University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA SCHOOL OF NURSING AND MIDWIFERY EXPLORING THE WELLBEING OF MEN POST PROSTATECTOMY IN THE HO MUNICIPALITY, GHANA. CYRIL AKATOR (10702044) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MSC NURSING DEGREE JULY, 2019 University of Ghana http://ugspace.ug.edu.gh DECLARATION This dissertation is submitted to the School of Nursing and Midwifery, University of Ghana, in partial fulfilment of the requirement for the award of the Master of Science in Nursing degree. I, CYRIL AKATOR, hereby declare that with the exception of references and quotations from other sources which have all been duly cited, the study on “EXPLORING THE WELLBEING OF MEN POST PROSTATECTOMY IN THE HO MUNICIPALITY, GHANA” is my independent work under the supervision of PROF. LYDIA AZIATO and DR. LILLIAN AKORFA OHENE has not been presented or accepted in any previous application for the award of degree in any institution. ……………………………… …………………………… Cyril Akator Date (Student) ……………………………….. …………………………… Prof. Lydia Aziato Date (Supervisor) ……………………………… ……………………………. Dr. Lillian Akorfa Ohene Date (Co-Supervisor) i University of Ghana http://ugspace.ug.edu.gh DEDICATION This work is dedicated to my wife Freda Godsway Boso and my children Alvin, Malvin and Tasha. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT The contributions received from several people made this work possible. I thank God Almighty for giving me life and the will to start this journey in the first place. My profound gratitude goes to my supervisors Prof. Lydia Aziato and Dr. Lillian Akorfa Ohene for their support, patience, unquantifiable guidance and for this work. I am sincerely grateful to all the faculty members at the School of Nursing and Midwifery who helped me with this dissertation in diverse ways. My sincere gratitude goes to my father in law, Apostle S.M.K. Boso, whose support saw me through this journey. To my lovely wife, Freda and my wonderful children, Alvin, Malvin and Tasha, I say thank you for your patience and sacrifices. I am also very grateful to the management and staff of the Volta Regional Hospital for their support during recruitment of participants. I am grateful to all my colleagues and everyone that supported me through this journey. I also thank all the participants who availed themselves for this study. iii University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ................................................................................................................... i DEDICATION ...................................................................................................................... ii ACKNOWLEDGEMENT .................................................................................................. iii TABLE OF CONTENTS ..................................................................................................... iv LIST OF FIGURES .......................................................................................................... viii LIST OF ABBREVIATIONS .............................................................................................. ix ABSTRACT .......................................................................................................................... x CHAPTER ONE ................................................................................................................... 1 1.0 Introduction ................................................................................................................. 1 1.1 Background to the Study ............................................................................................. 1 1.2 Statement of the Problem ............................................................................................ 4 1.3 Purpose of the study .................................................................................................... 5 1.4 Specific objectives of the Study .................................................................................. 5 1.5 Research Questions ..................................................................................................... 6 1.6 Significance of the Study ............................................................................................ 6 1.7 Operational Definition of Terms ................................................................................. 6 CHAPTER TWO .................................................................................................................. 8 LITERATURE REVIEW...................................................................................................... 8 2.0 Introduction ................................................................................................................. 8 2.1 Justification of the Quality of life model applied to Cancer ....................................... 8 2.2 The Quality of Life Model by Betty Ferrell .............................................................. 10 2.3 Physical Wellbeing of men post prostatectomy ........................................................ 14 2.4 Social Wellbeing of men post prostatectomy ............................................................ 17 2.5 Psychological Wellbeing of men post prostatectomy ............................................... 20 2.6 Spiritual Wellbeing of men post prostatectomy ........................................................ 22 2.7 Life satisfaction ......................................................................................................... 25 2.8 Summary of Literature Review ................................................................................. 25 CHAPTER THREE ............................................................................................................. 27 METHODOLOGY .............................................................................................................. 27 3.0 Introduction ............................................................................................................... 27 3.1 Study design .............................................................................................................. 27 3.2 Research setting ......................................................................................................... 27 iv University of Ghana http://ugspace.ug.edu.gh 3.3 Target population ...................................................................................................... 28 3.3.1 Inclusion criteria ................................................................................................. 28 3.3.2 Exclusion criteria ................................................................................................ 29 3.4 Sample size and sampling technique ......................................................................... 29 3.5 Data collection procedure and tool ............................................................................ 30 3.6 Piloting of the interview guide .................................................................................. 31 3.7 Data management ...................................................................................................... 31 3.8 Data analysis .............................................................................................................. 31 3.9 Methodological Rigour .............................................................................................. 32 3.10 Ethical considerations .............................................................................................. 34 CHAPTER FOUR ............................................................................................................... 36 FINDINGS .......................................................................................................................... 36 4.0 Introduction ............................................................................................................... 36 4.1 Demographic characteristics ..................................................................................... 36 4.2 Physical wellbeing of men post prostatectomy ......................................................... 37 4.2.1 Pain ..................................................................................................................... 38 4.2.2 Fatigue ................................................................................................................ 39 4.2.3 Sleep disruption .................................................................................................. 40 4.2.4 Constipation ........................................................................................................ 41 4.2.5 Impaired bladder control ..................................................................................... 42 4.3 Social wellbeing of men post prostatectomy ............................................................. 43 4.3.1 Financial Burden ................................................................................................. 43 4.3.2 Isolation .............................................................................................................. 45 4.3.3 Reduction in work/Employment ......................................................................... 46 4.3.4 Affection/Sexual function ................................................................................... 47 4.3.5 Secrecy ................................................................................................................ 48 4.4 Psychological Wellbeing of men post prostatectomy ............................................... 49 4.4.1 Fear ..................................................................................................................... 49 4.4.2 Anxiety................................................................................................................ 50 4.4.3 Depression .......................................................................................................... 51 4.5 Spiritual wellbeing of men post prostatectomy ......................................................... 52 4.5.1 Meaning .............................................................................................................. 52 4.5.2 Religiosity ........................................................................................................... 54 4.5.3 Hope .................................................................................................................... 54 v University of Ghana http://ugspace.ug.edu.gh 4.5.4 Uncertainty.......................................................................................................... 55 4.6 Spousal support ......................................................................................................... 56 4.7 Alternative /complementary sources of treatment ..................................................... 57 4.8 Life Satisfaction ........................................................................................................ 58 4.9 Summary ................................................................................................................... 58 CHAPTER FIVE ................................................................................................................. 60 DISCUSSION OF FINDINGS ........................................................................................... 60 5.0 Introduction ............................................................................................................... 60 5.1 Demographic characteristics ..................................................................................... 60 5.2 Physical wellbeing of men post prostatectomy ......................................................... 61 5.3 Social wellbeing of men post prostatectomy ............................................................. 64 5.4 Psychological wellbeing of men post prostatectomy ................................................ 68 5.5 Spiritual wellbeing of men post prostatectomy ......................................................... 70 CHAPTER SIX ................................................................................................................... 78 SUMMARY, IMPLICATION, LIMITATION, CONCLUSION AND RECOMMENDATION ...................................................................................................... 78 6.0 Introduction ............................................................................................................... 78 6.1 Summary of the study ................................................................................................ 78 6.2 Implications for Nursing ........................................................................................... 80 6.2.1 Nursing Research/Avenues for future Research ................................................. 81 6.2.2 Nursing Education .............................................................................................. 81 6.2.3 Nursing Administration. ..................................................................................... 82 6.2.4 Nursing Practice .................................................................................................. 82 6.3 Insight Gained ........................................................................................................... 82 6.4 Limitation .................................................................................................................. 83 6.5 Conclusion ................................................................................................................. 83 6.6 Recommendations ..................................................................................................... 84 6.6.1 Ministry of Health ............................................................................................... 84 6.6.2 The Volta Regional Hospital .............................................................................. 84 REFERENCES .................................................................................................................... 86 APPENDICES .................................................................................................................. 113 APPENDIX A: BACKGROUND INFORMATION FORM ........................................ 113 APPENDIX B: INTERVIEW GUIDE .......................................................................... 114 APPENDIX C: CONSENT FORM ............................................................................... 116 vi University of Ghana http://ugspace.ug.edu.gh APPENDIX D: GENERAL PROFILE OF PARTICIPANTS ...................................... 123 APPENDIX E: SUMMARY OF THEMES .................................................................. 124 APPENDIX F: ETHICAL APPROVAL LETTER ....................................................... 125 APPENDIX G: INTRODUCTORY LETTER .............................................................. 126 APPENDIX H: APPROVAL LETTER FROM THE VOLTA REGIONAL HOSPITAL ....................................................................................................................................... 127 APPENDIX I: INTRODUCTORY LETTER TO VOLTA REGIONAL HOSPITAL . 128 vii University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Quality Of Life Model Applied To Cancer (1995).............................................. 12 Figure 2: Map of Ghana showing the Ho Municipality ...................................................... 