Mensah et al. BMC Geriatrics (2023) 23:540 BMC Geriatrics https://doi.org/10.1186/s12877-023-04248-8 R E S E A R C H Open Access Impact of cancer diagnosis and treatment: a qualitative analysis of strains, resources and coping strategies among elderly patients in a rural setting in Ghana Adwoa Bemah Boamah Mensah1*, Maurice Mikare1,2, Kofi Boamah Mensah3, Joshua Okyere1,4, Er-Menan Amaniampong1,5, Abena Agyekum Poku1,6, Felix Apiribu1 and Joe-Nat Clegg Lamptey7,8 Abstract Background Rurality is fraught with numerous difficulties including a lack of advanced health facilities to provide health services, and an absence of specialist cancer services, and qualified personnel, among others. These factors exacerbate the challenges of elderly patients diagnosed with cancer and further pose limitations to activities/ instrumental activities of daily living. Yet, there is limited scholarship on the strains that affect elderly patients diagnosed with cancer and the resources that helps them to overcome them. This study explores the strains, resources, and coping strategies of elderly patients diagnosed with cancer and undergoing treatment in rural Ghana. Methods An exploratory, descriptive qualitative design was adopted. Purposive sampling was used to recruit 20 individuals to participate in in-depth interviews. The collected data was analysed inductively using Collaizi’s framework. QSR NVivo-12 was used in managing the data. Results The results were grouped into two main categories, namely: strains and resources. Within the category of strains, three main themes with their corresponding sub-themes emerged: cancer-related strains (systemic side effects from treatment, altered physical appearance and body image, and experience of pain), elderly strains (altered functional ability, limited social interactions and participation, psycho-emotional reactions, limited/ restricted economic participation, and financial strains), and health system strains (negative attitude and insensitive communication, delay in diagnosis, lack of geriatric oncology care, lack of community-based specialist cancer centre and long travel distance to access care, and limited availability of essential cancer medicines and other radiations services). Four types of resources were available to cancer patients: personal resources, family resources, community resources, and healthcare systems resources. Conclusion In conclusion, elderly patients diagnosed with cancer experience physical, economic, psychological, and emotional strains that threaten their health and well-being. However, they are able to leverage family, community, and health system-related resources to navigate through the strains. There is, therefore, a need to expand advanced *Correspondence: Adwoa Bemah Boamah Mensah bbemahc2000@gmail.com; abbmensah@knust.edu.gh Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Mensah et al. BMC Geriatrics (2023) 23:540 Page 2 of 17 health facilities with geriatric oncology units and specialists to improve access to cancer care in rural areas. The government needs to assist elderly persons with costs associated with their diagnosis and treatment through the expansion of the National Health Insurance Scheme to include this as part of the benefits package. Keywords Cancer, Coping strategies, Elderly, Resources, Strain, Qualitative research, Ghana Background (LMICs) exacerbates the impact of cancer and its treat- The global aging population is increasing exponentially, ment on patients. and is expected to reach 426 million by 2050, with more In Ghana, rurality is fraught with numerous difficul- than one in every five persons estimated to be 60 years ties including a lack of advanced health facilities to pro- or older by 2050 [1, 2]. These extra years are predomi- vide health services, absence of specialist cancer services nantly characterised by poor health such as increased and qualified personnel, long travel distance and finan- susceptibility to cancer, due to degenerative changes and cial costs to access healthcare, financial hardships due sedentary life that makes older adults relatively physi- to limited access to jobs, resulting in deepened poverty cally inactive [1–3]. For instance, by 2035, the number [17–19]. These factors magnify the challenges of elderly of cancer cases is predicted to increase by approximately patients diagnosed with cancer in rural communities 144% among the elderly in developing regions [4]. Ghana and further pose limitations to activities/instrumental is a sub-Saharan Africa (SSA) country on the Western activities of daily living, performance status, and quality coast of Africa with a population of nearly two million of life, reducing their overall survival [16, 20]. Yet, there (1,991,736) aged 60 years and older, comprising 1,129,906 is limited scholarship on the strains that affect elderly (56.7%) females and 861,830 (43.3%) males [5] who are at patients diagnosed with cancer and the resources that risk of developing cancer. In 2020 alone, 15,802 persons helps them to overcome these strains in sub-Saharan died of cancer in Ghana with approximately 8,399 older Africa, especially in Ghana where a substantial propor- persons being diagnosed with the disease [6]. A narrative tion of the elderly population is rural-domiciled [12, 13]. review on cancer control in Ghana indicates that 80% of This presents a significant gap in what we currently know elderly with cancer were living in rural areas and were about the resources that help elderly patients diagnosed commonly diagnosed at an advanced stage (stage III/IV) with cancer to cope with the strains that they experience. of the disease [7], many months (8–15 months) after first Considering this gap in the literature, this study explores noticing a sign or symptom of the disease [8]. This sta- the strains, resources, and coping strategies of elderly tistical evidence prospectively suggests that Ghana could patients diagnosed with cancer and undergoing treat- experience a rapid increase and deepened cancer-related ment in rural Ghana. Findings from this study provide health and economic burdens or needs among its older an insightful basis that could be used to inform practice adult population [9, 10], creating challenges for elderly and policy change to improve health outcomes of elderly cancer patients. According to the 2021 Annual Reports of patients living with cancer in rural areas. the Tamale Teaching Hospital, an average of 50 patients, 30 of which are elderly patients, seek cancer care from Methods the facility every month [11]. Study design Literature, however, indicates that the impact of cancer An exploratory, descriptive qualitative design was and its treatment for elderly patients living in rural areas adopted to explore and describe the strains, resources, is more pronounced and dire which greatly diminishes and coping strategies of elderly patients diagnosed with their health and well-being compared to urban areas [13– cancer [14, 15]. Anecdotal evidence suggests that elderly 15]. These areas are greatly deficient in healthcare access, patients living with cancer in rural Ghana might have specialised cancer services, and support resources as unique strains, resources, and coping strategies. Yet, found in many developing settings. For instance, in China studies reporting on the impact of cancer and its treat- and Mexico, rural areas have problems accessing cancer ment on these cohorts of patients are from developed care resources and inadequately qualified providers while countries and used quantitative study designs [16, 17]. faced with financial hardships [14], an absence of defini- Limited evidence focused on elderly patients living with tive treatment [13], and increased travel and financial the disease in sub-Saharan Africa, particularly, the elderly costs to access healthcare [16]. Webb et al. [15] added diagnosed with cancer in Ghana, and living in rural that aside from the limited qualified personnel, insuffi- communities. The design thus aided the comprehensive cient time and geriatric oncology principles being omit- understanding of the phenomenon under study. ted from formal training and continuous education of health professionals in low-and-middle-income countries Mensah et al. BMC Geriatrics (2023) 23:540 Page 3 of 17 Study setting to participate in the study after having been screened The study was conducted at the Tamale Teaching Hos- with the inclusion criteria. All 24 patients consented to pital (TTH). This is the only tertiary health facility pro- participate in the study. However, at the end of the study viding health services to the Northern region of Ghana. we had a sample of 20; these 20 participants provided This makes the hospital a major medical referral centre both in writing (n = 9) and thumbprints (n = 11). Partici- for the Savannah, Upper East, North-East, Northern, and pants’ identities were anonymised using unique study Upper West regions [18]. The hospital has a cancer treat- codes. The sample size of 20 was not predetermined but ment centre, launched