 16(2): 641-646. Park, C. L. (2010). Making sense of the meaning literature: An integrative review of meaning making and its effects on adjustment to stressful life events. Psychological Bulletin, 136, 257–301. doi: 10.1037/a0018301 Park, C. L. (2013). The meaning making model: A framework for understanding meaning, University of Ghana http://ugspace.ug.edu.gh 99 Posttraumatic Growth among Breast Cancer Survivors in Ghana spirituality, and stress-related growth in health psychology. Bulletin of the European HealthPsychology Society,15(2), 40-47 Park, C. L., & Folkman, S. (1997). Meaning in the context of stress and coping. Review of General Psychology, 1, 115-144. doi: 10.1037/1089-2680.1.2.115 Park, C. L., Folkman, S., & Bostrom, A. (2001). Appraisals of controllability and coping in caregivers and HIV+ men: Testing the goodness-of-fit hypothesis. Journal of Consulting and Clinical Psychology, 69, 481-488. doi: 10.1037/0022-006X.69.3.481 Park, C. L., et al. (2010). "Post-traumatic growth: finding positive meaning in cancer survivorship moderates the impact of intrusive thoughts on adjustment in younger adults." Psychooncology 19(11): 1139-1147. Park, J. H., et al. (2016). "Factors Influencing Posttraumatic Growth in Survivors of Breast Cancer." J Korean Acad Nurs 46(3): 454-462. Pat-Horenczyk, R., et al. (2015). "Posttraumatic Growth in Breast Cancer Survivors: Constructive and Illusory Aspects." J Trauma Stress 28(3): 214-222. Plante, T. G., et al. (1999). "Further Validation for the Santa Clara Strength of Religious Faith Questionnaire." Pastoral Psychology 48(1): 11-21. Prati, G. and L. Pietrantoni (2009). "Optimism, Social Support, and Coping Strategies As Factors Contributing to Posttraumatic Growth: A Meta-Analysis." Journal of Loss and Trauma 14(5): 364-388. Ramos, C., & Leal, I. (2013). Posttraumatic Growth in the Aftermath of Trauma: A Literature Review About Related Factors and Application Contexts. Psychology, Community & Health, 2(1), 43-54. doi:http://dx.doi.org/10.5964/pch.v2i1.39 Rahmani, A., et al. (2012). "Posttraumatic growth in Iranian cancer patients." Indian J Cancer University of Ghana http://ugspace.ug.edu.gh 100 Posttraumatic Growth among Breast Cancer Survivors in Ghana 49(3): 287-292. Ries Lag, H.D., Krapcho, M., Mariotto, A., Miller, B.A., et al. (2006) SEER Cancer Statistics Review, 1975-2003. Bethesda MD: National Cancer Institute, Based on November 2005 SEER Data Submission Posted to the SEER Website 2006. Ruini, C., et al. (2013). "Post-traumatic growth in breast cancer survivors: new insights into its relationships with well-being and distress." J Clin Psychol Med Settings 20(3): 383-391. Sariego, J. (2010). "Breast cancer in the young patient." Am Surg 76(12): 1397-1400. Sawyer, A., et al. (2010). "Posttraumatic growth and adjustment among individuals with cancer or HIV/AIDS: a meta-analysis." Clin Psychol Rev 30(4): 436-447. Schaefer, J. A. and R. H. Moos (1992). Life crises and personal growth. Personal coping: Theory, research, and application. Westport, CT, US, Praeger Publishers/Greenwood Publishing Group: 149-170. Scheier, M. F., Carver, C. S., & Bridges, M. W. (1994). Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): A re-evaluation of the Life Orientation Test. Journal of Personality and Social Psychology, 67, 1063-1078. Schmidt, S. D., et al. (2012). "The relationship of coping strategies, social support, and attachment style with posttraumatic growth in cancer survivors." J Health Psychol 17(7): 1033-1040. Schroevers, M. J., et al. (2010). "Type of social support matters for prediction of posttraumatic growth among cancer survivors." Psychooncology 19(1): 46-53. Schroevers, M. J., et al. (2011). "Cancer patients' experience of positive and negative changes due to the illness: relationships with psychological well-being, coping, and goal reengagement." Psychooncology 20(2): 165-172. University of Ghana http://ugspace.ug.edu.gh 101 Posttraumatic Growth among Breast Cancer Survivors in