28 viii University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS CAM…………………... Complementary and Alternative Medicine QoL……………………. Quality of Life ix University of Ghana http://ugspace.ug.edu.gh ABSTRACT Men who had prostatectomy are confronted with several negative health issues, some of which include pain, fatigue, sexual and urinary dysfunctions among others. The purpose of the study was to explore the wellbeing of men post prostatectomy in the Ho municipality in the Volta region of Ghana. The Quality of Life Model Applied to Cancer by Betty Ferrell (1995) was the organizing framework for this study. A qualitative exploratory descriptive design was employed. A purposive sampling technique was used and data was saturated with 13 participants. Data were collected with a semi-structured interview guide. All interviews were audio taped and transcribed verbatim. Data were analyzed using thematic content analysis. During the study, anonymity and confidentiality were ensured. The four themes specified by the model; the physical, social, psychological and spiritual well-being of cancer survivors were identified. Emerging themes were spousal support, complementary and alternative sources of treatment and life satisfaction. Most of the men experienced body pain, sleep disruption, fatigue, constipation and impaired bladder control. Their social wellbeing was affected by isolation, financial burden, secrecy, sexual dysfunctions and employment challenges. Psychologically, the men expressed fears and anxiety, experienced uncertainty and were depressed. Spiritually, men sought meaning to their illness by questioning God, they became more religious, and had hope that they will be better. They enjoyed tremendous support from their spouses. Men who survived prostate cancer resorted to complementary and alternative sources of treatment in the quest of getting a panacea for their illness. It was recommended that men be counselled and educated. In Conclusion, prostatectomy precipitated a lot of physical, psychological, social and spiritual lifelong challenges to men who had been diagnosed with prostate cancer. x University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.0 Introduction This chapter presents the background to the study, the problem statement, the purpose of the study, objectives and the research questions. The significance of the study and the operational definitions of keywords used are also presented. 1.1 Background to the Study According to GLOBOCAN (2018), the worldwide cancer scourge is appraised to have gone up to 18.1 million new cases and 9.6 million deaths in 2018 (GLOBOCAN, 2018). Up to 70% of the forecasted 24 million people at risk of being diagnosed with cancer yearly by 2050 will be from developing countries (Kingham et al., 2013). The incidence of cancer in these countries is on the ascendency due to lifestyle alterations, increased life expectancy, advancement in early diagnosis systems and advancement in treatment of infectious diseases (Kingham et al., 2013). In Ghana, cancer of the prostate has been implicated as the second commonest cause of cancer death in men (Wiredu & Armah, 2006). There is comparatively low level of research on prostate cancer incidence in Africa, and or across most African regions (Adeloye et al., 2016). While the GLOBOCAN studies have given estimates on major cancer types in Africa over the years, there are still worries if their evaluations really portrays the significance of cancer in the African population, especially due to the absence of data across many parts of Africa (Morhason-Bello et al., 2013). The rate of prostate cancer in Nigeria has in the past decade increased to as much as seven times those reported in the 1990s (Ajape, Babata, & Abiola, 2010). During a study that spanned a decade, over 500 genitourinary cancers were seen at the Korle-Bu Teaching Hospital in Ghana with prostate cancer the most prevalent (Ajape et al., 2010). It is still 1 University of Ghana http://ugspace.ug.edu.gh cumbersome to precisely delineate the burden of prostate cancer in Africa because of non- functional health management information system (Odedina et al., 2009). Prostatectomy is the most suggested surgery for patients diagnosed with confined prostate cancer, and it can bestow a life expectancy of more than 10 years for patients who have consented to the dangers of treatment associated consequences (Bill-Axelson et al., 2011). A number of men will be confronted with erectile dysfunction, urinary obstructive symptoms and some undesired changes in their bowel functioning alien to their confined cancer and these manifestations will exacerbate temporarily and in some instances permanently after a chosen cancer treatment (Sanda et al., 2008). In African countries, urologists also lack the requisite know-how to successfully perform corrective radical prostatectomies, and this is further compounded by the scarcity of artificial sphincters and needed devices useful in management of possible complications from the surgery (Kyei et al., 2013). Having an idea on the various dangers of the diverse treatment options is very imperative to making well thought treatment decisions, taking into cognizance that the continuity outcome is questionable, especially in patients who are at greater risks of prostate cancer (Hamdy et al., 2016). The undesirable outcomes of principal treatments for confined cancer can negatively affect quality of life (Bourke et al., 2015). The term wellbeing is often used in contexts which cut across mental, physical and emotional health as well as more abstract outlook of life satisfaction such as happiness. Wellbeing is also used universally and in various ways in health practice. However, there is limited understanding about the term use in the broader health perspective and how patients interpret it in relation to recovery from a disease condition or a surgical intervention (McMahon, Williams, & Tapsell, 2010). 2 University of Ghana http://ugspace.ug.edu.gh A prominent and often used definition of wellbeing in cancer survivors is one from Ferrell and Dow. They elucidated the realm for cancer survivors with four specifications; physical wellbeing is the control or relief of symptoms and the ability to have physical independence and ability to perform all the basic functions; psychological wellbeing is to experience a sense of control in the face of life against illness characterized by altered life priorities, emotional distress, and fear of the unknown as well as positive life change; social wellbeing is tuned by the effect of cancer on individuals, their roles and relationships and how effectively they can withstand those factors; spiritual wellbeing is hinged on how effective an individual can control uncertainty that is created by the hope and derived from the cancer experience (Nichols & Hunt, 2011). Moreover, wellbeing is also viewed by researchers as a dynamic and complex concept that has relevance to cancer patients’ care in nursing practice (Akugri, 2017). Admitting that cancer and its therapies can have an adverse long- term consequence on the quality of life has been increasing over the past 40 years. By the early 1980s, innovations such as tailored rehabilitation programs geared towards improving quality of life started to emerge (Bourke et al., 2015). Prostatectomy is the recommended surgical intervention for patients with limited prostate cancer, and it can provide a life expectancy of more than 10 years for those who accept the risk of treatment related complications (Bill-Axelson et al., 2011). There are several reports on complications and adverse events related to prostatectomy although life threatening ones are rare (Kakehi, Naito, & Association, 2008) . Complications resulting from prostatectomy can significantly influence men’s wellbeing and ultimately quality of life. These setbacks mostly include urinary incontinence and erectile dysfunction (Cornu et al., 2015). 3 University of Ghana http://ugspace.ug.edu.gh In recent times, research lens has been focused on showing and measuring wellbeing conclusions in combination with more tradition end points of survival and disease free status (Gacci et al., 2009). Many of the studies available on prostate cancer treatment are retrospective in nature and often have survival or death as endpoints of research rather than explaining the possibility that one can live life with quality as an outcome of a specific treatment (Vergis et al., 2008; Ward-Smith & Mehl, 2007; Waters, Yazer, Chen, & Kloke, 2012). This study adopted Betty Ferrell’s cancer specific model of Quality of life (1995) as the theoretical framework to guide the study. Betty Ferrell’s QoL model has the following domains; Physical wellbeing, Psychological wellbeing, spiritual wellbeing and social wellbeing which was utilized to explore the wellbeing of Ghanaian men in the Ho municipality post prostatectomy. 1.2 Statement of the Problem Prostatectomy is the most preferred surgical intervention for patients with confined prostate cancer, and it can bestow a life expectancy of more than 10 years for those who embrace the treatment related consequences (Bill-Axelson et al., 2011). There are several reports on complications and adverse events related to prostatectomy although life threatening ones are rare (Kakehi et al., 2008). Complications resulting from prostatectomy can greatly influence men’s wellbeing. (Iyigun, Ayhan, & Tastan, 2011). In recent times, research lens has been focused on showing and measuring wellbeing conclusions in combination with elaborate tradition end results of survival and healthy status (Bach, Döring, Gesenberg, Möhring, & Goepel, 2011). Many of the studies available on prostate cancer treatment are retrospective in nature and often have survival or death as 4 University of Ghana http://ugspace.ug.edu.gh endpoints of research rather than explaining the possibility that one can live life with quality as an outcome of a specific treatment (Vergis et al., 2008; Ward-Smith & Mehl, 2007; Waters et al., 2012). Preceding studies noted that African experienced diminished levels of physiological and psychological health in contrast to the levels noticed in white men (Assari, 2018; Chhatre, Wein, Malkowicz, & Jayadevappa, 2011; Gee, 2008). A grasp on the negative health mishaps experienced by African living with prostate cancer is imperative to effectively influence their health end results and enhance their general wellbeing (Dickey & Ogunsanya, 2018). Lastly, quantitative studies on men who had prostatectomy may not fully unravel important issues and their effects on the men’s wellbeing (Iyigun et al., 2011). There are very few studies that touched on the wellbeing of men post prostatectomy in Ghana due to the unavailability of a cancer registry in Ghana (Hsing et al., 2016). This study seeks to explore the wellbeing of Ghanaian men after prostatectomy using a qualitative approach. 1.3 Purpose of the study The purpose of the study is to explore the wellbeing of men post prostatectomy in the Ho municipality. 1.4 Specific objectives of the Study The specific objectives of this study are to: 1. Describe the physical wellbeing of men post prostatectomy. 2. Investigate the social wellbeing of men post prostatectomy. 3. Identify the psychological wellbeing of men post prostatectomy. 4. Elucidate the spiritual wellbeing of men post prostatectomy. 5 University of Ghana http://ugspace.ug.edu.gh 1.5 Research Questions 1. What is the physical wellbeing of men post prostatectomy? 2. What is the social wellbeing of men post prostatectomy? 3. What is the psychological wellbeing of men post prostatectomy? 4. What is the spiritual wellbeing of men post prostatectomy? 1.6 Significance of the Study The results of the research study will be of great importance to the Ministry of Health as a guide for policy formulation or policy reviews regarding prostate cancer management because accurate and relevant information is a prerequisite to the formulation and adoption of workable policies. Also, results of the study will bring to bear specific issues affecting the wellbeing of men who have undergone prostatectomy thereby, guiding major stakeholders of Health services in Ghana to come out with measures that will help improve the wellbeing of these men. Adding to the above, the findings in this study will inform the Ministry of Health and other stakeholders to come out with holistic ways of giving home-based nursing care to men who had prostatectomy. Moreover, findings of this study will go a long way to serve as a foundation of body of knowledge on prostate cancer in Ghana for researchers and give room for further studies on prostate cancer. 1.7 Operational Definition of Terms Wellbeing: The state of being comfortable, healthy or happy. Prostate cancer: Cancer that occurs in the prostate. Prostatectomy: A surgical operation to remove all or part of the prostate gland. 6 University of Ghana http://ugspace.ug.edu.gh Physical wellbeing: Wellbeing in the domain of fatigue, sleep disruption, function, nausea, appetite, constipation and aches/pain. Psychological wellbeing: Wellbeing in the domain of anxiety, depression, helplessness, difficulty sleeping, fear, useless, concentration, control and distress. Spiritual wellbeing: Wellbeing in the domain of meaning, uncertainty, hope, religiosity, transcendence and positive change. Social wellbeing: Wellbeing in the domain of isolation, role adjustment, financial burden, roles/relationships, affection/sexual function, leisure activities, burden and employment. 7 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.0 Introduction The literature review focused on the wellbeing of men who had undergone prostatectomy. The discussions hinged on the concepts of Quality of life as propounded by Betty Ferrell, which touched on Quality of life in the domain of physical, social, psychological and spiritual. Literature was retrieved from electronic databases such as Science Direct, SAGE, Willey, PubMed, Google scholar, Taylor & Francis Online Libraries and general Google search. The key terms used to retrieve important literature include “cancer”, “prostate cancer”, “wellbeing”, “quality of life”, “functional status”, “experiences”, “prostatectomy”, “physical wellbeing”, “social wellbeing”, “psychological wellbeing” and “spiritual wellbeing”. The rest of the chapter reviewed studies on the physical, social, psychological and spiritual wellbeing of men post prostatectomy. These comprise the constructs of the Quality of life model which underpins this study. 2.1 Justification of the Quality of life model applied to Cancer Wellbeing is often viewed as an ever changing, personalised and multifaceted, and it often include physical, social, psychological and spiritual factors (Fayers & Machin, 2013). There are many wellbeing and QoL models used to ascertain distinct optimum health and disease state among individuals, families, and communities. One of such models is the Ashing Giwa’s contextual model of health-related quality of life applied to the measurement of wellbeing of patients who had undergone cancer treatment. It is broadly categorized into macro and micro levels. The macro level has the following contextual dimensions; socio- 8 University of Ghana http://ugspace.ug.edu.gh ecological, cultural, demographic and healthcare system. At the micro level, the contextual dimensions include general health and comorbidities, cancer specific medical factors and health efficacy (Miller, Ashing, Modeste, Herring, & Sealy, 2015). Also, there is the biopsychosocial model of wellbeing developed by Engel used extensively in assessing the wellbeing of cancer patients and survivors. This model has the biological, psychological and social domains. At the conceptualization phase of this study, the Wilson and Cleary Conceptual model of QoL was reviewed and considered. The model focused on the association among different facets of health. The model linked physiological variables, symptom status, functional health, general health perceptions, and overall quality of life (Bakas et al., 2012). The model unified the biomedical and social paradigms to determine wellbeing. This study however, has no interest in the biomedical aspect of wellbeing, hence found this conceptual model a misfit. In addition, the City of Hope QoL model applied to caregiver/cancer survivor communication burden was perused. This model has the physical, social, psychological and spiritual domains. However, these domains were important to issues specific to impairments associated with caregivers/cancer patients’ communication. On the contrary, this study aims at exploring the wellbeing of men after prostatectomy. The City of Hope QoL model applied to caregiver/cancer survivor communication burden could therefore, not be used. Also, the biopsychosocial model developed by Engel (1977) was looked at. In-spite of the fact that the model has the biological, psychological and social domains; which could guide the exploration of the wellbeing of men post prostatectomy, it lacked a spiritual and cultural domain in trying to understand the lived experiences of patients who have suffered 9 University of Ghana http://ugspace.ug.edu.gh any health mishap. Spirituality cannot be overlooked in the sociocultural context of the Ghanaian man (Alomele, 2017). 