in 2021 by the Ministry of Health was informed by theoretical data saturation since further (MoH) of Ghana () to provide medical oncology services interviews yielded no additional insights [22, 23]. As a to patients diagnosed with various forms of cancer such result, the study reached saturation on the 18th partici- as breast, cervical, and prostate cancers [19]. The can- pant after which two more interviews were conducted for cer unit at the Tamale Teaching hospital is managed by a confirmation. medical oncologist and two Oncology Nurse Specialists. The 2021 TTH Oncology Attendance Register indicates Data collection tool and interviews that the average monthly attendance is 50 with about 30 Data were collected by the second author between March out of this number being elderly [11]. Main services ren- 2021 and September 2021, through individual, in-depth dered by the clinic are scheduled reviews for chemother- face-to-face interviews using a semi-structured interview apy and hormonal therapy. Patients needing radiation guide (Supplementary File 1). The study’s objectives and therapy are referred to the National Center for Radio- existing literature informed the development of the inter- therapy and Nuclear Medicine at the Komfo Anokye view guide. Oncology specialists and research supervi- Teaching Hospital, Kumasi or Korle-Bu Teaching Hospi- sor (ABBM) reviewed the interview guide to ensure it tal, Accra. These characteristics made TTH suitable for captures issues around strains, resources, and coping this study. strategies. The research supervisor is an academic who has decades of experience in qualitative cancer research. Population ad sampling technique Guiding questions were piloted using four elderly Elderly diagnosed with and receiving treatment for can- patients diagnosed with and receiving treatment for cer in the Tamale Metropolis were targeted for the study. cancer from a private Oncology Centre in the Northern Eligibility criteria were: (i) aged 60 years and above; (ii) region. This helped to determine the sociocultural suit- histologically confirmed malignancy and receiving treat- ability, relevance, and clarity of questions, as well as an ment at TTH at the time of the study, (iii) fluently in the opportunity to practically correct the initial design and “Twi”, “Dagbani”, “Dagaare” or English language, which wording of the interview guide. Data from the pilot inter- were the fluent languages spoken by the researcher. views were excluded from the main findings. Patients below the age of 60 years and those too ill to Interview venue, date, and time were scheduled in line communicate were excluded from this study. Participants with the participants’ preferences. All interviews were were purposively recruited into the study [20, 21]. conducted in their homes which enhanced their comfort during the interviewing process. At the beginning of each Recruitment procedure and sample size interview, both written and oral consent was sought. The Cancer Unit of TTH was the main recruitment out- Interviews lasted for an average of 50 min. All interviews let for this study. Ethical approval was granted by the were conducted in the Dagbani and Dagaare local lan- Committee on Human Research, Publication, and Ethics guages, except three interviews that were done in the Twi (CHRPE) at the Kwame Nkrumah University of Science local language. Probes were thoughtfully and thoroughly and Technology (KNUST). The second author visited used to deeply explore and understand the strains, the clinic every week, on Tuesdays when cancer patients resources and coping strategies participants shared. were scheduled for consultation, to recruit participants. However, throughout the interviews, guiding questions This was assisted by a recruitment link (an oncology were not added on but rather shaped and rephrased nurse specialist at the Oncology unit). Participants whose based on emerging data prior to attaining data satura- eligibility was confirmed using the inclusion criteria tion. Though data saturation was reached on the 18th were engaged in a discussion and were given the study’s participant, data collection continued with 19th and 20th information sheet. To ensure that participation was vol- participants for confirmatory purposes. Field notes com- untary, eligible participants provided their informed con- prising participants’ non-verbal cues (sighs, silence, etc.), sent within one week and were reminded of their rights concerns, and interviewer reflections were captured. to withdraw from the study at any point in time without any repercussions. For the period of recruitment, there were 31 patients, however, only 24 of them were eligible Mensah et al. BMC Geriatrics (2023) 23:540 Page 4 of 17 Data analysis might affect the data curation, analysis, and interpreta- An inductive thematic analysis was done using Collaizi’s tion [24] was assessed. Through this, the first and third framework for qualitative analysis. After each day of authors disclosed extensive experience in clinical prac- data collection, the audio data was transcribed verbatim tice in oncology and qualitative research on cancer dis- in Twi, Dagbani, and Dagaare languages by the second eases. However, both authors are currently in academia author (MM). An independent back-back translation and not working in the study setting, and therefore could process of the anonymised transcripts was carried out not directly influence the study participants, site, meth- by three language experts who were fluent in both local odological approaches, and study findings. The second languages. The reason for transcribing on the same day author who conducted all the interviews is a trained of the interview was to enable the second author (MM) healthcare educator and researcher with substantial to identify questions that may have been left unanswered experience conducting in-depth interviews. This author during the interview. Subsequently, MM followed up on does not work in the study settings and had no direct such transcripts and questions to get detailed accounts relationship with the participants. None of the authors from the participants. After the transcription of the was related to or had any relations with any of the par- data, the transcripts were vetted and proofread by the ticipants. Adopting these rigorous processes in this study first, third and fourth authors. When this vetting pro- meticulously enhanced the credibility and trustworthi- cess was completed, the transcripts were made accessible ness of the study [25]. to the first and fourth author, who performed the ini- tial independent thematic analysis. The transcripts were Ethics Approvals imported into QSR NVivo-12 for data management and The study conforms to the Declaration of Helsinki. Ethi- analysis. All 20 transcripts were independently, repeat- cal approval was obtained from the Tamale Teaching edly, and thoroughly read by the first and fourth authors Hospital (TTH) and the Committee on Human Research, to familiarise themselves with the data. Using the ‘nodes’ Publication, and Ethics (CHRPE) at the Kwame Nkrumah function in QSR NVivo-12, codes were assigned to the University of Science and Technology (KNUST) (ref- significant recurring phrases or statements in the tran- erence number: CHRPE/AP/275/21) respectively. To scripts. ‘Meanings’ were then formulated from these protect the identities of the study participants, the tran- significant phrases or statements to depict and describe scripts and audio files were anonymised. An information the fundamental reasons for the various contexts of par- sheet containing the purpose of the study, procedures, ticipants’ strains, resources, and coping experiences. possible risks, and benefits, compensations, who to Clusters of themes were developed from formulated contact, and affirmation of confidentiality, privacy, and meanings based on their relationship and similarities. autonomy, was provided to the study participants. The Recurring codes that were similar were categorised to interviewer sought written and oral informed consent generate themes and sub-themes. Extracts and quotes from the participants as approved by the CHRPE. This from the themes and sub-themes generated were used to indicated their decision to voluntarily participate in our support the results of the study. We conducted member study after having read and understood the terms of ref- checking with five participants who confirmed that the erence. The audio files and transcripts were encrypted to findings reflected their perspectives. prevent unauthorised persons from having access to the data. Trustworthiness and researchers’ reflexivity Recognising the importance of rigour and trustworthi- Results ness in qualitative research, the authors worked to ensure Participants’ demographic characteristics confirmability and transferability. The study findings Interviews were conducted among twenty (20) par- were transferable and confirmable due to the detailed ticipants, three (3) males and seventeen (17) females. description