Ghana Schroevers, M. J. and I. Teo (2008). "The report of posttraumatic growth in Malaysian cancer patients: relationships with psychological distress and coping strategies." Psychooncology 17(12): 1239-1246. Sears, S. R., et al. (2003). "The yellow brick road and the emerald city: benefit finding, positive reappraisal coping and posttraumatic growth in women with early-stage breast cancer." Health Psychol 22(5): 487-497. Shand, LK, Cowlishaw, S, Brooker, JE, Burney, S, and Ricciardelli, LA (2015), Correlates of post-traumatic stress symptoms and growth in cancer patients: a systematic review and meta-analysis. Psycho-Oncology, 24, 624–634. doi: 10.1002/pon.3719. Sherr, L., et al. (2011). "HIV infection associated post-traumatic stress disorder and post- traumatic growth--a systematic review." Psychol Health Med 16(5): 612-629. Sim, B. Y., et al. (2015). "Post-traumatic growth in stomach cancer survivors: Prevalence, correlates, and relationship with health-related quality of life." Eur J Oncol Nurs 19(3): 230-236. Soo, H. and K. A. Sherman (2015). "Rumination, psychological distress and post-traumatic growth in women diagnosed with breast cancer." Psychooncology 24(1): 70-79. Stanton, A. L., et al. (2007). "Health psychology: psychological adjustment to chronic disease." Annu Rev Psychol 58: 565-592. Stanton, A. L., et al. (2006). "Posttraumatic growth after cancer." Handbook of posttraumatic growth: Research and practice: 138-175. Stark, A., et al. (2010). "African ancestry and higher prevalence of triple-negative breast cancer: findings from an international study." Cancer 116(21): 4926-4932. Stewart, B. W. and C. P. Wild (2014). "World Cancer report 2014." from University of Ghana http://ugspace.ug.edu.gh 102 Posttraumatic Growth among Breast Cancer Survivors in Ghana http://site.ebrary.com/id/11014806. Svetina, M. and K. Nastran (2012). "Family relationships and post-traumatic growth in breast cancer patients." Psychiatr Danub 24(3): 298-306. Tabachnick, B. G. and L. S. Fidell (2013). Using multivariate statistics. Boston, Pearson Education. Taku, K., et al. (2009). "Intrusive versus deliberate rumination in posttraumatic growth across US and Japanese samples." Anxiety Stress Coping 22(2): 129-136. Tanriverd, D., et al. (2012). "Posttraumatic growth and social support in Turkish patients with cancer." Asian Pac J Cancer Prev 13(9): 4311-4314. Tanyi, Z., et al. (2015). "Positive consequences of cancer: exploring relationships among posttraumatic growth, adult attachment, and quality of life." Tumori 101(2): 223-231. Tedeschi, R. G., & Calhoun, L. G. (1995). Trauma and Transformation: Growing in the aftermath of suffering. Thousand Oaks, CA: Sage Tedeschi, R. G., & Calhoun, L. G. (1996). The Posttraumatic Growth Inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9, 455-471 Tedeschi, R. G. and L. G. Calhoun (2004). "TARGET ARTICLE: "Posttraumatic Growth: Conceptual Foundations and Empirical Evidence"." Psychological Inquiry 15(1): 1-18. Tomich, P. L. and V. S. Helgeson (2012). "Posttraumatic growth following cancer: links to quality of life." J Trauma Stress 25(5): 567-573. Torre, L. A., et al. (2015). "Global cancer statistics, 2012." CA Cancer J Clin 65(2): 87-108 Turner-Sack, A. M., et al. (2012). "Posttraumatic growth, coping strategies, and psychological distress in adolescent survivors of cancer." J Pediatr Oncol Nurs 29(2): 70-79. Turner-Sack, A. M., et al. (2016). "Psychological Functioning, Post-Traumatic Growth, and University of Ghana http://ugspace.ug.edu.gh 103 Posttraumatic Growth among Breast Cancer Survivors in Ghana Coping in Parents and Siblings of Adolescent Cancer Survivors." Oncol Nurs Forum 43(1): 48-56. Wang, M. L., et al. (2014). "Posttraumatic growth and associated socio-demographic and clinical factors in Chinese breast cancer survivors." Eur J Oncol Nurs 18(5): 478-483. Weinstein, S. E. and K. S. Quigley (2006). "Locus of Control Predicts Appraisals and Cardiovascular Reactivity to a Novel Active