2.2 The Quality of Life Model by Betty Ferrell The QoL model was coined to originate a theory that explains the domains of quality of life in patients with cancer to bring about in-depth understanding into the lived experiences of pain and fatigue and its effect on their health. The initial model is sometimes referred to as the conceptual model of pain and quality of life (King & Hinds, 2011). In 1985, Padilla and Grant developed a theoretical model to explain the correlation between the nursing process and the dimensions of QoL. Later, Ferrell, Wisdom and Wenz in 1989 postulated a conceptual framework from the theoretical model which was used in the development and testing of the QoL instrument which was utilized in a study. The QoL study was tailored to assess QoL as an end result in the management of cancer pain (Pud et al., 2008). More studies were done in which the instrument was used to gather information the correlation between pain and QoL (Ferrell, Grant, Padilla, Vemuri, & Rhiner, 1991). Emanating from these studies, a conceptual model normally referred to as the City of Hope Model came to the fore to explain the effect of pain on the dimensions of QoL. The four dimensions of Quality of life (QoL) included in this model were physical, social, psychological and spiritual well- being (King & Hinds, 2011). This first model brought forth other models, which includes the Quality of life model applied to cancer survivors. From the model, The QoL (cancer version) instrument has been developed to measure the Quality of life of cancer patients/survivors. The physical wellbeing points to the physical functioning of the patient and the health mishaps that may emanate are aches and pain, constipation, nausea, appetite, sleep disruption, fatigue and function (King & Hinds, 2011). 10 University of Ghana http://ugspace.ug.edu.gh The social wellbeing dwells on the interaction between the patient and others. The constructs under the social wellbeing are financial burden, role adjustment, isolation relationships/roles, sexual function/affection, leisure activities, employment and burden (King & Hinds, 2011). The spiritual wellbeing refers to meaning, religiosity, uncertainty, hope, transcendence and positive change (King & Hinds, 2011). It is the interrelationship between these domains that determines the wellbeing of patients diagnosed with confined tumours of the prostate. 11 University of Ghana http://ugspace.ug.edu.gh PHYSICAL SOCIAL WELLBEING W ELLBEING Isolation Fatigue Affection/sex function Sleep disruption Role adjustment Financial burden Function Leisure activities Nausea Employment Ap petite Burden Co nstipation Relationship/roles Ac hes/pain Quality of Life PSYCHOLOGICAL WELLBEING SPIRITUAL WELLBEING An xiety Meaning De pression Uncertainty Helplessness Hope Difficulty sleeping Fear Religiosity Uselessness Transcendence Concentration Positive change Control Distress Figure 1: Quality Of Life Model Applied To Cancer (1995) 12 University of Ghana http://ugspace.ug.edu.gh Surgical interventions for prostate cancer involves potential benefits and risks (Ficarra, Novara, Rosen, et al., 2012). Conditions inherent to the patient and the surgical process may have a bearing on the development of challenges related to cancer therapy and its duration (Clauser, Wagner, Bowles, Tuzzio, & Greene, 2011). Many problems linger on for long periods, having a toll on the patient’s wellbeing (Romanzini, Pereira, Guilherme, Cologna, & Carvalho, 2018). Men recounted prostatectomy as a transformative event or in some instances, they referred to it as new life (de Moraes Lopes et al., 2012; Svensk et al., 2015; Waller & Pattison, 2013) . After prostectomy, men recounted going through adverse alterations such as urinary impairment and or erectile impotence which then became their most noticeable issue (Powel & Clark, 2005; Waller & Pattison, 2013). Although most of the men considered these surgical complications as inevitable trade offs, post prostatectomy complications came up as sources of the most concerns to men (Eilat-Tsanani, Tabenkin, Shental, Elmaleh, & Steinmtz, 2013; Iyigun et al., 2011; Shaughnessy & Laws, 2010). Issues connected to the health of the individual and to prostatectomy (Aarts et al., 2012; Romanzini, Carvalho, & Galvão, 2015), adding to socio-cultural, emotional and physical aspects (Albuquerque & Tróccoli, 2004) and the state for the discharge of activities of daily living (Katter & Greenglass, 2013), determine wellbeing and quality of life expectations for the surgical recuperation of patients who consented to prostatectomy. Also, all men undergoing surgical intervention for non-metastasized prostate cancer endure clinically notable limitations in urinary, sexual and to varying degrees, some bowel abnormality (Mario Filho, Sotiris, Sebastião Filho, & Adenilson, 2009). 13 University of Ghana http://ugspace.ug.edu.gh 2.3 Physical Wellbeing of men post prostatectomy Ferrell’s framework has the physical well-being domain such as functional ability, aches and pain, appetite, fatigue, constipation, sleep disruption, nausea and overall health (Dickey & Ogunsanya, 2018). Bowel and bladder functioning is also assessed during disease state and recovery as a determinant of wellbeing in the physical domain (Chambers et al., 2014). Unfortunately, a significant segment of prostate cancer survivors who undergo radical treatment such as prostatectomy endure concerns of bowel and bladder impairment (Banerji et al., 2017; Bill-Axelson et al., 2013). Men experienced alterations to their physical health such as urinary impairment, erectile impotence, isolation, physical discomfort, pain, constipation and bleeding (Kong, Deatrick, & Bradway, 2017). Urinary impairment remains a cardinal consequence of radical prostatectomy and can have overwhelming consequences on wellbeing (Seth, Pakzad, Hamid, Greenwell, & Ockrim, 2018). In a retrospective cohort analysis conducted in the Netherlands involving 244 men who had prostatectomy between 1998 and 2012, it was reported that 30% of patients experienced urinary incontinence post prostatectomy (van Dessel, Reuvers, Bangma, & Aluwini, 2018). In another study conducted in Goteborg, Sweden, it was reported that men who were subjected to radical prostatectomy suffered urinary impairments and had to resort to the use of absorbent to mitigate issues of urine leakage (Carlsson et al., 2011). Urinary incontinence post prostatectomy can be due to bladder hyperactivity, poor bladder compliance, or dysynchronised sphincter activity. The exact sequence is likely to be multifaceted, accentuating the need for excellent urodynamic testing. Urinary sphincter malfunctioning is probably linked to the surgery, with shortening in the functional length or denervation injury (Porena, Mearini, Mearini, Vianello, & Giannantoni, 2007). 14 University of Ghana http://ugspace.ug.edu.gh Also, pain is a typical issue associated with prostatectomy (Brown, Ramirez, & Farquhar-Smith, 2014; Glare et al., 2014; Haugen et al., 2010) and is related to the reduction of patients’ wellbeing, particularly regarding sleep, social interaction and work activities (Haugen et al., 2010), but the effects on these activities diminished with time (Haythornthwaite, Menefee, Heinberg, & Clark, 1998; Strassberg et al., 2017). For many cancers including prostate cancer, surgery is a foremost treatment. Continuous or lingering pain may manifest in the aftermath of any surgical incision including prostatectomy and is encountered in and is largely important to cancer survivors due to its effect on compromised recovery outcomes and diminished wellbeing (Elliott et al., 2011; Ferreira et al., 2008). Pre-operative anxiety, depression and traits such as pain endurance threshold, pre-existing chronic pain states, young age and raised body mass index (BMI) have all been revealed to determine the onset of chronic cancer pain (Bruce et al., 2014; Meretoja, Leidenius, Tasmuth, Sipilä, & Kalso, 2014). African patients with cancer pain are at risk for receiving substandard therapies and go through appreciable morbidity due to cancer-related pain (Baker & Green, 2005). Cancer pain brings about compromised wellbeing (Ferreira et al., 2008), increased psychological distress and depression, and reduced levels of functional ability and social activities (Zaza & Baine, 2002). Prostate cancer patients may suffer arthritic pain which manifests as a triad of persistent, dull background pain, spontaneous pain snaps and pain triggered by mobility (Urch, 2004). Fatigue is a complaint given more often than any other manifestation during the trajectory of cancer and its management, and it is normally the most serious manifestation reported (Minton, Strasser, Radbruch, & Stone, 2012; Yanez, Pearman, Lis, Beaumont, & Cella, 2012). It is the most worrisome symptom basically due to its long lasting effects and interruptions with many aspects of daily life, even in cancer survivors without confirmation 15 University of Ghana http://ugspace.ug.edu.gh of active disease (Pachman, Barton, Swetz, & Loprinzi, 2012). Fatigue experienced by cancer survivors can be linked to physical exertions they undergo in their day to day interactions (Bevans & Sternberg, 2012). Also, fatigue in cancer patients often interrupt with their occupational activities (Taskila, De Boer, Van Dijk, & Verbeek, 2011). A study conducted in 2004 on 531 Norwegian men who survived prostate cancer after prostatectomy brought to light the prevalence of fatigue post prostate cancer treatment. The occurrence of fatigue as a late negative effect post treatment for non- metastatic prostate cancer is 15–40% and 10–17% after radical prostatectomy (Kyrdalen, Dahl, Hernes, Cvancarova, & Fosså, 2010). Similarly, in a cross sectional survey on 377 prostate cancer survivors who underwent prostatectomy at the Edinburg Cancer Centre in South East of Scotland, Data revealed that 29% of participants suffered clinically relevant fatigue (Storey et al., 2011). In addition to the above elaborated physical manifestations, insomnia or inability to sustain sleep is a known manifestation which affects cancer patients (Mercadante et al., 2015). Insomnia often goes undetected, it can be mismanaged and has dire effects on the wellbeing of cancer patients (Kyle, Morgan, & Espie, 2010; Mercadante et al., 2015). Men treated for prostate cancer are prone to developing sleep problems (Dirksen, Epstein, & Hoyt, 2009). Manifestations such problems with micturition and bowel movement, hot flashes, and nocturnal diaphoresis are mostly reported post radical prostatectomy and have potential to derange sleep (Savard, Hervouet, & Ivers, 2013). In fact, sleep disruption has come out as a clinically notable manifestation occurring in 32% of men managed for prostate cancer by radical prostatectomy (Savard et al., 2005). The consequences of varying therapies on the onset and maintenance of insomnia have been proven to be mediated through the treatment side effects such as prostatectomy experienced by men with prostate cancer, particularly nocturia (Mercadante et al., 2015; 16 University of Ghana http://ugspace.ug.edu.gh Miaskowski et al., 2011; Savard et al., 2013). Although pharmacologic agents are frequently used to treat sleep disruption in prostate cancer survivors, the evidence for interventions proven to help sleep outcomes lies with cognitive behavioural therapy for insomnia. These includes both psychological and behavioural treatments, specifically stimulus-control therapy, sleep restriction therapy, relaxation training, cognitive therapy, and sleep hygiene education (Morin et al., 2006). Constipation is common in individuals with cancer, occurring in almost 60% of patients overall (Wickham, 2017). The incidence compounds in patients with metastatic disease state, particularly in those placed on opioid analgesics or medications with anticholinergic characteristics (Larkin et al., 2018; McMillan, Tofthagen, Small, Karver, & Craig, 2013; Wickham, 2017). A total of 43% to 58% of patients with cancer report constipation, the third most common manifestation after pain and loss of appetite in those with advanced disease (Woolery et al., 2008). Constipation can range from a minimal discomfort to critical impaction with circulatory, cardiac, or respiratory symptoms (Clemens, Faust, Jaspers, & Mikus, 2013). In cancer patients, opioid analgesics are the most noted in incidences of constipation since pain is an inevitable companion to all forms of cancer (Rumman, Gallinger, & Liu, 2016). 2.4 Social Wellbeing of men post prostatectomy Researchers have noticed that cancer has major adverse effects on employment, although a lot of cancer survivors resume duty after recovery (Candon, 2015; Heinesen & Kolodziejczyk, 2013; Moran, Short, & Hollenbeak, 2011). Prostate cancer and its management have monumental negative effects on employment with severer consequences on those engaged in menial jobs (Heinesen, Imai, & Maruyama, 2018). The consequence of cancer is more pronounced where the cancer is noticed to have spread at diagnosis (Thielen, Kolodziejczyk, Andersen, Heinesen, & Diderichsen, 2015) and with recurrence (Heinesen 17 University of Ghana http://ugspace.ug.edu.gh & Kolodziejczyk, 2013). A significant number of prostate cancer patients on treatment or who had undergone treatment experienced changes in their employment status due to fatigue (Vayr et al., 2019). In relation to the overall work ability among cancer survivors, a Nordic study among survivors of prostate, breast and testicular cancers found that prostate and breast cancer survivors reported lower work ability 1–8 years after cancer diagnosis and management (Lindbohm et al., 2012). Also, a significant number of men who had prostatectomy and underwent post radical prostatectomy oncological therapy with radiotherapy and/or hormonal therapy reported that prostate cancer and its therapies had influenced their work life in an adverse manner (Dahl et al., 2015). Social isolation is a notable factor that significantly affects patient health outcomes and mortality (Pantell et al., 2013). It has been linked with a surge in risk for cancer recurrence and mortality among cancer patients (Kroenke et al., 2017). Recent studies reported that prostate cancer patients experience social isolation because of treatment- related side effects such as incontinence, fatigue and pain (Adams et al., 2013; Ettridge et al., 2018; Zhu et al., 2019). Majority of men after prostatectomy experienced negative effects on their sexual health (Haglind et al., 2015). Intermittent or absence of sexual ability was a distress among the survivors of prostate cancer (Baker & Green, 2005; Imm et al., 2017; Rivers et al., 2011). In a systematic review and meta-analysis of studies reporting potency rates post radical prostatectomy; it was concluded that erectile dysfunction is a significant complication of radical prostatectomy (Ficarra, Novara, Ahlering, et al., 2012). Erectile dysfunction is a well-publicised and feared functional consequence of surgery for prostate cancer (Whalen, 2018). The morphology of cavernous nerve fibres is far more varied and sophisticated than found in previous studies, and partial nerve sparing is likely a major precursor to erectile dysfunction (Walz et al., 2010). Also, urinary 18 University of Ghana http://ugspace.ug.edu.gh impairment has a negative impact on various domains of sexual function (Bekker et al., 2010). Existing research posited that individuals suffering from urinary impairment are prone to sexual problems, especially since the topic is very emotional and characterized by a feeling of embarrassment (Hayder, Cintron, Schnell, & Schnepp, 2009; Lasserre et al., 2009). On the contrary, some men mentioned that they did face any adverse alterations in their relationship (Eilat-Tsanani et al., 2013; Iyigun et al., 2011; Oliffe, 2005). Financial toxicity has become a term in vogue in the debate surrounding cancer drugs, and it is gaining prominence in studies, given the astronomical cost of cancer remedies (Carrera, Kantarjian, & Blinder, 2018). Red flags have been raised about difficulties in accessing chemotherapy, and affordability of cancer remedies is extensive and this is alluded to by patients (Schrag, 2004). In a study conducted in Australia in men diagnosed with prostate cancer, 20% of men realized the cost of treating their prostate cancer brought about untoward financial difficulties (Gordon et al., 2017). Financial challenges cover the self-financed medical and non-medical cost of receiving medical care, the impact on an individual’s employment status and on a caregiver’s employment. Cancer therapies can be lengthy and spread across health services and unbudgeted medical and related adjunct cost can swiftly add up (van Eechoud et al., 2016). The existence of secrecy among prostate cancer patients is established in societal misconceptions and stigmatization associated with cancers (Holland, Kelly, & Weinberger, 2010). Perceptions of the malady, particularly stigma, may prevent men from disclosing and connecting with others and seeking help (Hyde et al., 2017). Some men kept their conditions secret due to desire to project self‐reliance and to be seen to maintain a sense of normalcy (Yousaf, Popat, & Hunter, 2015). In a study conducted in Sweden, Helgason (2001), noticed that most patients lacked confidants and that of the patients who were married, only 1 in 10 shared their health concerns with someone outside their relationship (Helgason, Dickman, 19 University of Ghana http://ugspace.ug.edu.gh Adolfsson, & Steineck, 2001). Male patients are noted to have the tendency to reveal their thoughts and experiences to a closed social group than women. This tendency coupled with social challenges possibly exposes male patients to greater risk for low psychological well‐ being (Stinesen Kollberg et al., 2018). 