of the study circumstances and techniques. Participants’ ages ranged between 60 and 89 years. The Member-checking with five of the participants was car- diagnosis of participants was cervical cancer (n = 8), ried out to establish credibility; this was done one week breast cancer (n = 8), hepatocellular carcinoma (n = 1), following the completion of the analysis. None of the throat cancer (n = 1), prostate cancer (n = 1), and chorio- participants submitted revisions or raised issues about carcinoma (n = 1). Participants had lived with the dis- the content and quality of the interviews in articulat- ease between 3 months to 3 years. Five (5) participants ing their perspectives. After each interview, field notes owned their businesses, five (5) were unemployed, four were taken and referred to during the analysis, which (4) were farmers, three (3) were petty traders and three included the participants’ nonverbal indications, worries, (3) were retired public servants. With regards to their and interviewers’ reflections. Prior to data collection, religious affiliations, ten (10) participants were Muslims, each author’s prior beliefs, experience, and attitude that nine (9) were Christians, and one (1) was a traditionalist. Mensah et al. BMC Geriatrics (2023) 23:540 Page 5 of 17 Participants were from varied ethnic groups with a Systemic side effects from treatment majority from Mole-Dagomba origin (see Supplementary Findings from the study revealed that participants expe- file 2). rienced numerous side effects from the treatments received. This included nausea or vomiting, pain, and Themes cramps, fever, diarrhoea, dizziness, and thirst usually Table  1 illustrates the themes and sub-themes associ- because of the toxicity associated with the treatments ated with the strains, resources, and coping strategies they undergo. The symptomatic consequences of treat- of elderly patients diagnosed with cancer. For strains ments received were similarly disclosed by participants in encountered by participants, three major themes were this study. For instance, participants revealed that when identified: cancer-related strains, elderly strains, and they receive chemotherapy or radiotherapy, they become health system strains. Major themes reflecting the nauseated and experience frequent bowel movements. resources and coping strategies of participants com- prised: personal resources, family resources, community “As I mentioned earlier, the disease has affected resources, and healthcare system resources. me because anytime I go for the treatment (chemo-therapy) it makes me experience diarrhoea.” (EP008, female, 80 years, Breast cancer). Strains Challenges posed by cancer diagnosis and treatment to older adult patients were explored in this study. These Other participants added that undergoing anti-cancer challenges are conceptualized as strains, three major therapy affected their eating habits. This was linked to themes associated with participants’ strains were iden- the frequent loss of appetite and vomiting experienced tified and categorised as: (i) cancer-related strains; (ii) because of the chemotherapy and radiation therapy. This elderly strains; and (iii) health system strains. is evidenced in the quotes below: “…I lost my appetite following the diagnosis. This Major theme #1: Cancer-related strains This major theme describes the challenges experienced got serious with the chemotherapy. For now, I can- by participants as a result of the disease and its related not eat at all. I feel nauseated and vomit a lot any- therapies. Sub-themes that emerged were (1) disease time I receive injections (chemotherapy), and I have and systemic effects from ttreatment, (2) changes in completely lost my appetite. The little I eat, I vomit physical appearance (skin change, hair loss, etc.), and (3) so I do not eat…” (EP006, female, 60 years, cervical restrained functional ability. cancer). Table 1 Theme and sub-themes Domain Theme Sub-themes Strains Cancer-related strains • Systemic side effects from treatment • Altered physical appearance and body image • Experience of pain Elderly strains • Altered functional ability • Limited social interactions and participation • Psycho-emotional reactions • Limited/restricted economic participation • Financial strains Health system strains • Negative attitude and insensitive communication • Delay in diagnosis • Lack of geriatric oncology care • Lack of community-based specialist cancer center and long travel distance to access care • Limited availability of essential cancer medicines and other radiations services Resources and coping Personal resources • Religious beliefs strategies • Accepting, adapting to one’s condition, and self-reliance Family resources • Spiritual support • Psychological and emotional support • Practical support with activities of daily living/instrumental activities of daily living • Financial resources and support Community resources • Financial and instrumental support from community members Healthcare systems resources. • Follow-up assistance health support/ assistance Mensah et al. BMC Geriatrics (2023) 23:540 Page 6 of 17 Altered physical appearance and body image was very painful…” (EP004, Male, 69 years, Throat This theme describes the experiences of participants cancer). relating to the effect of cancer therapy on their physical bodies and appearance. Participants experienced weight I have been having some burning sensations over my loss, skin discolorations, and hair loss. Weight loss was entire body…When I take the medicine…, the medi- linked to altered eating habits which stem from the side cine also causes severe abdominal pain. It is very effects of treatment such as loss of appetite, nausea, and discomforting…” (EP003, female, 64 years, cervical vomiting, coupled with diarrhoea. Participants described cancer). themselves as looking ‘lean’ when they compared their current weight to their previous weight. This is illustrated in the responses below: Major theme # 2: Elderly strains “I have lost weight. Prior to the treatment, I was not This theme describes various physical, psycho-emotional, like this. I have grown too lean due to the vomiting economic, and social difficulties posed to the participants and sometimes diarrhoea which occurs when I take due to their cancer conditions and associated treatments. the injections (chemotherapy) It has affected the way I look and am not happy about it.” (EP010, female, Altered functional ability 68 years, cervical cancer). Elderly’ ability to function daily was one of the key areas they faced challenges due to their cancer disease and treatment side effects. Daily functioning here implies Additional findings as shared by participants specified their ability to perform activities of daily living (ADLs). that undergoing chemotherapy led to hair loss and dis- These ADLs are categorised into basic and instrumen- coloration of skin and nails. Participants cited darkened tal activities of daily living (IADLs). While personal care skin and nail beds and related these colour changes to the activities including bathing, washing, dressing, and feed- toxicity of the cancer medications. These are illustrated ing remain basic ADLs, other activities such as perfor- in the expressions below: mance of house chores, meal preparations, and grocery “…see my head, all my hair is gone, also my nails and shopping are considered as IADLs. Participants in this my skin colour are becoming dark. Ah! but it was not study commonly shared limitations in their activities of there, it is when I started coming here [hospital] that daily living, affecting their ability to live independently. all these started so it is the treatment that is causing The ability to feed, become mobile, and groom one’s it.