Coping Task." J Pers 74(3): 911-932. Weiss, T. (2002). "Posttraumatic Growth in Women with Breast Cancer and Their Husbands." J Psychosoc Oncol 20(2): 65-80. Williams, R. M., Davis, M. C., & Millsap, R. E. (2002). Development of the Cognitive processing of trauma scale. Clinical Psychology and Psychotherapy, 9(5), 349-360. DOI: 10.1002/cpp.343 Yeung, N. C. and Q. Lu (2016). "Perceived Stress as a Mediator Between Social Support and Posttraumatic Growth Among Chinese American Breast Cancer Survivors." Cancer Nurs. Yeung, N. C., et al. (2016). "The roles of needs satisfaction, cognitive appraisals, and coping strategies in promoting posttraumatic growth: A stress and coping perspective." Psychol Trauma 8(3): 284-292. Yi, J., et al. (2015). "Posttraumatic Growth Outcomes and Their Correlates Among Young Adult Survivors of Childhood Cancer." J Pediatr Psychol 40(9): 981-991. Zimet, G. D., et al. (1988). "The Multidimensional Scale of Perceived Social Support." J Pers Assess 52(1): 30-41. Zhou, X. and X. Wu (2016). "The relationship between rumination, posttraumatic stress disorder, and posttraumatic growth among Chinese adolescents after earthquake: A longitudinal study." J Affect Disord 193: 242-248. University of Ghana http://ugspace.ug.edu.gh 104 Posttraumatic Growth among Breast Cancer Survivors in Ghana Zhou, X. and X. Wu (2015). "Longitudinal relationships between gratitude, deliberate rumination, and posttraumatic growth in adolescents following the Wenchuan earthquake in China." Scand J Psychol 56(5): 567-572. Zhou, X., et al. (2016). "The role of posttraumatic fear and social support in the relationship between trauma severity and posttraumatic growth among adolescent survivors of the Yaan earthquake." Int J Psychol. Zhou, X., et al. (2017). "Understanding the relationship between social support and posttraumatic stress disorder/posttraumatic growth among adolescents after Ya'an earthquake: The role of emotion regulation." Psychol Trauma 9(2): 214-221. University of Ghana http://ugspace.ug.edu.gh 105 Posttraumatic Growth among Breast Cancer Survivors in Ghana APPENDICES APPENDIX 1: QUESTIONNAIRE Questionnaire Number: _________________ Section A (Sociodemographic information) 1. Age __________________ 2. Marital Status: Single Married Divorced Widow 3. Level of Education: No school Primary/JHS Secondary/vocational Tertiary 4. Current employment status: Not employed Employed full-time Employed part-time Self -Employed Student 5. Religion: Christianity I s lam African Traditional No Religion Other (Please Specify) __________________ 6. Number of years of survival form Breast Cancer: __________________ University of Ghana http://ugspace.ug.edu.gh 106 Posttraumatic Growth among Breast Cancer Survivors in Ghana Section B (Posttraumatic Growth Inventory) Indicate for each of the statements below the degree to which this change occurred in your life as a result of the experience of breast cancer, using the following scale. 1 = I did not experience this change 2 = I experienced this change to a very small degree 3 = I experienced this change to a small degree 4 = I experienced this change to a moderate degree 5 = I experienced this change to a great degree 6 = I experienced this change to a very great degree 1 2 3 4 5 6 I did not I I I experienced I I experience experienced experienced this change experienced experienced this this change this change to a this change this change change to a very to a small moderate to a great to a very small degree degree degree degree great degree 1 I changed my priorities about what is important in life. 2 I have a greater appreciation for the value of my own life. Decisions I developed new interests. 4 I have a greater feeling of self- reliance. 5 I have a better understanding of spiritual matters. 6 I more clearly see that I can count on people in times of trouble. 7 I established a new path for my life. 8 I have a greater sense of closeness with others. 9 I am more willing to express my emotions. 