2.5 Psychological Wellbeing of men post prostatectomy Men diagnosed with prostate cancer are at a greater risk of going through psychological breakdowns due to unattained psychosocial needs, malignancy induced symptoms, and treatment adverse effects such as sexual problems and urinary impairment (Chambers et al., 2017; Pitman, Suleman, Hyde, & Hodgkiss, 2018). Several men with prostate cancer are likely to suffer from further health problems such as anxiety and cardiac conditions that predisposes them to psychological breakdowns (D’Amico, Chen, Renshaw, Loffredo, & Kantoff, 2008; Saini et al., 2013). Depression among men with prostate cancer has come out as a notable issue with prevalence reported at 16% to 30% (Christie & Sharpley, 2014; Sharp, O'Leary, Kinnear, Gavin, & Drummond, 2016; Sharpley, Bitsika, & Christie, 2010). It is worth noting that emotional distress, such as extreme sadness as well as other psychological health mishaps such as anxiety, may manifest at various time points in a cancer trajectory (Ravi et al., 2014). Also, men who suffer anhedonia, sleep disruption, pain, easy fatigability, concentration lapses, and cognitive impairments are the likeliest to experience depression (Rice et al., 2018), and men with diminished ability to withstand stress presented greater problems post prostatectomy (Kjølhede, Langström, Nilsson, Wodlin, & Nilsson, 2012). Fear and anxiety in men diagnosed with localised tumour who have undergone surgery or any other form of treatment has been reported in studies (Hart, Latini, Cowan, 20 University of Ghana http://ugspace.ug.edu.gh Carroll, & Investigators, 2008; Simard & Savard, 2015; Simard et al., 2013). Anxiety was related to lower quality of life, with heightened pain and sensitivity to symptoms. These symptoms may have a negative bearing on patients’ drive, verve, how they confront the disease, adherence to therapy regimen and the recuperative process (Duivenvoorden et al., 2013; Tavlarides et al., 2013). In a cross sectional study on 318 patients diagnosed with localised prostate cancer and treated with restorative radical prostatectomy between 1992 to 2012, it was reported that 36% of the men displayed high fear of cancer relapse (van de Wal et al., 2016). The emotional challenges confronted by the patient diagnosed with prostate cancer may be linked to fear of the limitations with cancer and its therapy and uncertainties about life. Psychological stress can also be manifested by warped assumptions of reality, by actual assessments or distressing memories, and by pessimistic predictions regarding the treatment (Sumalla, Ochoa, & Blanco, 2009). The negative consequences brought about by prostate cancer does not only affect the wellbeing of the individual, but also the depth of interaction between the patients and their spouses (Glajchen, 2012). Moreover, men diagnosed with prostate cancer experience uncertainty as a result of perceptions of danger regarding prostate cancer and lingering doubts over prostate cancer treatment outcomes (Kazer et al., 2013). Uncertainty throughout the cancer survivorship spectrum can be related to the disease's course, side effects, treatment decision‐making, and inadequate or lacking health information (Howlader et al., 2013). If these uncertainties are not tackled, it leads to patient experiencing psychological distress which may in the long run manifest in patient suffering depression (Eisenberg et al., 2015). 21 University of Ghana http://ugspace.ug.edu.gh 2.6 Spiritual Wellbeing of men post prostatectomy Religiosity was also a concept ingrained in Ferrell’s spiritual well-being sphere. The surge in the inclusion of religion and spirituality in the examination of quality of life give credence to its importance as a realm within Ferrell’s model (Puchalski et al., 2009). There is a concrete correlation between religiosity and wellbeing, with more spiritual involvement being seen as a conduit to with better physical and mental wellbeing in cancer survivorship (Mollica, Underwood, Homish, Homish, & Orom, 2016; Visser, Garssen, & Vingerhoets, 2010; Zavala, Maliski, Kwan, Fink, & Litwin, 2009). It has been documented that harrowing incidence or critical illness such as cancer can bring about a surge in religiosity (Caplan, Sawyer, Holt, & Brown, 2014; Salgado & Freire, 2008). Religiosity and health are knitted closely in African culture, with understanding of illness and healing being associated with God and faith (Stroman, 2000). Also, religion and spirituality are interrelated through seeking something regarded as holy through engagements from the rituals or personal encounters (Ali, Wattis, & Snowden, 2015). Infact, religion was pointed to as a significant element in the physical and emotional well-being of African men with prostate cancer (Hamilton et al., 2017; Maliski, Connor, Williams, & Litwin, 2010). The currency of religion in contemporary society is notable, given that majority of Americans professed to some embodiment of religion (Twenge, Exline, Grubbs, Sastry, & Campbell, 2015). Similarly, religion was regarded as an established indicator for maintaining the health of African (Roth, Usher, Clark, & Holt, 2016). The issues inherent within the religion and spirituality realm include belief, prayer, and the use of adjunctive and alternative remedies. Faith and belief have a great bearing on the health of the African (Koenig, Koenig, King, & Carson, 2012). 22 University of Ghana http://ugspace.ug.edu.gh Furthermore, Hope is a relevant tool for cancer patients because it can affect one’s perspective of self, one’s health status, and one’s future dynamics (Rustøen, Cooper, & Miaskowski, 2010). For patients with cancer, hope is mooted as a principal and successful coping style in overcoming the cancer during and after treatment (Zhang, Wei, Ping, & Wu, 2010). Global studies point to elevated levels of hope among cancer patients, which in effect helps them to adjust and cope with the debilitating consequences of cancer and its treatmemt (Afrooz et al., 2014; Baljani, Khashabi, Amanpour, & Azimi, 2011; Moghimian & Salmani, 2012). Rahmani et al (2014), reported that cancer patients derived Hope from sources such as God, prophets, Imams, treatment resources (including healthcare professionals), family and spouse. Meaning is the belief in a divinely intricate designed nature of the world, which, in turn, can be acquired from religion and/or spirituality (Sherman & Simonton, 2012). According to Scheffold et al (2014), cancer patients derive great meaning from financial security. This, Scheffold, argued could be as a result of bother relating to job insecurity associated to cancer diagnosis and treatment (Scheffold et al., 2014). Findings suggest that maintaining or restoration of personal meaning correlates highly with psychological adjustment among persons grappling with cancer (Park, Edmondson, Fenster, & Blank, 2008; Sherman & Simonton, 2012; Sherman, Simonton, Latif, & Bracy, 2010). 2.7 Spousal Support The wives of prostate cancer survivors were a vital spring of help and served as advocates for their partners (Rivers et al., 2011). An interrogation of the bearing of companionship through marriage on prostate cancer survival, supposed that social support was a windfall of matrimony (Aizer et al., 2013). It has been suggested that the social cover associated with companionship minimized death and metastatic cancer rates among only the married men (Aizer et al., 2013; Shi et al., 2016). The spouse of a prostate cancer survivor 23 University of Ghana http://ugspace.ug.edu.gh was an invaluable source of assistance for those confronted with challenges with regaining sexual potency (Rivers et al., 2012). When faced with the news and management of prostate cancer, patients often wish to open up about their encounters, pointing to a need for emotional support (Jackson et al., 2010). It is possible that the most relevant means of assistance, affecting a patient's adaptation to prostatectomy, is the wife as she is often the most engaged in the patient's illness and is often turned to for provision of caregiving and emotional support (Stinesen Kollberg et al., 2018). In distinction to women, inclined to draw on other sources of support, men happen to derive the most important emotional support from their partners (Kollberg et al., 2016). 2.8 Alternative/complementary Sources of Treatment Several cancer patients are leaning towards Complementary and Alternative Medicine (CAM) as the main therapeutic intervention to manage the physical, psychological, and spiritual effects of malignancy (Corner et al., 2009; Garland et al., 2013; Yang, Chien, & Tai, 2008). The patronage of CAM has firmly appreciated, especially, among patients diagnosed with cancer (Marsh et al., 2009). CAM involve actions that are not usually part of orthodox medical care, such as acupuncture, massage, prayer, diet, and use of biologic products (Quandt et al., 2009). Prayers for instance was mentioned by Carvalho et al. (2014), to have a profound impact on health including reduction of anxiety in cancer patients undergoing treatments (Carvalho et al., 2014). Some cancer patients resorted to complementary and alternative treatments for their conditions out of eagerness and curiosity to find solution from any source for their conditions (Buckner, Lafrenie, Dénommée, Caswell, & Want, 2018). 24 University of Ghana http://ugspace.ug.edu.gh The patronage of herbal medication for the management of cancers is high in Africa (Tuasha, Petros, & Asfaw, 2018). Verifiable data on the usage of CAM among patients in Sub-Sahara Africa points to an upward trend (Erku, 2016; Ezeome & Anarado, 2007; Yarney et al., 2013). They are regarded by the general populace to be wholesome, brings about less adverse effects, and are less likely to cause dependency (Olaku & White, 2011). Most cancer patients use herbal remedies in concomitance with orthodox treatment in the believe of improving the efficacy of orthodox medicine (Richardson, Mâsse, Nanny, & Sanders, 2004). 2.7 Life satisfaction The diagnosis and treatment for cancer has a notable effect on the life satisfaction (Leuteritz et al., 2018). Life satisfaction is an abstract strongly linked to wellbeing (Zullig, Valois, Huebner, & Drane, 2005), and It can be viewed as a precursor of wellbeing because it portrays how content one is with one’s life in totality (Moons, Budts, & De Geest, 2006). According to Jafari et al (2010), there is a significant interrelationship between spiritual well-being, hope and life satisfaction in patients suffering from malignancy (Jafari et al., 2010). Life satisfaction is a broad concept that psychologist often associates with determinants of normal emotional functioning, such as self-actulization and happiness. Furthermore, it appears to serve as a precursor to adaptive coping (Brandstätter et al., 2014; Park, Park, & Peterson, 2010; Wnuk, Marcinkowski, & Fobair, 2012), functioning as a measure that allows for the propensity to withstand suffering and a better adaptation to cancer (Sherman & Simonton, 2012; Vehling et al., 2011). 2.8 Summary of Literature Review The literature reviewed so far point to the fact that wellbeing is a multidimensional and subjective domain that can be assessed around the physical, social, psychological and 25 University of Ghana http://ugspace.ug.edu.gh spiritual perspectives of the lives of men who have been diagnosed of prostate cancer and subsequently underwent prostatectomy. Out of the total number of lirterature reviewed in relation to prostate cancer and prostatectomy, it is only a few that were centered on Africa and for that matter, Ghana. The few that were seen on Africa were over 10 years old and were focused on the diagnosis of prostate cancer, not on prostatectomy or its after effects. Thus, there exists a gap in knowledge about the wellbeing of men who had prostatectomy after being diagnosed with prostate cancer in Ghana and Africa as a whole. One glaring gap noticed was the fact that the studies on wellbeing after prostatectomy in the Western world seemed to have ignored the spiritual and cultural aspects of wellbeing. This could be due to their cultural orientation which placed less emphasis on spirituality. In the African domain however, every facet of life is intertwined with spirituality, hence spirituality cannot be overlooked in interrogating wellbeing. In this study, the wellbeing of Ghanaian men post prostatectomy will be brought to the fore. It is the researcher’s expectation that, the findings from the study will be used to develop appropriate policies that will address the needs of these men. 26 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.0 Introduction This chapter outlines: Research design, Research setting, Target population, Sampling technique and sample size, Procedure for data gathering and Data analysis. Ethical considerations and Methodological rigour were also highlighted. 3.1 Study design A qualitative research design was employed for the study. A Qualitative study, precisely exploratory descriptive design, entails a researcher eliciting responses from participants on their experiences through interviews and interpreting these responses. The interpretation must reflect the people’s point of view. Interviews must be conducted in the natural settings of the participants (Delgado-Romero, Singh, & De Los Santos, 2018). The centrepiece of this study was on the wellbeing of men post prostatectomy. 3.2 Research setting The study was conducted in the Ho municipality of Ghana. The Volta Regional Hospital (In transition of becoming a Teaching Hospital) was used as the outlet for the recruitment of participants for this study. The Volta Regional Hospital is a 277 bed capacity hospital. It is the only referral hospital in the Volta Region. It has several departments such as Urology, dialysis unit, pain clinic, cardio centre, radiology, an ultra-modern magnetic resonance imaging (MRI) unit among others. 27 University of Ghana http://ugspace.ug.edu.gh Figure 2: Map of Ghana showing the Ho Municipality 3.3 Target population The target population for this study were men who had undergone prostatectomy in the Ho municipality. 3.3.1 Inclusion criteria The inclusion criteria were: o Adult aged 18 and above 28 University of Ghana http://ugspace.ug.edu.gh o Resides in the Ho municipality o Will give consent to participate in the study. o Must have undergone prostatectomy between 6 months or more at the time of the study o Can speak English, Ewe, Twi 3.3.2 Exclusion criteria The exclusion criteria were: o Mentally impaired o Speech impaired o Resides outside the Ho municipality 3.4 Sample size and sampling technique Qualitative research demands that, responses are sought from a number of participants to the point where subsequent participants seem to be giving the same responses without the occurence of new information (Bernard, 2017). This study utilized a sample size of thirteen (13) because saturation was achieved at this stage. The study utilized purposive sampling technique to recruit participants who are well versed in the phenomenon under study.The rational and strength of purposive sampling is in the richness of the information given out by participants, in that, participants possesses characteristics that the researcher sees to be relevant to the purpose of the phenomenon under study (Hancock & Algozzine, 2016). Ethical clearance was obtained from the Ghana Health Service Ethics committee and the Volta Regional Hospital management with introductory letters from the School of Nursing and Midwifery, University of Ghana. The Urology unit’s register was used in identifying and locating participants for this study. The researcher obtained permission from the participants and their significant others before including them in this study. The 29 University of Ghana http://ugspace.ug.edu.gh researcher briefed the participants on the goal of the study and gave them the information sheet which outlines every information on the study. The researcher booked an appointment with the participants who showed interest in participating in the study based on their convenience, choice of location, day and time; to complete the consent form, and conduct the interview. 