…” (EP002, female, 65 years, cervical cancer). self, were major areas of daily living activities that par-ticipants reported facing difficulties in performing. The expressions below illustrate participant’s constraints with ADLs: Experience of pain In this study, pain was a common feature that charac- “As you see me laying here now, I cannot bathe terised the development of the diseases and the expo- myself, I cannot groom myself and I feel weak when sure to anti-cancer medications. The pain was typically am walking. Things were not like this before the diag- described as burning sensations and abdominal contrac- nosis. The last time I walked to the urinary myself, I tions. The passion and emotions with which participants nearly fell so I have been advised not to walk there described the pains they experience inform the extent of alone.” (EP006, female, 60 years, cervical cancer). the pain they experienced. One of the participants, an 80-year-old woman suffering from breast cancer quizzed “The treatment I was given in Tamale has further while narrating her ordeal: made me weak and walking has become more diffi- cult. When I walk small, I have to sit down to rest, it “…the pain associated with this disease is not small, is always like this anything I take the chemotherapy” so how will this end?” (EP008, female, 80 years, (EP005, female, 64 years, Breast cancer). Breast cancer). An 85-year-old breast cancer patient further confirmed To the participants, the pain became worse after they had how being able to perform activities of daily living is cru- received treatments: cial to one’s independence. She explained: “Another thing that bothered me so much was the “Oh…it [the treatment] has really affected me pain I was going through. The pain was so severe because I cannot lift my hands due to the pain in that I couldn’t even bear. When I swallow saliva, it my shoulder after the surgery. And if you cannot lift Mensah et al. BMC Geriatrics (2023) 23:540 Page 7 of 17 your hands, how will I be able to bath. So I am not Psycho-emotional reactions able to bath unless I lie down for them to bath and This theme describes how being diagnosed with cancer dress me. .” (EP007, female, 85 years, cervical can- affected the psychological and emotional health of par- cer). ticipants. Being diagnosed with cancer in later life was characterised by negative stressors that adversely exerted Female participants expressed cultural obligations to dire consequences on the mental and emotional health maintaining their households. These include house of participants such as depression, worry anxiety, fear, chores, meal preparations, and grocery shopping. How- and distress. Participants related their psycho-emotional ever, in addition to facing difficulties performing the reactions to the news of the diagnosis, long travel to basic activities of daily living, female participants shared hospitals, increased hospital stays, cost of medical care, that their ability to perform these instrumental daily liv- side effects of cancer therapy, poor treatment outcomes, ing activities was greatly affected. These are illustrated in uncertainty about their recovery, and fear of death. This their responses below: is illustrated in the quotes below: “…For cooking too, I am not able to cook. I do not “…when I was told I had cancer I was so frightened. I think I could cook at this time with this disease…” thought the world had come to an end. Was so afraid (EP016, Female, 63 years, Choriocarcinoma). I will die. So honestly, I didn’t feel good at all and up till now, I don’t feel good with this disease. Imagine “…Also, with this heavy bleeding am not able to cook after all these years of suffering and labouring for me again but earlier I could so. the disease has affected to retire only to meet this disease…So now I am not me. Hmmm…” (EP003, female, 64 years, cervical happy at all… too disturbed emotionally.” (EP016, cancer). female, 63 years, Choriocarcinoma). “When I was told that it was cancer, I was very wor- Limited social interactions and participation ried and scared knowing and hearing about cancer. Side effects of treatment with its constrained functional I knew I was in a critical situation which is between ability made it impossible for the participants to engage life and death…I was scared and anxious and not in forms of social interactions and to participate in social sure of recovery…” (EP008, female, 80 years, Breast events such as group or association meetings, funerals, cancer). and church services. This failure on their part to attend social events in some instances led to their withdrawal Some of the participants further expressed worry and or being ostracised from their groups. This portrays how anxiety concerning the ability to finance their treatment. their disease worsens their social functioning and inte- This is borne out of the fact that cancer was regarded as gration into society. The following quotes reflect these a ‘disease of the rich.’ Hence living in a rural area where experiences of the participants: economic resources are scarce could limit the ability of “Now I cannot visit my friends and children as I use participants to finance their treatment. This was evident to. I have even stopped going to the pensioners’ asso- in the narratives of a participant as follows: ciation meeting, I use to be active in the association. “I had spent so much money moving from one Even funeral I cannot attend again. I urinate fre- facility to the other to get diagnosed, so when they quently due to the disease and the treatment always finally told me I have cancer, I was worried about makes me weak.” (EP017, male, 73 years, Prostate the money I will use to fund the treatment. I have cancer). always known cancer to be a disease of the rich. Living in a village with this disease was a source of “…and I use to be active in church as well but with worry because I do not have that kind of money to the weakness, I experience now I cannot always be cover the cost of care.” (EP002, female, 65 years, cer- in church…I am even scared to interact with people vical cancer). because of the bleeding. I don’t feel comfortable to even mixing with people because those who know you will be asking so many questions…” (EP016, Limited/restricted economic participation female, 63 years, Choriocarcinoma). This theme describes the economic and financial hard- ships faced by participants. Most participants in this study mainly earned their source of livelihood from their informal economic activities and being able to maintain Mensah et al. BMC Geriatrics (2023) 23:540 Page 8 of 17 these informal business activities was dependent on in their 3-weekly treatment cycles. For instance, not all their continuous engagement. However, with the advent the cancer drugs and laboratory investigations were listed of their disease, participants argued otherwise. This is as insured. There was also frequent shortage of insured because their disease subjected them to deteriorating cancer drugs, laboratory reagents, and other medi- physical strength since they easily become tired with the cal supplies at the hospital necessitating participants to least activity done. A 63-year-old female diagnosed with outsource these services from private institution out cervical cancer, who was involved in her business trades of pocket. Participants described this as expensive and explained saying: draining, causing a financial crisis. This is illustrated in “…It has affected my ability to work. I use to buy and the quotes below: sell things but now I can’t do them because of this “.…The treatment is very expensive. I have been disease. Others are older than me but they are still spending all my money and all these things [labo- doing their business very well so I still believe that ratory diagnostics, medications] we do here are not all these problems are from this disease.” (EP012, covered by the health insurance. I have to cough out female, 63 years, cervical cancer). the money, so I do not interrupt the chemotherapy. It is difficult…” (EP009, female, 70 years, cervical can- A male participant whose informal business activity cer). required him to physically move around to potential cus- tomers described how his inability to walk for longer dis- “The disease and treatment have brought financial tances limited his ability to market his business to others: hardship on me because the treatment process is costly…Is very difficult to get money lately because “I could not walk for long because of my condition, I am not working and have no source of regular and this has affected my ability to walk for long dis- income. Not all the medicines are under insurance, tances to potential customers since I get tired easily. so I pay for it. Most often, insured drugs are not Due to my condition, I am not able to talk or com- available when I visit for the injection (chemother- municate with people about my business anymore.” apy) so I have to buy from drug store at a very high (EP004, male, 69 years, Hepatocellular cancer). price. All the labs I am asked to do are not covered by insurance. I spend so much time every 3 weeks. Participants’ inability to engage in their usual economic Truthfully, sometimes I skip the treatment due to activities further affected their income generation. money.” (EP014, female, 75 years, breast cancer). Hence, the ‘insufficient monies’ as described by partici- pants were no longer earned. This was indicated by A Similarly, participants whose cancers were excluded from 70-year-old petty trader diagnosed with breast cancer: the NHIS package made out-of-pocket payments for all “Currently I cannot sit by my table to sell which diagnosis and treatment services, imposing greater finan- means that the small money I use to get is not also cial constraints on them. This led some to sell their life- coming again because of this disease.” (EP013, acquired properties to aid them access treatment. This female, 70 years, breast cancer). was affirmed in the response below: “My cancer is not supported by the insurance at all. Hence, I had to pay for everything from the diagnos- ing period. Every lab test I was made to do to con- Financial strains This theme describes the monetary challenges that par- firm the disease was very expensive. Then came the ticipants faced because of