10 I know better that I can handle University of Ghana http://ugspace.ug.edu.gh 107 Posttraumatic Growth among Breast Cancer Survivors in Ghana 1 2 3 4 5 6 I did not I I I experienced I I experience experienced experienced this change experienced experienced this this change this change to a this change this change change to a very to a small moderate to a great to a very small degree degree degree degree great degree difficulties. 11 I am able to do better things with my life. 12 I am better able to accept the way things work out. 13 I can better appreciate each day. 14 New opportunities are available which wouldn‟t have been otherwise. 15 I have more compassion for others. 16 I put more effort into my relationships. 17 I am more likely to try to change things which need changing. 18 I have a stronger religious faith. 19 I discovered that I‟m stronger than I thought I was. 20 I learned a great deal about how wonderful people are. 21 I better accept needing others. University of Ghana http://ugspace.ug.edu.gh 108 Posttraumatic Growth among Breast Cancer Survivors in Ghana Section C (Cognitive Processing of Trauma Scale) Please rate the extent to which you agree with each of the following statements, using the following rating scale: 1 = strongly disagree 2 = moderately disagree 3 = slightly disagree 4 = neither mainly agree nor disagree 5 = slightly agree 6 = moderately agree 7 = strongly agree 2 1 3 4 5 6 7 strongly moderately slightly neither slightly moderately Strongly disagree disagree disagree mainly agree agree agree agree nor disagree 1 There is ultimately more good than bad in this Breast cancer experience. 2 I have figured out how to cope with the distress of Breast Cancer Decisions I say to myself „this isn‟t real‟ 4 I have moved on and left Breast Cancer in the past 5 Overall, Breast Cancer feels resolved for me 6 I have come to terms with this experience of Breast Cancer 7 I often think, „if only I had done something different‟ 8 I blame myself for what happened 9 I refuse to believe that this really happened to me 10 I wish I could have handled this differently 11 Other people have had worse experiences than mine 12 I act as if this event never University of Ghana http://ugspace.ug.edu.gh 109 Posttraumatic Growth among Breast Cancer Survivors in Ghana 2 1 3 4 5 6 7 strongly moderately slightly neither slightly moderately Strongly disagree disagree disagree mainly agree agree agree agree nor disagree really happened 13 Even though my experience was difficult, I can think of ways that it could have been worse 14 My situation is not so bad compared to other peoples‟ situations 15 I am able to find positive aspects of the Breast Cancer 16 I have been able to find a „silver lining‟ after experiencing Breast Cancer 17 I pretend this didn‟t really happen University of Ghana http://ugspace.ug.edu.gh 110 Posttraumatic Growth among Breast Cancer Survivors in Ghana Section D (Life Orientation Test-Revised) Please be as honest and accurate as you can throughout. Try not to let your response to one statement influence your responses to other statements. There are no "correct" or "incorrect" answers. Answer according to your own feelings, rather than how you think "most people" would answer. 1 = I strongly disagree 2 = I disagree 3 = I neither agree nor disagree 4 = I agree 5 = I strongly agree 1 2 3 4 5 I strongly I I neither I agree I disagree disagree agree nor strongly disagree agree 1 In uncertain times, I usually expect the best. 2 It‟s easy for me to relax. Decisions If something can go wrong for me, it will. 4 I‟m always optimistic about my future. 5 I enjoy my friends a lot. 6 It‟s important for me to keep busy 7 I hardly ever expect things to go my way 8 I don‟t get upset too easily. 9 I rarely count on good things happening to me. 10 Overall, I expect more good things to happen to me than bad. University of Ghana http://ugspace.ug.edu.gh 111 Posttraumatic Growth among Breast Cancer Survivors in Ghana Section E (Santa Clara Strength of Religious Faith Questionnaire) Please answer the following questions about your religious faith using the scale below. Indicate the level of agreement (or disagreement) for each statement. 