3.5 Data collection procedure and tool A semi-structured interview guide was used to conduct a face-to-face interview with each participant. This enabled participants to recount their experiences in great details. It also accorded the researcher the opportunity to redirect participants’ responses when out of context (Richards, 2014). The semi structured interview guide had two sections. Section – A contained information on the demographic characteristics of participants while Section- B comprised of questions that were guided by the objectives of the study, the Ferrell’s QoL model and the literature reviewed. The researcher established rapport and explained into details the purpose of the study to each participant. The participants were asked to sign the consent form to affirm their willingness to participate in the study. Permission was sought from participants for the interviews to be audio taped. This enabled them to share information willingly on their quality of life experiences post prostatectomy. The interview commenced with a grand tour question. This enabled participants to settle on a convenient way to give responses. Additionally, every murky response from the participants was elucidated in a follow up question during the interview (Corbin, Strauss, & Strauss, 2014). Probes were used to dig participants’ experiences and perceptions about alterations and adjustments they made in the journey post prostatectomy. The interviews were recorded and brief notes taken down to monitor respondents’ ideas for further exploration. Participants were observed for verbal and non-verbal behaviour (Mehrabian, 2017). The interviews were transcribed verbatim. It was conducted in the participants’ place of 30 University of Ghana http://ugspace.ug.edu.gh convenience and choice. The language for the interview was determined by the participant and lasted approximately between thirty (30) minutes to forty-five (45) minutes. The interview questions focused on issues and concepts cardinal to the participant’s experience with regards to their wellbeing. Also, vital concepts identified prior to starting the study were captured (Klassen, Pusic, Scott, Klok, & Cano, 2009). 3.6 Piloting of the interview guide Pretesting of a research tool ensures the accurateness of the tool to obtain anticipated responses and also to aid in amending the tool prior to its administration to participants (Brédart, Marrel, Abetz-Webb, Lasch, & Acquadro, 2014). The semi-structured interview guide was pretested at the Sogakope District hospital with two men who had undergone prostatectomy. The piloting was to ensure that questions asked will be comprehensible. Questions that were not clear were reframed. This process is to help improve the instrument. The pilot data was not included in the study. 3.7 Data management Participants were assigned numbers (1-13) according to the order of the interview. A verbatim transcription was done after each interview. Each recording was replayed severally to ensure precise transcription in order to minimize errors and omissions. The numbers allotted to participants were replaced with false names. Each transcription was saved as an autonomous file in a folder with a unique identification. Printed copies of the interview were kept in a safe under lock and key. Additionally, participant’s demographic characteristics were segregated from hard copies. Electronic copies of the transcription were kept in a folder on a computer with a password to ensure the security and safety of the data. 3.8 Data analysis Data analysis was done together with data collection. In qualitative study, data analysis goes with data collection and spans the entire duration of the study (Lewis, 2015). 31 University of Ghana http://ugspace.ug.edu.gh Data analysis is a seamless phase of any inquiry that is carried out from the onset of the study. Individual interviews were conducted separately at different time intervals. This strengthened data collection and analysis concurrently. Initially conducted interviews were analyzed before proceeding with another. The researcher familiarized himself with the data by listening and reading the transcripts multiple times, taking note of inceptive ideas after each interview. Consequently, inceptive coding was built by noting distinct ideas, words or concepts. This type of open coding involved labelling sections of text that will be useful to the research questions. It involved labelling participants own words with labels in order to remain close to the data. Categories were created by fusing identical codes and using circumscribed labels. The labels were juxtaposed and relationships noted between categories. Themes and underlying ideas that seem related to all data were taken note of. Two seasoned supervisors were involved in the coding and data analysis in order to have a quality data analysis. The transcripts were transferred to the Nvivo software version 11. This software was utilized to manage the data. 3.9 Methodological Rigour Researchers maintained that rigour of qualitative research amounts to the concepts reliability and validity and all are necessary components of quality (Tappen, 2015) . Rigour is basically defined as the richness or state of being very accurate, circumspect, or with strict exactness or the quality of being comprehensive and accurate (Cypress, 2017). Rigour is a key factor in a qualitative enquiry (Speziale, Streubert, & Carpenter, 2011). A qualitative study which lacks rigour is not credible and will not generate new knowledge (Gioia, Corley, & Hamilton, 2013). Kitto, Chester & Grbich (2008), came up with six criteria for assessing overall quality of qualitative research: (i) Clarification and justification, (ii) procedural rigor, (iii) sample representativeness, (iv) interpretative rigor, 32 University of Ghana http://ugspace.ug.edu.gh (v) reflexive and evaluative rigor and (vi) transferability/generalizability (Kitto, Chesters, & Grbich, 2008). Credibility determines whether the findings from a study portrays the accurate information derived from the participants raw data and is the exact interpretation of what the participants sought to put across (Graneheim & Lundman, 2004; Lincoln & Guba, 1982). To achieve this, the researcher purposively recruited participants who met the inclusion criteria and were able to give out in-depth information on their experiences with regards to their quality of life post prostatectomy. Iterative questioning and probes to elicit detailed information from participants were utilized. Also, member checks in the form of iterative verification to confirm the accuracy of the data was done (Morse, Barrett, Mayan, Olson, & Spiers, 2002). One interview was transcribed and analyzed before the next one conducted. Transferability refers to the extent to which the results of qualitative study can be generalised or transferred to other contexts or settings (Bitsch, 2005; Tobin & Begley, 2004). There was a clear description of the study setting, the design that was used for the study, the sample size and the method of data collection. In addition, there was a description of the inclusion and exclusion criteria, the number and length of data collection sessions that will be done and the period within which the data will be collected. According to Bitsch (2005), dependability centres on the consistency of findings over time (Bitsch, 2005). Dependability involves researchers appraising their findings and recommendations to be certain that conclusions they arrived at are consistent with data generated from participants (Plomp, 2013). Dependability is achieved through an audit trail, a code-recode strategy, stepwise replication, triangulation and peer examination or iterator comparisons (Ary, Jacobs, & Razavieh, 2010; Schwandt, Lincoln, & Guba, 2007). In order to ensure dependability of this study, the researcher wrote in detail the research process which includes the design and its implementation, data gathering as well 33 University of Ghana http://ugspace.ug.edu.gh as evaluation of the success of the research methodology for future replication by another researcher. This allowed for the examination of the research process so as to establish whether it has been properly applied. Confirmability has to do with the level of confidence that the research findings are based on the participants’ narratives and not the researchers imagination (Tobin & Begley, 2004). The researcher ensured that, the findings of the study represented the participants’ perspective of wellbeing after undergoing prostatectomy, and not his imaginations and preferences by bracketing his biases and assumptions. He kept an audit trail which showed how data was collected, analyzed and processed to get the findings of this study. 3.10 Ethical considerations Ethical clearance was obtained from the Ghana Health Service Ethics committee, University of Ghana and management of the Volta Regional hospital with an introductory letter from the School of Nursing and Midwifery, University of Ghana. Potential participants were given the information sheet which spelt out the purpose and objective of the study. They were notified on possible benefits, risks and inconveniences involved in the study. They were guaranteed confidentiality, voluntary participation and the right to withdraw from the styudy at any given time. The interviews were conducted in the participants’ chosen location and language. Participants were also made to consent to recording of their interviews before the interview was audio recorded. A follow up was done to confirm if they will participate in the study. Potential participants, who agreed to participate in the study were given consent forms to sign. In the event of participants who could not read or write, the consent form were be translated in to their mother tongues in the presence of a witness. Both the participants and the witness were made to sign and thumb print consent form to validate it. In addition, participants were made aware of the fact that, after appending signatures on the consent form, they reserved the right to withdraw from the study without any consequences. They were assured that, all the 34 University of Ghana http://ugspace.ug.edu.gh information they had divulged will be given utmost confidentiality and will not be used against them in any way. Also, participants were assigned Arabic numerals chronologically in order of encounter, so as to mask their identity. This ensured anonymity. Thereafter, pseudonyms replaced these Arabic numerals in the findings chapter when participants were being quoted in the dissertation. Participants were notified that, the information they provided, the consent form and the audio recordings would be in the researcher’s possession for a period of at least five years after the dissertation. Participants’ demographic data were dichotomized from the hard copies. Soft copies of the transcriptions were kept in electronic folders with a unique password on the researcher’s hard drive to ensure data security. In the course of the recount of life experiences, research participants were allowed to express unpleasant emotions. In such events, arrangements were made for a counsellor to attend to participants who may require counselling services in the course of data collection. 35 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR FINDINGS 4.0 Introduction This chapter present the findings from the analysis of the data collected in the study: exploring the wellbeing of men post prostatectomy in the Ho municipality. A total of thirteen participants in the Ho municipality were interviewed about their wellbeing after they had undergone prostatectomy. The organizing framework that underpinned this study is the Quality of Life (QoL) model applied to cancer by Betty Ferrell (Hinds & King, 2011). The themes and sub-themes that were generated were based on the constructs of this framework as well as the objectives of the study. Participant’s verbatim quotes corresponding with these themes and subthemes were presented. The four main themes according to the framework are: physical, social, psychological and spiritual wellbeing of men post prostatectomy. Additionally, new themes that emerged from the content analysis were: spousal support, alternative and complementary sources of treatment and life satisfaction. Impaired bladder control and secrecy were new subthemes that emerged under physical wellbeing and social wellbeing themes respectively. 4.1 Demographic characteristics In all, thirteen participants (men who had undergone prostatectomy) were interviewed for the study. They were all Ghanaians living within the Ho municipality. Saturation was reached at the thirteenth participant. Participants spoke English, Ewe and Twi. The ages of the participants ranged between thirty-seven (37) to sixty-seven (67) years. Out of the thirteen (13) participants, two (2) were between the ages of 30 to 39 years, six (6) were between the ages of 40 to 49 years, four (4) were between the ages of 50 to 59 and one (1) was sixty-seven (67) years. This implies that majority were middle age men. Ten 36 University of Ghana http://ugspace.ug.edu.gh (10) of the participants were Christians, two (2) were Traditionalists and one (1) practices the Islamic faith. Four participants had prostatectomy three (3) years ago. Five (5) had the prostate surgery two (2) years ago, three (3) had it a year ago and one (1) participant underwent prostatectomy four (4) years ago. All thirteen (13) participants were married. One (1) participant had no child. Seven (7) of the participants belonged to the Ewe tribe, three (3) were Akans, one (1) belonged to the Kusasi tribe, the Guan and Ga tribes had a participant each in this study. Three (3) participants were farmers, three (3) were pensioners, two (2) were drivers, one (1) a mason, two (2) were civil servants, one (1) mechanic and one (1) trader. Six (6) had tertiary education, four (4) senior high school (S.H.S) education. Three (3) had Junior High School (J.H.S) education. 4.2 Physical wellbeing of men post prostatectomy The theme physical wellbeing emerged from exploring the first research question “What is the physical wellbeing of men post prostatectomy in the Ho municipality?”. The data unravelled that physical exertions resulted in prostate cancer survivors experiencing diverse degrees of pain in different body parts. Participants got exhausted/fatigued at various times with some little work done. Also, men who underwent prostatectomy experienced disrupted sleep because of pain, discomforts that comes with urethral catheters in position or in some instances, due to urinary incontinence. Some men suffered from constipation after they had undergone prostatectomy. Finally, men who survived prostate cancer grappled with impaired bladder control. The subthemes found which were consistent with the QoL Model were: pain, fatigue, sleep disruption, and constipation. The sub-themes are presented below with verbatim quotes from participants to support the findings. For the purpose of confidentiality, pseudonyms were used to identify the participants. 