the costs associated with main cancer treatment! Things have not been easy at diagnosing and treating the disease. The participants all. Hardship upon hardship. I had no option but to expressed that despite their enrolment onto the national sell my farm in support of my treatment. The treat- health insurance scheme (NHIS), they still faced signifi- ment is draining…” (EP017, male, 73 years, Prostate cant financial constraints in respect to cancer manage- cancer). ment. This was mainly from ancillary health expenditure such as doctor’s consultation and treatment fees, medi- The cost of medical care was further worsened by other cation, and laboratory investigations. This was typically indirect costs such as transportation and feeding during described by the participants as ‘co-payment/top-up’ review visits. Due to the geographical location of the can- Other situations beyond participants’ control further cer center (capital city), most participants traveled long led them to frequently pay out of pocket for drugs and distances from their rural communities to access care on laboratory investigation services to avoid interruptions an outpatient basis via appointment. The travel and cost Mensah et al. BMC Geriatrics (2023) 23:540 Page 9 of 17 of living for this 3-weekly review visit exacerbated their Negative attitude and insensitive communication financial difficulties. This is evident in the narrations This theme describes various perceived negative attitudes below: health providers portrayed towards participants in this “…The cost of transportation from my village to study during their diagnosis and treatment. Participants Tamale is high. We come here very often and because complained of disrespectful and abusive care as well as I cannot walk, I have to always come with somebody the insensitive way some providers (including cancer in a chatted taxi which is expensive. As I sit, I don’t specialists) communicated with them and their accompa- work and have no regular source of income, so it is nying family caregivers. In some instances, the provider difficult…” (EP007, female, 85 years, breast cancer). displayed anger and talked rudely to participants when they are approached about chemotherapy administration. These are illustrated in the narrative below: “…Financially it has not been easy. At some points I could not even come to the hospital on the days “…some providers will not even listen to you when they asked me to come because I don’t even have the you are registering a concern. You know we do return lorry fare to transport myself from Navrongo all the travel from far for the treatment. We get here early way here [hospital in Tamale] …” (EP010, female, 68 in the morning by 6:30 am with the hope of returning years, cervical cancer). home early. Normally, after consultation, the doctor will tell you to go for the injections (chemotherapy) One’s inability to co-finance the treatment and its associ- which sometimes take up to 3hours of administra- ated cost suggested that treatment could be discontinued tion. However, the nurses will delay and keep you or delayed. This is portrayed by a 70-year-old petty trader waiting for hours and when you remind them of suffering from breast cancer: the chemo, they get angry and talk harshly to you as if you are a small child. They just disrespect you” “…When I reported to the hospital, they prescribed (EP009, female, 70 years, cervical cancer). some drugs which were not available, and I had to buy them from outside for the treatment. I was asked to also do some lab tests but I could not do it The lack of patience, lack of respect, and absence of com- because I had no money, hence, I went home without forting and encouraging words from health providers the treatment. Travel cost to Tamale (cancer center) were also identified by participants as healthcare system is also high and I have to always come with someone strain, they encountered. This is evident in the narration every 3 weeks. Looking at it, I had no option than below: to wait until I get the money, so I delayed the treat- “…As I said earlier if they give you a date and you ment for some months before coming back.” (EP013, don’t come on that date, they get angry, but they for- female, 70 years, breast cancer). get that we need money to come… They should be patient. They just give me a prescription for medi- Besides transportation costs, diagnostic or imaging pro- cine without adding anything. Some will not will cedures including laboratory tests, X-Rays and dressing even talk to you to encourage or comfort you. They of cancer wounds further heightened the financial bur- just want to give you medicine and go away.” (EP010, den on participants. These are illustrated below: female, 68 years, cervical cancer). “…See all these laboratory test and scans they made to do at Navrongo, they were very expensive. The dis- Some of the participants complained of not being directly ease has brought financial burden on me” (EP002, involved in their treatment decisions. They felt left out female, 65 years, cervical cancer). of the treatment plan and complained that no provider had open conversations with them regarding their diag- nosis, stage of the disease, treatment goals, and recov- ery. They wondered why physicians preferred to discuss Major theme # 3: Healthcare system strains issues regarding their disease conditions and treatment Almost all participants in this study talked about health with their children and other family caregivers who system strains and related them to unfavourable experi- accompany them to the hospital other than them. This is ences with providers during their diagnosis and treat- reflected in the expressions below: ment processes. Sub-themes identified include negative and insensitive communication and delays in diagnosis “It’s like when they diagnosed it, they do not discuss and treatment. anything with you the patient, they just barrel you into this protocol and you don’t have the oppor- Mensah et al. BMC Geriatrics (2023) 23:540 Page 10 of 17 tunity to ask questions about it and the treatment like the general population with minimal health condi- plan, no time to think…they only talk to the one tions. This they explained as: accompanying you to the hospital but not to you the adult patient. Even now I still have plenty of ques- “The workers [nurses and doctors] are just like those tions…” (EP005, Female, 64 years, breast cancer). who take care of me when I visit the general clinic. You know our condition, coupled with old age “No, they didn’t tell me anything. The test too, they requires much attention… As elderly patients, it will don’t tell me anything, as to why I have been put on be better we are attended to by professionals trained injections, I do not know. I am not involved in the on our condition [cancer].” (EP009, female, 70 years, decisions. They just short you when you try to ask.” cervical cancer). (EP003, female, 64 years, cervical cancer). “The doctors and nurses at the center are not spe- Participants further complained about the insensitive cially trained for cancer and elderly care. You can manner providers communicated with them. To them, see that…. You see, it is different when a specialist providers used inappropriate words loosely that con- attends to you! For this, I am treated like any other stantly reminded them of their impending death. Espe- patient at the general clinic (EP017, Male, 73 years, cially, when they report their pains and other distressing Prostate cancer). symptoms to them. This is illustrated in the quotes below: “I had pains and difficulty swallowing so I com- plained to the nurse…. she laughed and asked me to Lack of community-based specialist cancer center and long draw closer to God… That I should not worry even travel distance to access care if I die because I have already enjoyed all the good Health facilities within the communities of participants food in the world…, now I have cancer so anything were low level health facilities (i.e., health centers and can happen.” (EP004, Male, 69 years, Hepatocellular CHPS compounds) that do not have cancer units. Due cancer). to their geographical location, participants had to travel long distances and hours to be able to access special- ist cancer services, thus, posing geographical barriers in accessing healthcare. These health system barriers were Delay in diagnosis disclosed by participants below: This theme describes how participants felt the strain of delays in getting diagnoses or test results, and the strain “I have to be travelling long distances and hours to of having inadequate time to make complex medical the Tamale hospital to access care for my condition.” decisions. All the participants complained about the lack (EP004, male, 69 years, Throat cancer). of competence and skills among health providers in their local facilities (not the highly valued cancer specialists) “…Each time, I have to travel for hours to the Tamale who kept them for multiple reviews, repetitive diagnos- hospital or other city centers that have