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree 1 2 3 4 strongly disagree agree strongly disagree agree 1 My religious faith is extremely important to me. 2 I pray daily. 3 I look to my faith as a source of inspiration. 4 I look to my faith as providing meaning and purpose in my life. 5 I consider myself active in my faith or church. 6 My faith is an important part of who I am as a person. 7 My relationship with God is extremely important to me. 8 I enjoy being around others who share my faith. 9 I look to my faith as a source of comfort. 10 My faith impacts many of my decisions. University of Ghana http://ugspace.ug.edu.gh 112 Posttraumatic Growth among Breast Cancer Survivors in Ghana Section F (Brief Cope) These items deal with the ways you‟ve been coping with the stress associated with breast cancer. There are many ways to try to deal with problems. These items ask what you‟ve been doing to cope with breast cancer. Obviously, different people deal with things in different ways, but I‟m interested in how you‟ve tried to deal with it. Each item says something about a particular way of coping. I want to know to what extent you‟ve been doing what the item says. Don‟t answer on the basis of whether it seems to be working or not – just whether or not you‟re doing it. Use these response choices. Try to rate each item separately in your mind from the others. Make your answers as true for you as you can. 1= I haven’t been doing this at all 2= I have been doing this a little bit 3= I have been doing this a medium amount 4=I have been doing this a lot 1 2 3 4 I haven’t I have been I have been I have been been doing doing this a doing this a doing this a this at all little bit medium lot amount 1 I‟ve been turning to work or other activities to take my mind off things 2 I‟ve been concentrating my efforts on doing something about the situation I‟m in 3 I‟ve been saying to myself “this isn‟t real”. 4 I‟ve been using alcohol or other drugs to make myself feel better 5 I‟ve been getting emotional support from others 6 I‟ve been giving up trying to deal with it (the disease) 7 I‟ve been taking actions to try to make the situation better 8 I‟ve been refusing to believe that it has happened 9 I‟ve been saying things to let my unpleasant feelings escape 10 I‟ve been getting help and advice from other people 11 I‟ve been using alcohol and other drugs to help me get through it 12 I‟ve been trying to see it in a different light, to make it seem more positive 13 I‟ve been criticizing myself 14 I‟ve been trying to come up with a strategy about what to do 15 I‟ve been getting comfort and understanding University of Ghana http://ugspace.ug.edu.gh 113 Posttraumatic Growth among Breast Cancer Survivors in Ghana 1 2 3 4 I haven’t I have been I have been I have been been doing doing this a doing this a doing this a this at all little bit medium lot amount from someone 16 I‟ve been giving up the attempt to cope 17 I‟ve been looking for something good in what is happening 18 I‟ve been making jokes about it 19 I've been doing something to think about it less, such as going to movies, watching TV, reading, daydreaming, sleeping, or shopping 20 I‟ve been accepting the reality of the fact that it has happened 21 I‟ve been expressing my negative feelings 22 I‟ve been trying to find comfort in my religious or spiritual beliefs 23 I‟ve been trying to get advice or help from other people about what to do 24 I‟ve been learning to live with it 25 I‟ve been thinking hard about what steps to take 26 I‟ve been blaming myself for things that happened 27 I‟ve been praying or meditating 28 I‟ve been making fun of the situation University of Ghana http://ugspace.ug.edu.gh 114 Posttraumatic Growth among Breast Cancer Survivors in Ghana Section G (The Multidimensional Scale