37 University of Ghana http://ugspace.ug.edu.gh 4.2.1 Pain Pain was a major finding associated with post prostatectomy. Most men who underwent prostatectomy pointed to pain in different body parts for various reasons. One man reported pain in his testes which radiates to his waist whenever he visits the washroom to micturate or to move his bowel. Another person complained of pains between his testes and anus whenever he walks. “The pain holds both my testes anytime I try to urinate. I had to scream at times just to urinate” (Joe) “At times too I feel some sharp pains between my anus and testes. I could be walking well then suddenly I feel this sharp pain around my anus and testes. When it happens like that then I have to stop and rest for some time before I continue walking. It is so painful that you feel it in your backbone” (Isaac) Also, some men who survived prostate cancer narrated how they feel pains in their penis. “I do feel pain in my penis. But it doesn’t occur on daily basis. It can come at any time. At times I experienced this pain in the evening or late at night when I am sleep” (Kofi) “On some days too, I feel a sharp pain in my penis when I am urinating. It burns me as if there is pepper in my penis” (Kwame) In addition to localized pain, it was identified that radiating pain was also present. Some men who had prostatectomy mentioned that they experienced pain in the abdomen. One of them noticed that his abdominal pain begins as waist pain which radiates to the abdomen. “I experience severe waist pains. Before the operation, the waist pain comes once a while but as for these days, it can be there for three days. It is so severe that I feel it around my abdomen at times” (James) 38 University of Ghana http://ugspace.ug.edu.gh “I feel severe pains in my lower abdomen whenever I want to pass urine. The moment I am done urinating then the pain also goes. It has been like this ever since I had the operation” (Kwame) Furthermore, a participant mentioned that he feels the pain in his abdomen but noticed it radiates to the tip of his penis. “As for the pain, I feel it in my abdomen then it moves to the tip of my penis before the urine begins to flow. It only comes when I am urinating” (Frederick) On the contrary, few of the men who underwent prostatectomy did not experienced any form of pain beyond the acute phase of surgery. “As for pain, I have no issue with pain. I can’t remember any moment that I experienced any form of pain that I think is because of the operation I had” (Kwao) “I don’t experience any pain after the surgery. Maybe it is because I chose not to do anything that will cause me pain” (Annor) 4.2.2 Fatigue Male cancer survivors who underwent prostatectomy reported tiredness/fatigue during one activity or the other. Participants mentioned that; the fatigue was related to activities of daily living. Some mentioned being tired whilst walking. Others stated that, they were tired because the work they do demands some amount of physical exertion. Most experienced unusual tiredness during the course of working “The one that worries me most is that I get tired quickly when I do some little work. At first, I could stand for several hours at the printing press working” (Yao) “I do get tired frequently than before. I become so tired even by doing some little work on the farm. I complained to the doctor and he only advised me to reduce the hard work I do on the farm, but the question is how do I survive without working on the farm?” (Annor) “I get very tired after driving for even 2 hours. Before the operation, I can start loading at the station as early as 4am, but these days because of the frequent tiredness, I start loading around 5:30am to 6:00am.” (Godwin) 39 University of Ghana http://ugspace.ug.edu.gh “I have realized that I get so tired quickly after doing some little work. It was not like this” (Frederick) In addition, a participant said that he gets tired when he stands for long, a situation he said is alien to him. “The only change I noticed after the operation which was not part of me was the fact that I get tired frequently, especially when I stand for long” (Kojo) Furthermore, a prostate cancer survivor mentioned that he gets exhausted very often when he does his routine exercise. “I used to go for jogging at dawn on Saturdays, but I have realized that after the surgery, I don’t have my strength again. The moment I jog for about 15 minutes then I become so tired” (Kwame) 4.2.3 Sleep disruption Abnormal sleeping pattern was identified as physical problem associated with pain men experienced post prostatectomy. Almost every participant reported sleep disruption due to intermittent pain at night. Participants mentioned that when they felt the pain at night, they are awakened from their sleep and were unable to have enough sleep. “As for the sleep, it comes but when sometimes the pain comes at night then I can’t sleep. Sometimes I woke up around 11:00pm then I realized that I am in pain” (William) “The only problem is that these days I experience severe waist pains at night. With that, I struggle to sleep” (James) Some participants reported urine incontinence at night. Their sleep were disturbed as urine dripped onto their beds at night. Participants were forced to wake up and were unable to sleep as they should. “Even there are instances that urine drips on me and that wetness wakes me up” (Annor) “The only problem at night at times is that my pant could become wet with urine. This wakes me up. It is not comfortable at all” (Isaac) 40 University of Ghana http://ugspace.ug.edu.gh Other participants reported that they were compelled to wake up severally at night to empty their bladder or the urine bags. “I wake up several times to urinate during the night. It disturbs my sleep a lot. I can wake up as much as 5 times before day break. I don’t get that sound rest I need after the hard day’s work. All these things are affecting my health” (Frederick) “There are times I have a normal sleep without issues. But there are times too that I have to be waking up to urinate. And you know what happens if I don’t wake up early to urinate. I may soil myself. So, unlike the way I used to sleep before the prostate issue and operation, my sleeping has changed a bit” (Godwin) “At first, I could sleep throughout the night without waking up to urinate. That is not the case now. I wake up as much as 4 times to urinate” (Annor) “Hmm! That is another issue oooo!! You know I have a rubber in my penis to pass urine. This thing is not comfortable at all. I have to be waking up to empty the bag, I am used to waking up at night to pour the urine away from the bag. It is really a problem. I do put a small bucket close to the bedside to pour the urine in it at night” (Kofi) 4.2.4 Constipation Constipation was a common experience of men post prostatectomy. A few of the participants reported experiencing inability to move the bowel regularly as expected. A participant mentioned that he could not point to what actually caused the constipation. Others just observed that they had difficulties emptying their bowel. “Whenever I visit the toilet I go through a lot of pain. My stool gets so hard these days. I suffer to bring out the toilet. I am not sure if it is because of the operation I had” (Aziz) “The only issue is that I get constipation frequently. I know it is normal to have constipation once in a while, but mine is very often. I can stay for 3 days without going to the toilet. I know this is not normal. It was not like this before I had the operation” (Kwame) “My stool becomes very hard a lot of times when I go to the toilet. There are some days that I won’t go to toilet for four days. At first, I go to toilet normal but I see these changes after the operation. I am not saying it is because of the operation ooo but it was not like this before” (Kojo) 41 University of Ghana http://ugspace.ug.edu.gh 4.2.5 Impaired bladder control A new sub-theme that emerged was impaired bladder control. Most of the men who had undergone prostatectomy indicated that they experienced urinary incontinence. Some participants had urethral catheter passed for them since they had no control over their bladder. “But what happens is that, whenever the rubber is taken out, the urine just flows on its own without any effort from me, not like how you will feel like going to urinate and pushing for the urine to come. This one, it just flows without any control. Because of this, they just put the rubber back” (Joe) “After the surgery, I was no longer finding it difficult to urinate, but rather I had urine pouring even when I don’t feel the urge to urinate. That was how come I have this rubber in place to help me pass urine without any trouble” (Kwao) A few participants noticed that, they tend to soil their pants before they felt the urge to urinate. “At first when the rubber was taken out, I was able to urinate on my own without any difficulty. It was after a year ago that I noticed that urine drops into my pants without my knowledge. On some occasions, before I run to the washroom to urinate, the urine had already began dropping” (Annor) “There are times too that I noticed that the urine itself pours into my underpants before I will move to urinate. It is just embarrassing at times” (Frederick) “The only problem about it is that, I have noticed that some urine enters into my pants before I feel like going to urinate. It is shameful” (Isaac In contrast, one of the men reported urine retention “At first, I was able to pass urine normally but I think from 5 months or so, I began to notice that the urine doesn’t come as it should. It makes my abdomen to be hard and painful. At times too, I push so hard to urinate in great pain. It is very bad” (Kofi) From the findings relating to the physical wellbeing of men post prostatectomy, it came to light that men experienced pain at different parts of their bodies, they had disruptions to their sleep patterns, some get tired frequently on little physical exertions, 42 University of Ghana http://ugspace.ug.edu.gh others had challenges in regards to controlling their bladder. A few experienced difficulties in emptying their bowels. 4.3 Social wellbeing of men post prostatectomy The theme social wellbeing emerged from exploring the second research question “what is the social wellbeing of men post prostatectomy”. Data analysis pointed to a trend that, participants could not attend social events such as, weddings or funerals. All participants purchased expensive drugs and spent a lot of money on their surgeries. Other participants could not work as they used to. A number of participants kept their conditions secret from friends and relatives for various reasons. Some participants had difficulties having sexual intercourse with their spouses post prostatectomy. The sub-themes found which were consistent with the QoL Model were: Financial burden, Isolation, Employment and affection/sexual function. Two new sub-themes which emerged are secrecy and spousal support. These are presented below with verbatim quotes from participants using their pseudonyms. 4.3.1 Financial Burden Financial challenges were faced by participants post prostatectomy. All men who had prostatectomy reported that they spent so much money to buy expensive medicine. Participants had to dig deep to settle their hospital bills. Some participants had to exhaust their life savings to buy medication. “My only source of income now is the little I earn from my pension. It is from this that I use to buy my drugs. They are very expensive, and I buy them every month. As for the little savings I made whilst working, I finished everything to take care of the operation and the drugs I bought when I was on admission” (Kwao) “Everything I managed to save at the bank was what I used on my treatment so things are not like before. I don’t have anything at the bank again. My wife is the one who supports me with money these days” (Isaac) 43 University of Ghana http://ugspace.ug.edu.gh Also, a participant mentioned that he used his savings to finance the prostatectomy. “It is a big problem to me. I financed my operation personally. The little savings I made from my business is what I used to cater for myself when I was on admission. It is very expensive. I spent about GHC6000 during my stay at the hospital for the operation” (Kojo). Other participants lamented about the expensive nature of the medication they buy on monthly basis. “I buy drugs every month for my health. the drugs are very expensive. They are too expensive. I buy about four different drugs every month. All these demands money” (Joe) “A lot has changed. I spend a lot of money buying medication for myself. I spend not less than GHC300 every month on medication alone” (Frederick) In addition, some participants had difficulties getting their medication to buy from their localities, hence had to source for them from distant places. “I have to spend so much to buy the drugs. It really takes a lot out of my income. We don’t even get some of the drugs in Ho so I have to send for them in Accra” (Aziz) “I spend so much on drugs every month. If I may not be lying to you, I spend almost GHC800 every month on drugs alone. You know, I use both herbal and what the doctor prescribes, it takes a lot of money to get them. Even most of the drugs I use are hard to come by in Ho, so I have to go all the way to Accra to get them” (Yao) A participant mentioned that he resorted to the use of agrochemicals on his farm since he no longer has the strength to weed. The purchase of the agrochemicals has negatively affected his financial status. “I have shifted more to the use of agrochemicals instead of the manual weeding that I am used to. I have lost my strength after the operation so I cannot weed as much as I used to. These chemicals are very expensive as well but without them, I cannot maintain the farm. I do all these things in addition to buying my drugs every month ooo. You can understand what I have been going through” (Annor). 44 University of Ghana http://ugspace.ug.edu.gh 4.3.2 Isolation Most participants stated that, they could not attend weddings, funerals, or naming ceremonies for various reasons after undergoing prostatectomy. Some participants mentioned that they could not attend social events because of the pain they experienced post prostatectomy. “Sometimes when the pain comes, I don’t go anywhere. When there is pain, to me there is nothing like attending any gathering ooo” (William) Other participants stated that the stress of having to go to such events with urine bags made them to decide not to go to weddings, funerals or naming ceremonies. “Imagine you are at a funeral and your urine bag is full. It is now that you have to find a convenient place to empty the bag. Those things make me uncomfortable, so when I think about it, there is no need to be attending those social events” (Joe) “Apart from my family members and a few of my school mates back then in elementary school, I don’t really mingle with people. I prefer the isolation because I cannot be comfortable socializing with rubber and urine bag around me and to be among people. It is very uncomfortable to carry those things along” (Kwao) “How is that possible, my brother? To carry the urine bag around to watch football. Because of this prostate problem, I am always alone these days” (Kofi) Also, a participant decided not to go to social events for fear of soiling himself with urine at such places. “With all these urine problems, how do you expect me to go to such programs. I am afraid I will end up soiling myself with urine when I am among people so I don’t even try it” (Frederick) On the contrary prostatectomy did not restrict some of the men from attending social gatherings. “I love football very much. You know I have some colleagues whom I go to watch football on DSTV with in town? We sit around with our beers and we enjoy ourselves. I used to play football in my active years so as for football, I enjoy it a lot. I love the English football league. You know, it is nice when you are with 45 University of Ghana http://ugspace.ug.edu.gh colleagues and you argue over such football issues. So as for my weekends dierrrr, it’s for football. Hahahahah!!” (Kofi) “As for those things I always make sure I attend. It is part of our culture and daily life so there is no reason to be giving excuses why you could not attend those programs. Even if people don’t see you at those places then they suspect that there is something wrong with you. As for me, I always attend those programs” (Isaac) 4.3.3 Reduction in work/Employment Participants reported reduction in their work output after undergoing prostatectomy. Others engaged people to take control of certain jobs they were themselves before they had prostatectomy. Some of the participants could not work as they used to before they had prostatectomy. Participants had to reduce what they do at work due to pain. “I was told not to be doing hard work after the operation, but the question is, how do I survive without the hard work? I feel pains in my abdomen anytime I lift something heavy. It has made me to reduce the way I work. It is only the mason work I have been doing. At times your colleagues think you are just being lazy because they don’t know what you are going through” (Frederick) “You know when you are in pain, all activities grinds to halt. You can’t do anything because your concentration will be on the pain so those days or those times when I experience it, you know I told you I used to do monitoring on my shops and other things. I don’t go. I sit at home” (William) In addition, some of the participants could not work as they used to due to the experience of fatigue. “These days you will realize that I sit more often than standing to work. I get tired so quick so I have to be sitting more. How will work go on with this attitude? It is not my fault too, my brother” (Yao) “You know my work demands standing and moving about. We carry heavy things like cement when we are attending to our customers. We mostly help them to load their trucks when they come to buy from us. These days, the little work I do makes me feel so tired” (Kojo) “At times you can be driving for 8 to 9 hours. As for these days, I get tired after driving for even 2 hours. At first, I can start loading at the station as early as 46 University of Ghana http://ugspace.ug.edu.gh 4:00am, but these days because of the frequent tiredness, I start loading around 5:30am to 6:00am. See, it is not easy ooo!” (Godwin) “I noticed that after weeding for a few minutes, I get very tired. At first, I thought it was because it has not been long after the operation. Even to this day I am not able to work like before” (Isaac) 4.3.4 Affection/Sexual function Participants reported impairments in their sexual functions after undergoing prostatectomy. Some participants attributed their inability to engage in sexual intercourse after prostatectomy to the indwelling urethral catheters that they had to live with. “When it comes to sexual intimacy, I am not able to do anything. You know there is rubber in there so sex is out. I don’t even know what they call sex anymore” (Joe) “As for sex, it is out!! How am I supposed to sleep with her with rubber in my penis? She is just 49 years so obviously she is not beyond sex, but there is nothing I can do about that. As for me, I don’t even have the feeling for sex” (Kofi) “The only intimacy between my wife and I is sitting down and watching TV. If it is about sexual intimacy, there is none between us. How can I get intimate with my wife with the rubber in my penis?” (Kwao) Also, other participants lamented that, they could not get erections after undergoing prostatectomy. “My brother, the thing cannot even stand firm so how am I going to satisfy my wife?” (Isaac) “At first, I was able to get erection some eight months or so after the surgery. It was later that I realized I could not get an erection at all. I have two wives so, I cannot continue like this for long. Very soon they will start complaining, then I am in trouble” (Aziz) “There is no issue about that. Like I told you earlier, I have issues with having an erection so there is nothing like sex between us” (James) In addition, a participant mentioned that he could not perform sexually due to episodic pains he experiences during sexual intercourse. 