cancer cen- tic tests, misdiagnosis, and mistreatment before referring ters and doctors to be able to access care…in my them to a tertiary-level facility for specialist care. Some community, there is no such facilities or specialists to of this is related to delayed diagnosis: attend to us.” (EP020, female, 67 years, breast can- cer). “So, I kind of blame my original doctor at the local clinic for not picking up the signs earlier and for poor follow-up care. I reported to that clinic early, but the doctor was treating me with the wrong drugs and Limited availability of essential cancer medicines and other giving me dates to report back. He wasted all the radiation services time…” (EP006, female, 60 years, cervical cancer). According to participants, even after travelling to city centers with the needed cancer facilities and special- ists, they were faced with the problem of unavailable or insufficient medications since these facilities could Lack of geriatric oncology care not provide them with the medications to manage their The study found that health providers who provided care conditions: to participants were general health providers and nurses who do not have training in caring for elderly patients “I am not able to get all the medications for my injec- with cancers. This resulted in participants being managed tions [chemotherapy] most time I come. I always have to go from pharmacy to pharmacy searching Mensah et al. BMC Geriatrics (2023) 23:540 Page 11 of 17 for those medications…” (EP016, female, 63 years, resources, family resources, community resources, and Choriocarcinoma). healthcare systems resources. “When I come here, there has never been an instance Major theme #1: personal resources where they will say that they have the medications This theme describes how participants relied on their I need available. Always there is a shortage of my innate resources including religious beliefs and psycho- medications…” (EP011, female, 67 years, cervical logical resources to cope with the experiences and chal- cancer). lenges their conditions and treatment had subjected them to. Sub-themes identified included religious beliefs and Besides, depending on the nature and stage of partici- accepting, adapting to one’s condition, and self-reliance. pants’ cancer conditions, a combination of treatments involving chemotherapy, surgery and radiation therapy Religious beliefs were used to manage participants’ conditions. Although Beliefs were frequently mentioned as helpful by most participants can access the surgery and chemotherapy of our participants. Many Participants questioned why from the Tamale Teaching Hospital, the facility lacks they got cancer and sought for the strength to accept radiotherapy facilities. Hence, they are referred to other the uncertainty and challenges they faced, turned to or tertiary facilities in other regions to be able to access reconnected with their belief in a higher power. It is part these treatment services: of the process of searching for meaning in a situation that “…one of the issues is that this place they do not have defies their understanding. Participants expressed their all the treatment that I am supposed to undergo. The religious beliefs in the form of giving alms, having faith radiotherapy for instance, they said they do not have and belief in God, and surrendering their condition to the machine to do it for me. So, the doctor referred God through prayers. These were identified as significant me to the Komfo Anokye Teaching Hospital. That is personal resources adopted by participants to cope with where I go for that treatment all the time. I have to the strains associated with the cancer experiences. This is travel to the place from here [this region] …” (EP001, evident in the quotes below: Male, 61 years, Hepatocellular). “But I believe in God so that keeps me going. In my life, I have been through a lot of difficulties and dis- This also comes with its own challenges since they had eases, but God has always delivered me, and I know to travel to these distant regions, with no relatives to he will deliver me this time around too. Yea, yea … I host them. Their unfamiliarity with these geographical know God has a purpose for me.” (EP004, Male, 69 settings and health systems imposes some difficulties years, Throat cancer). on them such as increased travelling and accommoda- tion costs for themselves and their caregivers. This was Another reiterated the resourceful role of her religious shared: beliefs: “…travelling from the north to Accra is not an easy “…I was already bleeding so I was praying that God journey and the cost involved too. The sad part is should help the doctors to see the problem so that that when I get there with my daughter, we have to they will give me medications so that I will be free…” look for a place to sleep. We do not have any fam- (EP012, female 63 years, cervical cancer). ily members there. Sometimes we have to even sleep at the hospital opens paces since our money can- not afford a hotel throughout the treatment period and at the same time cater for the treatment costs. Accepting, adapting to one’s condition, and self-reliance Hmmm…” (EP007, female, 85 years, breast cancer). This theme describes personal psychological resources or characteristics developed and used by participants to cope with their condition. To address side effects, and psychological and emotional strains experienced, partici- Resources and coping strategies pants adjusted to their conditions by accepting and learn- Participants in the study were able to identify many posi- ing to stay with them. This strategy was summarised by tive things and characteristics of people that helped them EP001, a 61-year-old male Hepatocellular cancer patient: in dealing with the many strains associated with the can- “I have learned to stay with it.” (EP001). cer experience. These positive factors associated with the Being aware of the gravity and implications of hav- cancer experience are conceptualized as resources and ing a cancer, participants described how they employed coping strategies. Major themes identified are: personal Mensah et al. BMC Geriatrics (2023) 23:540 Page 12 of 17 mental, emotional, and behavioural changes to adapt to how they come to sit by me and talk to me is what is the situation still giving me hope to move on.” (EP010, female, 68 years, cervical cancer). “…With the changing of the sheets now I do it myself…Initially as I said everything was done for me. Now, most of these things [washing and chang- ing of bed sheets] I always try to do it myself, am Practical support with activities of daily living/instrumental not ready to give up now…” (EP004, Male, 69 years, activities of daily living Throat cancer). This theme describes the support provided by family members to help participants cope with their inability to perform their daily living activities and instrumental activities of daily living. Due to participants’ lack of func- Major theme # 2: family resources and support tional ability which limited their ability to perform both Various resources, and support obtained from family ADLs and IADLs, family members assumed the role of members are described under this theme. Sub-themes performing these essential activities of daily living to help identified comprised: spiritual support, psychological and participants have a quality life. These roles include assist- emotional support, practical support, financial resources, ing participants in bath, grooming themselves, and aiding and support. with cooking to ensure they eat. One of the participants described how his siblings and relatives helped him in Spiritual support performing these roles. Spiritual beliefs are used as a coping resource. This was reinforced by participants’ families. Family member as “… my sister and people are always around to pro- disclosed by participants strengthened their religious vide support for all practical activities such as wash- beliefs and spirituality through prayers and emphasised ing, cleaning, and cooking. So I don’t do anything.” on believing in God for recovery. This was shared by par- (EP004, Male, 69 years, Throat cancer). ticipants who clarified the spiritual support they received from their families: Another participant recounted how their children and “Mmm, they say that things will get better I should grandchildren aided them with their activities of daily liv- believe in God and pray, that one day I will be fine ing. They explained as follows: again. Even when the sickness started, we [patient “…They also cook for me to eat, wash my things when and family] did saraka [alms giving]” (EP001, Male, they are dirty and also support me in all my other 61 years, Hepatocellular). daily activities. My children and my brothers have been so helpful…” (EP009, female, 70 years, cervical “All those taking care of me at home I will say are cancer). doing well. They pray for me and support me spiritu- ally.” (EP009, female, 70 years, cervical cancer). Financial resources and support Though most