of Perceived Social Support) I am interested in how you feel about the following statements. Read each statement carefully. Indicate how much you agree or disagree to each statement. Use the following answers: 1= Very strongly Disagree 2= Strongly Disagree; 3= Mildly Disagree; 4= Neutral; 5= Mildly Agree; 6= Strongly Agree; 7= Very strongly Agree 1 2 3 4 5 6 7 Very Strongly Mildly Neutral Mildly Strongly Very strongly Disagree Disagree Agree Agree strongly Disagree Agree 1 There is a special person who is around when I am in need 2 There is a special person with whom I can share my joys and sorrows. 3 My family really tries to help me 4 I get the emotional help and support I need from my family. 5 I have a special person who is a real source of comfort to me 6 My friends really try to help me. 7 I can count on my friends when things go wrong. 8 I can talk about my problems with my family 9 I have friends with whom I can share my joys and sorrows. 10 There is a special person in my life who cares 11 My family is willing to help me make decisions. 12 I can talk about my problem with friends. University of Ghana http://ugspace.ug.edu.gh 115 Posttraumatic Growth among Breast Cancer Survivors in Ghana APPENDIX 2: Disease and Treatment Checklist 1. Type of Breast Cancer i. Ductal Carcinoma In Situ ii. Invasive Ductal Carcinoma iii. Tubular Carcinoma of the Breast iv. Medullary Carcinoma of the Breast v. Mucinous Carcinoma of the Breast vi. Papillary Carcinoma of the breast vii. Cribriform Carcinoma of the Breast viii. Invasive lobular Carcinoma ix. Inflammatory Breast Cancer x. Lobular Carcinoma In Situ xi. Paget‟s Disease of the Nipple xii. Phyllodes Tumor of the Breast xiii. Recurrent & Metastatic Breast Cancer 2. Stage of Breast Cancer: i. Stage I ii. Stage II iii. Stage III iv. Stage IV 3. Type of treatment: select as many as applicable i. Type of Surgery a. Lumpectomy b. Mastectomy ii. Radiotherapy iii. Chemotherapy iv. Hormone therapy University of Ghana http://ugspace.ug.edu.gh 116 Posttraumatic Growth among Breast Cancer Survivors in Ghana APPENDIX 3: Principal Component Analysis using Varimax with Kaiser Normalization of the Posttraumatic Growth Inventory. Component Communalities 1 2 3 4 PTG1 .279 -.034 .649 .031 .50 PTG2 .822 .053 .234 -.114 .75 PTG3 .014 .143 .820 .210 .74 PTG4 .475 -.147 .526 .174 .56 PTG5 .565 .364 .020 .294 .54 PTG6 .459 .590 -.023 .249 .62 PTG7 .270 .094 .699 -.271 .64 PTG8 .648 .310 .038 .447 .72 PTG9 .272 .128 .122 .769 .70 PTG10 .817 .180 .164 .204 .77 PTG11 .615 .514 .043 -.155 .67 PTG12 .207 .306 .482 .188 .40 PTG13 .793 .215 .222 .142 .75 PTG14 -.154 .280 .558 .514 .68 PTG15 .695 .376 .203 .110 .68 PTG16 .416 .685 .063 .214 .69 PTG17 -.072 .703 .448 -.041 .70 PTG18 .744 .349 .163 .053 .70 PTG19 .551 .304 .264 .316 .57 PTG20 .291 .751 .149 .047 .67 PTG21 .331 .730 -.037 .267 .71 Eigenvalue 8.76 2.14 1.70 1.15 %variance 41.70% 10.19% 8.11% 5.48% explained KMO statistic = .847; Bartlett test = 1383.65 (df = 210), p < .001. Factor loadings < .3 are Highlighted. University of Ghana http://ugspace.ug.edu.gh 117 Posttraumatic Growth among Breast Cancer Survivors in Ghana APPENDIX 4: Principal Component Analysis using Varimax with Kaiser Normalization of the Cognitive Processing of Trauma Scale Component Communalities 1 2 3 4 CPOTS1 .762 -.221 .270 .037 .70 CPOTS2 -.026 .097 .840 .108 .73 CPOTS3 -.579 .445 -.011 .166 .56 CPOTS4 .410 -.422 .436 .022 .54 CPOTS5 .252 -.290 .737 -.073 .70 CPOTS6 .385 -.233 .413 .370 .51 CPOTS7 -.302 .757 .085 .047 .67 CPOTS8 -.053 .821 -.009 -.256 .74 CPOTS9 .072 .654 -.121 -.064 .45 CPOTS10 -.171 .632 -.331 .184 .57 CPOTS11 .440 .016 -.139 .362 .34 CPOTS12 -.096 -.042 .028 .761 .59 CPOTS13 .513 -.328 .146 .344 .51 CPOTS14 .436 -.196 .088 .467 .46 CPOTS15 .837 -.015 .071 .028 .71 CPOTS16 .781 .016 .135 .157 .65 CPOTS17 .167 .068 .033 .689 .51 Eigenvalue 5.16 1.94 1.45 1.39 .70 %variance 30.37% 11.43% 8.53% 8.17% explained KMO statistic = .791; Bartlett test = 630.474 (df = 136), p < .001. Factor loadings < .3 are highlighted. University of Ghana http://ugspace.ug.edu.gh 118 Posttraumatic Growth among Breast Cancer Survivors in Ghana APPENDIX 5: Principal Component Analysis using Varimax with Kaiser Normalization of the Life Orientation Test. Component Communalities 1 2 3 LOT1 .744 -.137 .224 .62 LOT2 .120 .822 .124 .71 LOT3 .305 -.035 .749 .65 LOT4 .523 .674 -.118 .74 LOT5 -.203 .641 .397 .61 LOT6 .800 .137 .037 .66 LOT7 .020 .158 .803 .67 LOT8 .440 .203 .412 .41 LOT9 .527 .136 .319 .40 LOT10 .589 .511 -.040 .61 Eigenvalue 3.376 1.356 1.342 %variance 33.77% 13.56% 13.42% explained KMO statistic = .714; Bartlett test = 265.096 (df = 45), p < .001. Factor loadings < .3 are highlighted. APPENDIX 6: Principal Component Analysis using Varimax with Kaiser Normalization of the Santa Clara Strength of Religious Faith Questionnaire. Component Communalities 1 2 Religiousity1 .881 .157 .80 Religiousity2 .232 .770 .65 Religiousity3 .749 .141 .58 Religiousity4 .537 .173 .32 Religiousity5 .031 .765 .59 Religiousity6 .842 .107 .72 Religiousity7 .717 .102 .52 Religiousity8 .139 .763 .60 Religiousity9 .532 .356 .41 Religiousity10 .549 .030 .30 Eigenvalue 4.012 1.477 %variance explained 40.12% 14.77% KMO statistic = .808; Bartlett test = 366.203 (df = 45), p < .001. Factor loadings < .3 are highlighted. University of Ghana http://ugspace.ug.edu.gh 119 Posttraumatic Growth among Breast Cancer Survivors in Ghana APPENDIX 7: Principal Component Analysis using Varimax with Kaiser Normalization of the Brief Cope. Component Communalities 1 2 3 4 5 6 7 8 Cope1 .213 -.095 -.021 .820 -.032 .133 .098 .080 .76 Cope2 .096 .072 .034 .125 .702 .251 -.007 .249 .65 Cope3 -.244 .243 .699 .059 -.169 .047 -.087 .165 .68 Cope4 -.013 .750 .056 -.251 .136 .016 .005 .079 .65 Cope5 .536 -.098 -.067 .243 .195 -.097 -.546 .224 .76 Cope6 .071 .681 .145 .173 -.084 -.113 .194 .145 .60 Cope7 .113 -.056 -.111 .111 .187 -.025 .029 .861 .82 Cope8 -.025 .192 .349 .035 -.547 -.066 -.192 .399 .66 Cope9 .814 .079 -.078 .056 -.191 .118 .235 .108 .80 Cope10 .782 -.284 .035 .171 .307 -.001 -.190 .182 .89 Cope11 -.042 .815 .175 .030 -.014 .116 -.018 -.181 .74 Cope12 .701 -.118 -.112 -.066 .360 .192 .196 .256 .79 Cope13 .041 .148 .790 -.056 .144 -.126 .195 -.248 .79 Cope14 .263 .156 .131 .296 .129 -.015 .729 .085 .75 Cope15 .805 -.058 -.114 .131 .109 -.115 -.304 -.029 .80 Cope16 -.124 .806 .267 .083 .027 .115 .048 -.076 .77 Cope17 .670 -.018 -.075 .258 -.175 -.045 -.085 -.064 .57 cope18 .832 .119 -.034 .072 .168 .214 .143 .026 .81 Cope19 .236 .159 .101 .735 .193 .174 .133 .070 .72 Cope20 .244 -.048 -.092 .521 .397 .030 -.174 .042 .53 Cope21 .256 .266 -.142 .198 .533 -.279 -.008 .126 .57 Cope22 .628 -.030 -.118 .158 .104 .563 .151 .095 .79 Cope23 .774 -.216 -.078 .153 .273 -.136 -.050 -.015 .77 Cope24 -.078 .122 .154 .173 .038 .712 -.020 -.039 .59 Cope25 .443 .280 -.172 .326 -.227 -.092 .222 -.138 .54 Cope26 -.162 .277 .799 -.013 -.173 .195 .061 -.045 .82 Cope27 .562 -.015 -.219 .063 .164 .530 .000 -.025 .68 Cope28 .865 .120 .002 .185 .049 -.094 .189 .002 .84 Eigenvalue 7.944 3.875 1.787 1.529 1.486 1.319 1.119 1.066 %variance 28.37% 13.84% 6.38% 5.46% 5.31% 4.71% 4% 3.81% explained KMO statistic = .729; Bartlett test = 1821.771 (df = 378), p < .001. Factor loadings < .3 are highlighted. University of Ghana http://ugspace.ug.edu.gh 120 Posttraumatic Growth among Breast Cancer Survivors in Ghana APPENDIX 8: Principal Component Analysis using Varimax with Kaiser Normalization of the Multidimensional Scale of Perceived Social Support Component Communalities 1 2 SocialSupport1 .924 .140 .87 SocialSupport2 .895 .168 .83 SocialSupport3 .749 .378 .70 SocialSupport4 .808 .340 .77 SocialSupport5 .897 .208 .85 SocialSupport6 .265 .895 .87 SocialSupport7 .231 .865 .80 SocialSupport8 .663 .418 .61 SocialSupport9 .399 .782 .77 SocialSupport10 .871 .105 .77 SocialSupport11 .761 .344 .70 SocialSupport12 .083 .887 .79 Eigenvalue 7.364 1.973 %variance explained 61.37% 16.45% KMO