47 University of Ghana http://ugspace.ug.edu.gh “You know sometimes you are having this intimacy then you feel pain suddenly deep down there so just one round then you are off. You don’t want to engage yourself again” (William) Lastly, another participant attributed his sexual impairment to easy fatigability; a situation he pinned on the prostate surgery he had. “The only issue is that I get tired now compared to the past so I think maybe I am not meeting her expectation as before” (Yao) 4.3.5 Secrecy A sub-theme that emerged from the analysis of the data is secrecy. Men who had prostatectomy hid their condition from close associates including extended family members and friends for diverse reasons. “Issues about my health are not things to be telling people about” (Annor) “I doubt if anyone else apart from my wife even knows about my condition. Sickness is not something you go about telling people. For all you know, the person you are talking to about your sickness even has a hand in it. For me, I won’t make those mistakes” (Kojo) Some men confided in their wives only on issues bothering on their health. “My wife is the only one I share my concerns with” (Kofi) “I have not disclosed my condition with any other person apart from my wife and children. Even my pastor is not aware of what I have been going through” (Kwao) “She is the only one with me in the house so she is the one I share my problems with. I don’t involve extended family and friends in health matters for personal reasons so my wife is my everything now” (Isaac) However, some men disclosed their condition to others with the hope that they could suggest solutions to their conditions. “My pastor is a close family friend to us. He even knows a lot about my condition that even my family members are not aware of” (Annor) 48 University of Ghana http://ugspace.ug.edu.gh “I am very close with my pastor. There is nothing I hide from him concerning my condition. There are times he hears of some drugs for cancer treatment and he will call me or my wife to give it a try” (Yao) In the domain of social wellbeing, men who had prostatectomy had to endure financial burdens as a result of the monies they expended on their treatment. Their conditions made it difficult for them to patronize social events. They therefore tend to isolate themselves from such gatherings. Participants withheld information about their condition to others. Issues bothering on their health were kept in secret. Some participants experienced difficulties to function sexually. Participants either lost their abilities to gain penile erection or had urethral catheter passed which made it impossible for them to have any form of penetrative sexual contact with their spouses. Others’ condition brought about a reduction in their work and employment due to pain and easy fatigability. In the face of all these challenges, participants enjoyed tremendous support from their spouses in diverse ways. 4.4 Psychological Wellbeing of men post prostatectomy To answer the third research question “what is the psychological wellbeing of men post prostatectomy?”, the theme psychological wellbeing was emerged. Participants experienced worries, fears and uncertainty about the outcome of their condition. The uncertainty surrounding that outcome of their condition made some men depressed. Some feared that they would die and leave their loved ones behind. The sub-themes that came to the fore which were in line with Betty Ferrell’s QoL Model (2001) were: anxiety, fear and depression. A new sub-theme that emerged from the analysis of the data was Life satisfaction. 4.4.1 Fear From the analysis of data, participants were afraid they would die or things could get worse for them as a result of stories they heard about the debilitating effects of cancer. 49 University of Ghana http://ugspace.ug.edu.gh Some participants mentioned that they became afraid for no apparent reason. “The thought of being told I have cancer alone is enough to scare any human being, so truthfully anytime my mind goes on that I become afraid” (Annor) “I may say some little fear that things can become worse. You know cancer is a stubborn thing. Even it kills the white men so as for us, we only trust in God to protect us” (James) Also, some of the men became afraid due to the news they have heard about the debilitating nature of cancer. “My mind comes to it when I am alone. There is one thing about cancer, no matter how strong you are, you have to be scared and worried about it. Cancer will kill you no matter what. I have been hearing a lot of bad things about how cancer kills. Hmmm” (Yao) “You cannot not just take your mind off it like that. No matter what I do, there are times that I have to accept that all is not well. I don’t think there is anything that kills these days than cancer. This puts some fear into me” (Kojo) “The only thought that makes me sad and worried is my current situation. I don’t know how long I am going to live with cancer. I get worried. Cancer is not merciful. The worst thing is that they say you will be in so much pain before it may even kill you. You can pretend to be strong but there are times that the fear is something you cannot take you mind from” (Kwao) 4.4.2 Anxiety A number of participants expressed anxiety due to the uncertainty surrounding their condition. They wondered what the future holds for them in the face of cancer. “Whenever I remember the fact that I am not as strong as I used to be, it makes me worried. I don’t even know what the future holds for me. I am only trusting God to heal me. I sincerely get worried that I may not be able to get my wife pregnant. I think about it a lot” (Frederick) “It is all about my condition. When I think about it, I get worried a lot. I don’t even know how things will be in the future. You know cancer has no cure. The doctor keeps giving me assurance but let us see how things will go” (Godwin) 50 University of Ghana http://ugspace.ug.edu.gh Furthermore, a cancer survivor became anxious due to the believe that his condition could become worse. “I may say some little fear that things can become worse. You know cancer is a stubborn thing. Even it kills the white men so as for us, we only trust in God to protect us” (James) A participant expressed worry that his wife may not be able to get pregnant due to his inability to have and sustain erection. “Whenever I remember the fact that I am not as strong as I used to be, it makes me worried. I don’t even know what the future holds for me. I am only trusting God to heal me. I sincerely get worried that I may not be able to get my wife pregnant. I think about it a lot” (Frederick) 4.4.3 Depression Some men who had undergone prostatectomy experienced depression. Men became sad, cried and felt self-pity as a result alteration to their daily lives and pain due to prostate cancer. To begin with, some of the participants mentioned that they shed tears whenever they think about their conditions. “There were times I just sit on my farm thinking about my condition and the way forward. On some days I am all alone on the farm and out of nowhere, tears just flow” (Annor) “There are times I sit down and think about myself and before I realize, tears start dropping” (Yao) “The thought of cancer scares me. Whenever I take my mind to it, I get worried. At times I cry” (Kojo) “It gets worse when I read those stories about cancer and how difficult is it to get well. It draws me close to tears if I am alone at home and I am thinking about myself” (Kwame) Also, a participant mentioned that he breaks down psychologically due to his inability to have and maintain an erection. 51 University of Ghana http://ugspace.ug.edu.gh “To be truthful to you, it is very difficult for a man to get married and cannot get your wife pregnant because your penis has a problem. It breaks me down so many times” (Aziz) Men who have had prostatectomy experienced fear and anxiety. They dreaded the future outcome of their condition. Some feared that they may die and leave their loved once behind. Others became anxious and scared because of the excruciating pain they learned is associated with cancer. Participants suffered depression post prostatectomy. They hid themselves and cried about their health situation. Some participants derived strength and happiness from their accomplishments in life. While some gave meaning to their lives due to physical infrastructure they put up, others took delight in the progress of their children. 4.5 Spiritual wellbeing of men post prostatectomy The theme physical wellbeing emerged from exploring the fourth research question. “What is the spiritual wellbeing of men post prostatectomy?”. Some participants wondered and questioned God about why they had to be diagnosed with prostate cancer and all the health issues that comes with it. Other participants also mentioned that, they have become very religious in the face of their condition. Participants prayed more often and became regular in church activities. Also, most participants have uncertainty about the outcome of their condition. Some of the participants haboured the hope that they will recover from cancer and be in good health. The sub-themes found which were consistent with Betty Ferrell’s QoL model were: Meaning, religiosity, uncertainty and hope. 4.5.1 Meaning Some participants wondered and questioned God as to why such situation should befall them. “When I go back and think about this thing, I was like why should God let this thing happen to me. Sometimes I feel like God doesn’t love me so the closeness isn’t there 52 University of Ghana http://ugspace.ug.edu.gh between me and God. I have given a distance between myself and God. I feel like God does not love me” (William) “Hmm! A lot of things come to mind. At times I feel like questioning God why I have to be going through this. It beats my mind. I have not lived my life anyhow to say maybe I have done something against someone. I don’t quarrel with anyone to think it is a spiritual attack. But whatever it is, we are in it” (Kofi) “I am a Christian but when I think about certain things going to church becomes meaningless to me. How can you be going to church and such things befall you? Does it make sense? What then is the benefit of going to church to worship God” (Joe) In addition, some of the men wondered how they got diagnosed with prostate cancer. Whilst one thought he was too young to be diagnosed of such, another man thought he has lived a relatively “upright” life, hence could not understand why he had cancer. “Like I said, I am only 39 years. I thought it is older men who go through this prostate issue. At times I will sit alone and ask myself so many questions. Why will God allow me to go through this Ahh well, I am human so I am not supposed to question God” (Kwame) “Hmm! It is only God who can tell why I have to get this disease. I have not offended anybody in anyway. You can ask around. They will tell you I am not a difficult person at all. When I look back and think about a lot of things, I don’t get an answer from anywhere. The whole thing is hard to understand” (Isaac) However, some of the men saw their condition as something that was bound to happen, without questioning God about it. “You see, some of these things happens. Nobody will ask that things like this should come close to him but we are only human. I don’t want to put my mind on any spiritual reason why I should have prostate cancer. It happens to a lot of men, so maybe I am just one of the unlucky ones” (Godwin) “My brother, this thing can happen to anybody. So long as we remain human beings, some of these things are bound to happen. Just look at even the food we eat. Every has chemicals in it. Some of these things could be the reason why cancer has become very common these days. We brought this upon ourselves” (James) 53 University of Ghana http://ugspace.ug.edu.gh 4.5.2 Religiosity The participants pointed that, they have become more prayerful and involved in church activities after they were diagnosed of prostate cancer and had undergone prostatectomy. They prayed for God’s healing. “Cancer has really drawn me closer to God than before. I believe very much in the power of God to turn things around. I have become really close to God. I do follow my wife to prayer camps for help” (Annor) “My condition has left me with no choice than to run to God. I used to take going to church for granted, but when I started going through this, no one asked me to run to God. Since then, I have been deep in church activities” (Yao) “I am a strong Muslim so I am very close to Allah” (Aziz) “How can I distant myself from God this time rather in my life? It is when a goat is injured that it knows its owners house” (Kojo) “He is the only one I am hoping can cure me so I am closer than ever. My Bible has become my favorite book now” (Kofi) However, some of the participants rather detached themselves from God. They questioned the essence of being close to God and still go through the burden of prostate cancer. “When I go back and think about this thing, I was like why should God let this thing happen to me. Sometimes I feel like God doesn’t love me so the closeness isn’t there between me and God. I have given a distance between myself and God. I feel like God does not love me” (William) “I am a Christian but when I think about certain things going to church becomes meaningless to me. How can you be going to church and such things befall you? Does it make sense? What then is the benefit of going to church to worship God?” (Joe) 4.5.3 Hope Most of the men who had undergone prostatectomy had the believe that their conditions will improve one way or the other. 