participants complained about the height- Psychological and emotional support ened cost of treatment for their disease, family mem- This theme portrays how participants with cancer were bers acted as a major source of financial resources for supported by their family members to cope with the psy- their medical care and cost of living. EP009 for instance chological and emotional strains they experienced due revealed that her children catered for all the costs associ- to their diagnosis and treatment. Participants explained ated with her diagnosis and treatment though it has not that their family members acted as a major source of psy- been an easy task: chological and emotional resources that helped them to cope with their disease. Here, family members encour- “Now as am sitting here it is my children who are aged, and shared the participant’s sadness. These were supporting me bit by bit, they have to pay for the described in the comments below: laboratory investigations, the treatment, the cost of my transportation, and the person who will accom- “…They [my family] also give me encouragement and pany me here. They are doing their best.” (EP018, reassurance that I will be fine.” (EP003, female, 64 female, 66 years, cervical). years, cervical cancer). “It is my children who are helping to raise money “…They show me love and even encourage me…., to pay for the labs and other things. I have received Mensah et al. BMC Geriatrics (2023) 23:540 Page 13 of 17 so much financial support and I have never lacked women was specified by a participant who is a member of anything. If these supports were not available, I the club. She indicated: would have been dead by now…They have been very supportive, they are very good unless I don’t cough “…As a market woman I am a member of the women [ask or request]. When I cough [when I ask], they will group in the market so when I was taken ill, they provide…” (EP004, Male, 69 years, Throat cancer). contributed money to come and support me. They also come to visit me from time to time.” (EP012, female, 63 years, cervical cancer). Major theme # 3: community resources and support Participants in this study revealed that support from the Another participant who was faced with financial strains community provided them with useful resources to help to get her treatment commence after visiting several them cope with their strains. They were provided mon- health facilities to get diagnosed with cancer explained etary support, were visited, and assisted with tasks. Sup- how a health worker helped her by prosocial assisting her port from the community and support from the church to finance her treatment through an NGO foundation. were sub-themes that emerged. This is what she had to say: “Luckily when I came here and my money finished, Financial and instrumental support from community one of the doctors [Dr. A.M] added me to a certain members Forms of support provided by community members and foundation that helps old people and they hav- religious bodies are described under this theme. This ing been paying for my treatment anytime I come.” results in trust among members, and this leads to an (EP002, female, 65 years, cervical cancer). increased willingness to engage in helping behaviours. These helping behaviours could include comfort, emo- tional support, and instrumental support including finan- Major theme # 4: Healthcare system resources cial resources. Yet, in most instances, those who receive While participants noted strains that emanated from the such helping behaviours return the favour. Primarily, par- healthcare system, they explained how the healthcare ticipants explained that they received financial support, system facilitated access to resources to help them cope visits, and assistance from friends, neighbours, religious with their strains. Only one theme emerged from the institutions, and their social clubs to manage the strains data: health support/assistance. faced due to their treatment. One of the participants in this study revealed the support he received from his Follow-up health support/ assistance friends: It was found from the study that though the healthcare “They [friends] help me a lot because this my sick- system posed numerous strains to participants, some ness is about a year now and they support me a lot. characteristics of the healthcare system served as a They give me money; they contribute money, and resource for participants to cope with their health-related they also visit.” (EP001, male, 61 years, Hepatocel- strains. This was disclosed by a female participant in this lular). study: “…I have one doctor’s number. He gave me his num- With the mutual dependence and intimate familiarity ber to call him whenever I face any health issue after among rural dwellers, the basis for reciprocity was iden- attending to me. So I have been calling to complain tified. Helping others within the community creates the when am having any problem regarding the disease foundation for others to extend similar help in times of sometimes he will pick and direct me on what to do need as evidenced here: or encourage me to come to the hospital…” (EP010, female, 68 years, cervical cancer). “They are doing well; I was a cheerful giver, so my neighbours and friends express the same attitude to me. Some of my neighbours especially those I am in the same group with come around, and they send Discussion their contributions very often.” (EP004, male, 69 The study explores the strains associated with being diag- years, Throat cancer). nosed with cancer and the related treatments as well as resources and coping strategies used to address these strains among elderly patients in a rural setting in Ghana. The instrumental support, particularly monetary sup- The results from this study revealed that cancer diagno- port and visitations by a social club comprising market sis and treatment exposed persons living with cancer to Mensah et al. BMC Geriatrics (2023) 23:540 Page 14 of 17 side effects including diarrhoea, nausea, loss of appetite, covers breast and cervical cancers only [35–37] which and body weakness due to the chemotherapy and medi- does not absorb diagnostics and treatment costs. This cations which in turn made them appear physically lean led to increased financial burden and subjective financial compared to their previous weights, discoloured skin, toxicity among patients due to frequent travels to city and skin peeling off. This aligns with a previous study by centres to access oncology specialists, units and facilities, Invernizzi et al. [26] who reported that “pharmacothera- and co-payment despite not being economically active, pies and intrinsic tumour-related factors may lead to a which sometimes delayed and halted the treatment pro- wide spectrum of treatment-related disabling complica- cess till funds were obtained by these elderly patients. tions, such as breast cancer-related lymphedema, axil- This could deteriorate their life quality meaningfully and lary web syndrome, persistent pain, bone loss, arthralgia, increase their mortality. These findings underscore the and fatigue”. Consistent with previous studies [26–28] need for the NHIS and the three-tier pension scheme our study found that elderly patients experienced severe to respectively cover the cost of care in part or fully and pains characterised by burning sensations and abdominal help informal sector workers plan towards end-of-life for cramps, due to the disease and treatment they are under- the elderly. going. Though analgesics are prescribed for elderly can- Elderly patients’ physical immobility due to their dis- cer patients, ageing alters their physiology that reduces ease limited social interactions and participation in the metabolism, absorption, distribution, and purging of activities of sociocultural significance in their rural com- pharmacological palliatives [28, 29]. This creates the need munities, leading to some being withdrawn from the for a tailored approach to adequately control and man- groups, which could reduce treatment outcomes because age pains experienced by this cohort of cancer patients such social circles could enhance illness-management based on their geriatric specificities [30]. Accordingly, behaviours and treatment adherence [39]. Moreover, symptomatic characteristics of the disease and treatment the participants acknowledged that experiencing health toxicity including bodily weakness and pains, impaired system strains where health providers portrayed disre- the ability of these elderly patients to remain functional spectful, impatient attitudes, lack of encouraging and in terms of performing ADLs and IADLs because pain discomforting words, worsened by insensitive communi- reduced physical or muscle strength and endurance. The cation, not being directly involved in treatment decisions, pain intensity and severity experienced by the elderly as well as delay in diagnosis. Nukpezah et al. [40], how- limit their physical activity and functioning that threat- ever, reported that nurses globally are well-informed