statistic = .897; Bartlett test = 1347.412 (df = 66), p < .001. Factor loadings < .3 are highlighted. University of Ghana http://ugspace.ug.edu.gh 121 Posttraumatic Growth among Breast Cancer Survivors in Ghana APPENDIX 9: ETHICAL APPROVAL LETTER University of Ghana http://ugspace.ug.edu.gh 122 Posttraumatic Growth among Breast Cancer Survivors in Ghana APPENDIX 10: INTRODUCTORY LETTER. University of Ghana http://ugspace.ug.edu.gh 123 Posttraumatic Growth among Breast Cancer Survivors in Ghana Regression Tables Descriptive Statistics Mean Std. Deviation N Posttraumatic Growth 104.0667 14.59140 105 Age 52.9333 10.39255 105 Years of Survival 5.0067 3.29660 105 Optimism 27.9333 2.14506 105 Cognitive Processing 89.9524 7.64901 105 Religiosity 37.9048 2.42393 105 Coping 79.4952 9.88406 105 Social Support 4.7675 1.40401 105 Model Summary Std. Error Change Statistics R Adjusted of the R Square F Sig. F Model R Square R Square Estimate Change Change df1 df2 Change a 1 .258 .067 .049 14.23310 .067 3.651 2 102 .029 b 2 .724 .524 .490 10.42181 .457 18.649 5 97 .000 a. Predictors: (Constant), Years of Survival, Age b. Predictors: (Constant), Years of Survival, Age, Social Support, Cognitive Pros, Religiosity, Optimism, Coping a ANOVA Model Sum of Squares df Mean Square F Sig. b 1 Regression 1479.243 2 739.622 3.651 .029 Residual 20663.290 102 202.581 Total 22142.533 104 c 2 Regression 11606.956 7 1658.137 15.266 .000 Residual 10535.577 97 108.614 Total 22142.533 104 a. Dependent Variable: Posttraumatic Growth b. Predictors: (Constant), Years of Survival, Age c. Predictors: (Constant), Years of Survival, Age, Social Support, Cognitive Processing, Religiosity, Optimism, Coping University of Ghana http://ugspace.ug.edu.gh 124 Posttraumatic Growth among Breast Cancer Survivors in Ghana a Coefficients Unstandardized Standardized Collinearity Coefficients Coefficients Correlations Statistics Std. Zero- Model B Error Beta t Sig. order Partial Part Tolerance VIF 1 (Constant) 87.655 7.306 11.998 .000 Age .240 .136 .171 1.761 .081 .199 .172 .168 .973 1.028 YrSurv .743 .429 .168 1.730 .087 .196 .169 .165 .973 1.028 2 (Constant) -21.663 22.118 -.979 .330 Age .208 .103 .148 2.022 .046 .199 .201 .142 .916 1.092 YrSurv 1.386 .333 .313 4.166 .000 .196 .390 .292 .869 1.151 Optimism 2.603 .617 .383 4.220 .000 .528 .394 .296 .597 1.676 CoGPros -.049 .164 -.026 -.301 .764 .217 -.031 -.021 .664 1.506 Religiosity -.022 .523 -.004 -.042 .966 .335 -.004 -.003 .650 1.538 Coping .367 .159 .248 2.300 .024 .480 .227 .161 .421 2.377 Social 2.350 .938 .226 2.506 .014 .527 .247 .175 .602 1.661 Support a. Dependent Variable: Posttraumatic Growth a Excluded Variables Collinearity Statistics Partial Minimum Model Beta In t Sig. Correlation Tolerance VIF Tolerance b 1 Optimism .598 7.629 .000 .605 .953 1.050 .928 b CoGPros .249 2.660 .009 .256 .986 1.014 .963 b Religiosity .380 4.189 .000 .385 .958 1.044 .932 b Coping .534 6.406 .000 .538 .944 1.059 .922 b Social Support .538 6.739 .000 .557 .998 1.002 .972 a. Dependent Variable: Posttraumatic Growth b. Predictors in the Model: (Constant), Years of Survival, Age University of Ghana http://ugspace.ug.edu.gh 125 Posttraumatic Growth among Breast Cancer Survivors in Ghana a Collinearity Diagnostics Variance Proportions Social Mode Dimensio Eigenvalu Conditio (Constant Ag YrSur Optimis CoGPro Religiosit Copin Suppor l n e n Index ) e v m s y g t 1 1 2.773 1.000 .00 .00 .03 2 .209 3.643 .03 .03 .97 3 .019 12.224 .97 .97 .00 2 1 7.610 1.000 .00 .00 .00 .00 .00 .00 .00 .00 2 .283 5.184 .00 .00 .82 .00 .00 .00 .00 .01 3 .063 10.957 .00 .10 .03 .00 .00 .00 .00 .55 4 .028 16.371 .00 .80 .02 .00 .02 .00 .00 .14 5 .008 31.829 .02 .01 .01 .08 .08 .03 .43 .07 6 .004 42.070 .02 .03 .09 .08 .56 .03 .42 .17 7 .002 57.847 .04 .02 .00 .79 .05 .47 .00 .04 8 .001 73.331 .91 .05 .02 .05 .29 .46 .14 .02 a. Dependent Variable: Posttraumatic Growth University of Ghana http://ugspace.ug.edu.gh 126 Posttraumatic Growth among Breast Cancer Survivors in Ghana