and ens their health-associated quality of life, life expectancy, play a crucial role in cancer treatment modalities. This and capacity to independently live in a society [31–33]. difference in findings might be due to the limited num- While other scholars attributed psychological and emo- ber of nurses with training in oncology and palliative care tional consequences of cancer disease and treatment to skills in Ghana. Also, the absence of shared decision con- unrelieved pain, their treatment decisions and prognosis, cerning treatment could limit full geriatric assessment and ageing process [34, 35] our findings suggested that and reduces the patient-centeredness of care which is uncertainty, poor treatment outcomes or recovery, fear important for elderly patients involved with multiple cli- of death, side effects from therapeutic procedures, cost of nicians [41, 42] as in this study. These findings highlight care, care-related expenses and inability to finance treat- the need for trained oncology and palliative nurses, a col- ments including hospital stays, and transportation were laborative model of care, and communication interven- crucial factors. This aligns with a previous study [36] that tions designed for elderly cancer patients. found the significance of high existential distress on poor Elderly patients were found to rely on personal, family quality of life of persons living with cancer. Compared to support and community resources to cope with strains developed countries, this resource-deprived rural setting experienced from their disease and treatment. Personal in Ghana lacks well-structured health facilities that pro- religious beliefs acted a source of positive reflections vide treatment options and reduce outcome uncertainties and thoughts that enhanced their perseverance in the as well as economic or welfare systems to offer financial face of their strains as found by Caplan et al. [43] and support throughout diagnosis and treatment, particu- Kahana et al. [44]. This supports the fact that the Gha- larly for the aged. In this rural setting, health services are naian, especially religious folks are inseparable from their provided through health centres and Community-based religion since it defines their thoughts and actions [45]. Health Planning and Services (CHPS) compounds [37, The elderly patients in this study were also able to garner 38] that lack oncology units, experts, and facilities to instrumental coping resources including assistance with diagnose and treat cancer diseases. Besides, the National ADLs/IADLs, financial support, spiritual, and emotion- Health Insurance Scheme (NHIS) aimed at eliminating focused strategies from their families and community cost barrier to healthcare access, only exempts the elderly members. However, in rural areas, it is worth noting that aged 70 years and above from paying premiums and intimate familiarity (near closeness to each other) and Mensah et al. BMC Geriatrics (2023) 23:540 Page 15 of 17 reciprocity (extending support to others in times of dif- List of abbreviationsADL Activities of daily living ficulties) [27] underpins instrumental support portrayed CHPS Community-based Health Planning and Services by community members as identified towards elderly CHPRE Committee on Human Research, Publication, and Ethics patients in this study. Problem-focused coping strategy IADL Instrumental activities of daily livingNHIS National Health Insurance Scheme where elderly cancer patients were assisted with some health workers to help cope with disease-related symp- toms experienced at home is also featured in the current Supplementary Information study. The online version contains supplementary material available at https://doi. org/10.1186/s12877-023-04248-8. Strengths and limitations of the study Supplementary Material 1 As a study that employed an exploratory design, the Supplementary Material 2 study was able to provide an in-depth exploration of the strains, resources and coping strategies of elderly patients diagnosed with cancer. Also, the study adopted appropri- Acknowledgements We are grateful to all participants who shared their experiences in this study. ate methodologies to arrive at the findings. Nevertheless, there are some limitations that must be considered. The Author contributions study was limited to only one specialised hospital. There- ABBM conceptualised the study, provided methodological insights, curated the data, and was a major contributor to the writing of the manuscript. fore, we cannot assume that their experiences necessar- MM and KBM also contributed to the conceptualization of the study, ily reflect all elderly patients who have been diagnosed methodology, investigation, and the writing of the manuscript. EA curated of cancer because the study did not capture the views of the data and contributed to the drafting of the original manuscript. FA and JO contributed to providing methodological insights, interpretation of the those who were not accessing the health facility. Also, data and the writing of the manuscript. ABBM and JO performed the formal the family caregivers of the patients were not included analysis. JCL provided methodological insights and supervised the study. All of in the study even though they play an essential role in authors read and approved the final manuscript. the journey of the elderly patient diagnosed with cancer. Funding There is also the likelihood of recall bias since this is a The authors received no financial support for the research and publication of self-reported study. this article. Data Availability Conclusion The datasets generated and/or analysed during the current study are This study highlights that elderly cancer patients in rural not publicly available due ethical reasons but are available from the corresponding author on reasonable request. areas in Ghana faced numerous strains associated with being diagnosed with cancer and treatment procedures. Declarations These elderly cohorts faced physical, economic, psycho- logical and emotional strains that threatens health and Competing interests wellbeing. However, they can leverage family, community The authors declare no competing interests. and health system related resources to navigate through Ethics approval and consent to participate the strains. The study has implications for policy and The study conforms to the Declaration of Helsinki. We received institutional cancer care for the elderly in rural settings. First, a need and ethical approval from the Tamale Teaching Hospital (TTH) and the Committee on Human Research, Publication, and Ethics (CHRPE) at the to expand advanced health facilities with geriatric oncol- Kwame Nkrumah University of Science and Technology (KNUST) (reference ogy units and specialists to improve access to cancer care number: CHRPE/AP/275/21) respectively. To protect the identities of our study in rural areas. This may potentially reduce the high-cost participants, the transcripts and audio files were anonymised. An information sheet containing the purpose of the study, procedures, possible risks, and burden associated with travelling to access diagnosis and benefits, compensations, who to contact, and affirmation of confidentiality, treatment. Also, a tailored approach to effective pain privacy, and autonomy, was provided to the study participants. We sought control and management among elderly cancer patients written and oral informed consent from the participants. informed by full geriatric assessment is required. Involv- Consent for publication ing elderly patients and their families in treatment deci- Not applicable. sions to improve the person-centred approach to cancer Author details diagnosis and treatment is also paramount. The results 1School of Nursing & Midwifery, College of Health Sciences, Private Mail from this study offer underlying reasons for trained bag, Kwame Nkrumah University of Science and Technology, University oncology and palliative nurses, a collaborative model Post Office, Kumasi, Ghana2Nursing and Midwifery Training College - Zuarungu, P. O. Box 660, of care, and communication interventions designed for Bolgatanga, Ghana elderly cancer patients. Finally, the government must 3Department of Pharmacy Practice, Faculty of Pharmacy and assist elderly persons with costs associated with their Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, University Post Office, Private Mail diagnosis and treatment through the expansion of the bag, Kumasi, Ghana NHIS to include this as part of the benefit package. Mensah et al. BMC Geriatrics (2023) 23:540 Page 16 of 17 4Department of Population and Health, University of Cape Coast, 18. Tamale Teaching Hospital. Tamale Teaching Hospital | Center of Excellence. University Post Office, Cape Coast, Ghana 2017 [cited 29 Aug 2022]. Available at: http://www.tth.gov.gh/. 5Department of Sociology and Social Work, Faculty of Social Sciences, 19. Graphic online. General news: Tamale teaching hospital gets cancer centre. 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