54 University of Ghana http://ugspace.ug.edu.gh “We didn’t bring ourselves into this world for sure so, there is God in whom I trust. I have been through a lot of difficult moments in life. I have been involved in about 4 serious accidents within 8 years but I survived all. Do you think I have an idea why I am always lucky to survive those accidents? My faith in God keeps me going” (James) “My entire hope of survival lies in my faith in God. I have seen healings and deliverance with my eyes, so why should I stay away from God? The spirit world is real. I go to church every Sunday. See, one thing I can tell you for sure is that I will get well” (Kwame) “I just hope things will be well just as we are all expecting. Apart from my condition, I am a happy man. My doctor said the cancer has not spread so I will be completely healed. I hope so” (Kojo) “There are times that I take the Bible to read and come across things that you think were written for you. It gives me so much hope” (Kwao) 4.5.4 Uncertainty Most of the participants were uncertain about what the future holds for them in the face of prostate cancer. “Although I try to live as normal as I could with it, there are times I stay away from people and cry. The fear of the how things will end makes me to pity myself. The more I think about my health, the more I get confused about how thing will end one day. I just don’t know. I have been very healthy and active person all my life. Little did I know this will happen to me” (Kwao) “I do think about it a lot. I do have a lot of fear and uncertainty over my current state, especially the rubber in my penis. I won’t lie to you. I do think a lot. This isn’t how I am supposed to be. It is as if I am not complete. Will the rubber remain there forever, I don’t know?” (Joe) In addition, some of the male prostate cancer survivors wondered about how they are going to live with the condition. “My, brother, I won’t lie to you, I don’t know how long I am going to live with this condition. At times I have the believe that I am going to be fine, but there are times that I get scared about dying from this. You just cannot tell how everything will end” (James) 55 University of Ghana http://ugspace.ug.edu.gh “I don’t even know how things will be in the future. You know they say cancer has no cure. The doctor keeps giving me assurances but let us see how things will go. We are in God’s hands” (Godwin) Also, the unpleasant stories about prostate cancer made some of the men who had undergone prostatectomy to be uncertain about their condition. “It is the uncertainty about my condition that bothers me at times. My minds come to it when I am alone. There is one thing about cancer, no matter how strong you are, you have to be worried about it. There are several stories to follow about it. How some prominent and wealthy personalities lost their battle to cancer. It scares me sometimes. Doctors will tell you all the sweet stories about how you are making progress, but if God doesn’t come in, you will be gone unexpectedly” (Yao) “I am afraid because I don’t really know how this whole thing will end. You know, cancer is not good news to anyone. Even the white man struggles with it. Those with all the money in this world are even struggling to cure cancer, how much a little farmer in Ghana. See, I have been told after the operation that I am free but the truth is that I don’t even know if they are telling me the truth. I live everyday in fear because I really don’t know the way forward about my condition” (Isaac) 4.6 Spousal support A new theme that emerged from the analysis of the data was Spousal support. All the men mentioned that they had tremendous support from their spouses. “She has been my backbone from day one all through this time. She is a very supportive woman” (Kwao) “My wife is always home aside on major market days so when she is around, she keeps me company” (Kofi) “She knows that I need her now than ever so she is always here for me” (Kwame) “We are very close. You see me moving up and down like I don’t have any problem because she supports me in a lot of ways” (Frederick) Some participants had financial support from their spouses to buy their medication. “She is the one who supports me financially when I am broke. She takes very good care of me. She gives me hope about the outcome of my treatment so I get a lot of strength from her. She is a very wonderful woman” (Kojo) “My wife has been very helpful and supportive. She attends every review with me. She even buys drugs for me whenever she comes across it” (Yao) 56 University of Ghana http://ugspace.ug.edu.gh 4.7 Alternative /complementary sources of treatment Another new theme that emerged from the analysis of the data was alternative sources of treatment. Participants recalled that, they sought remedies from spiritualists and prophets at prayer camps. Other participants also used herbal concoctions they got from herbalists with the hope of getting a solution to their problems. This theme was not part of Ferrell’s QoL model. “I use a lot of herbal medicines along with what I am given at the hospital” (Annor) “I do buy herbal medicines when those selling pass by the shop” (James) “I like taking herbal medicine a lot so there are times I go to these herbalists for help” (Godwin) Some men traveled long distances to consult herbalists in search of solutions to their health concerns. “I went to a place in Hohoe for some herbal preparations for the cancer. I went as far as Bawku as well for a herbal preparation. Some of these herbal medicines work wonders so, there is no harm in trying” (Yao) “There was even a time I had to travel all the way to Benin to see a herbalist about my erectile issue” (Aziz) “I have been to a herbalist once at Mampong and some other time, my wife and I went to see a herbalist at Hohoe for some herbal preparations” (Kwame) Also, some of the men went to see prophets at prayer camps, crusades/revivals in search of solutions. “I do follow my wife to some prayer camps for help. There was a time that my wife and I spent almost a month at a prayer camp out of town.” (Annor) “I do go to crusades and revivals hoping for a miracle. You see, you don’t know where your healing will come from. My wife also goes to prayers for me” (Isaac). Spiritually, participants questioned God about their disease condition. Others became very religious by praying often, visiting pastors and Mallams and going to prayer 57 University of Ghana http://ugspace.ug.edu.gh camps. Participants were uncertain about how to live life in their current state. Some participants had hope in God that they will recover from cancer. Participants resorted to the use herbal and spiritual remedies for their condition. 4.8 Life Satisfaction Another new theme that emerged from the analysis of data was life satisfaction. Their numerous problems notwithstanding, most of participants found strength and consolation from variety of things. These gave them some sorts of satisfaction in the face of prostate cancer. Some of the participants took consolation in things they put premium on. “I am over 40 years now. I am living in my own house. My children are in school. You look back at your peers who are even older than you but still are not at the level at which you are though they are not in battle with any condition. I look back at those things and I smile” (William) “Let me say when I take stock of my life and I look at the little I have been able to acquire; I feel some sort of self-satisfaction. When I look at some of my friends and their positions now, I can say my life has not been a failure at all inspite of the fact that I am just into farming and poultry” (Joe) “You see, looking back at time I feel like I have fulfilled some basic requirements in life. I built my own house. I educated my children to the best of my ability so if I cast my mind back, I feel happy anyway” (Kofi) A participant took pride in the progress of his children’s education. “Life itself is a gift from God. So long as I am alive, I am a happy person. Even when I take a look at my children, I can say they are making progress in school. Two of my children are in the university. I am happy looking at how far we have come” (Annor) 4.9 Summary The findings of this study unraveled diverse facets of the experiences of men who had undergone prostatectomy in the Ho municipality. Most of the findings were in line with 58 University of Ghana http://ugspace.ug.edu.gh Betty Ferrell’s QoL model applied to cancer. The findings pointed that, prostate cancer survivors who had prostatectomy experienced health challenges during their daily lives. Physically, they grappled with impaired bladder control, constipation, fatigue and pain in various parts of their bodies. Sleep disruption was a notable mishap they experienced at night. Socially, they experienced isolation, they had challenges in fulfilling their sexual obligations, they were confronted with financial burdens and faced issues with employment. A new sub-theme which emerged under the social wellbeing theme but was not consistent with the QoL model was secrecy. Men who had undergone prostatectomy kept their conditions to themselves or in some instances gave disclosure to their spouses only for varied reasons. Also, a new theme that emerged was spousal support. Men who had undergone prostatectomy enjoyed a wide range of support from their spouses in the course of their daily lives with prostate cancer. Psychologically, they experienced anxiety, haboured uncertainties about their condition, they were depressed and entertained fears. Life satisfaction was another new theme that came to the fore from the findings. Most men took solace in things they considered as achievements in the course of their lives. This was not consistent with the QoL model. Spiritually, they sought meaning into their condition by questioning God and in some cases rationalizing. Men became more religious and had hope that their conditions will turn out for the better. A new theme that the findings unraveled was complementary and alternative sources of treatment. Participants used herbal medicines concomitantly with prescribed orthodox medications from their doctors. Some participants sought help from spiritualists by patronizing prayer camps. 59 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION OF FINDINGS 5.0 Introduction This study set out to explore the physical, social, psychological and spiritual wellbeing of men who had undergone prostatectomy. The chapter discusses the findings of the study in relation to existing literature. The discussion is organized on the demographic characteristics, physical, social, psychological and spiritual wellbeing; these themes are consistent with the themes in the Quality of Life Model applied to cancer survivors by Betty Ferrell. Thus, the underpinning theoretical framework for this study guided the organization of this chapter. The new emerged themes outside the construct of the theoretical framework were also discussed. 5.1 Demographic characteristics All participants in this study were men diagnosed of prostate cancer and had undergone prostatectomy at the Volta Regional hospital. Participants are residents in the Ho municipality in the Volta region of Ghana. They had to live their everyday lives in the face of the challenges that their health status brought upon them. They confronted issues in the physical, social, psychological and spiritual domains in life. Their day to day activities required some levels of physical exertions which in effect triggered pains and other adverse physical manifestations. In the face of these challenges, men leaned on their spouses for support in order to cope with the impairments that come with prostate cancer. This is so based on supportive nature of marriage in the African perspective (Phillips, 2018). Most men diagnosed of cancer kept it secret from family and friends. This is probably due to superstitious beliefs that African have about illness, disease causation and etiology (Tenkorang, Gyimah, Maticka-Tyndale, & Adjei, 2011) . 60 University of Ghana http://ugspace.ug.edu.gh 5.2 Physical wellbeing of men post prostatectomy The physical wellbeing of the participants in this study hinged on issues concerning pain, fatigue, sleep disruption, constipation and urinary impairment. In this study, participants reported pain in different body parts. The reported body pains probably could be due to metastasis even after undergoing prostatectomy. Pain is a common symptom in advanced prostate cancer, which is present in approximately 70–90% of patients (Thompson, Wood, & Feuer, 2007). Also, pain is a notable denominator to prostatectomy and is implicated in the reduction in the general wellbeing of patients especially, on social interactions and work activities (Haythornthwaite et al., 1998; Strassberg et al., 2017). Most participants in this study experienced pain during or after urination, a situation that can be attributed probably to dutrusor overactivity as a results proliferation of that muscle by cancer cells (Giannantoni et al., 2008). Other participants complained of abdominal pain and severe waist/back pain. Although rare, the reported waist pains could be attributed to bone structural distortion, local tissue destruction, changes in sensory innervation and the release of pro-inflammatory mediators (Urch, 2004). Bone cells are recruited, activated and stimulated by these factors leading to abnormal bone destruction and remodelling which brings about pain (Mantyh, 2014). In addition to pain, another physical effect reported was fatigue. Frequent exhaustion is one of the most prominent negative consequences of cancer that might linger on for years after treatment completion in otherwise healthy survivors (Bower, 2014; Bower & Lamkin, 2013). Cancer induced fatigue brings about dyssynchronisation in every facet of wellbeing and might be a precursor to poor prognosis (Bower, 2014). Participants mentioned that they got exhausted after minimal exertion during activities of daily living. This easy exhaustion interfered with their daily lives including their productivity at work, thereby, having a negative effect on their wellbeing. Fatigue in cancer survivors is seen 61 University of Ghana http://ugspace.ug.edu.gh as a primary response to central nervous mechanisms (Yavuzsen et al., 2009). Participants attributed their fatigue to physical exertions they experienced in the course of carrying out activities of daily living (Bevans & Sternberg, 2012) . It has also been reported that symptoms, such as lack of energy and feeling depressed, are associated with reduction in work hours or change in occupational role (Steiner et al., 2008). In the study, some participants alluded to a reduction in their work input due to easy fatigability. One mentioned that he could not stand for long hours to work as he used to due to the fact that he gets tired easily whenever he stood to perform his role at work. The actual cause of fatigue among participants can be attributed to pain and psychological stress that cancer patients and survivors go through (Nieboer et al., 2005). Most participants in the study experienced pain in different parts of their bodies whilst they suffer psychological mishaps such as depression, fear and anxiety. It is interesting to note that most of the participants were oblivious of what could be the cause of the easy fatigability they experienced in the course of their normal daily activities. Participants may need counseling to urge them to request for assistance from family members in carrying out some activities of daily living (Alomele, 2017). It will also be important for them to disclose their health status to the appropriate channel at their work places so that they may be reassigned to perform less exhaustive roles at work. Prescribing duty restrictions may help the cancer survivor to conserve energy to work efficiently (Frazier et al., 2009). Men who were diagnosed of prostate cancer and had undergone prostatectomy indicated in this study that they experienced sleep disruption. This finding agrees with Hoyt et al. (2016), which pointed that a substantial portion of men treated for prostate cancer reported clinically significant sleep problems and disturbance in sleep quality constitutes significant risk for the development of depressive symptoms in survivors (Hoyt, Bower, 62 University of Ghana http://ugspace.ug.edu.gh Irwin, Weierich, & Stanton, 2016). Symptoms such as urinary and bowel problems, hot flashes, and night sweats are commonly reported after radical prostatectomy, radiation therapy, or hormone treatments, and have potential to disrupt sleep (Savard et al., 2005). Although none of the participants stated that he had any additional therapy after undergoing prostatectomy, they mentioned urinary incontinence and pain as major reasons why they had to wake up either voluntarily or involuntarily at night. A finding that emerged among participants was constipation. This finding agrees with Yokota et al. (2009) that, constipation has a positive relationship with prostate cancer (Yokota et al., 2009). A few of the participants reported staying for days without moving their bowels. Others also mentioned that their stools became unusually hard after they had undergone prostatectomy. Constipation is an unusual symptom in men diagnosed with prostate cancer (Elabbady & Kotb, 2013). According to Elabbady and Kotb (2013), the incidence of constipation in men with prostate cancer could be attributed to possible locally advanced prostate cancer. This may not necessarily be the case in participants who reported experiencing constipation in this study since none of them mentioned being told about the advancement or otherwise of cancer cells after undergoing prostatectomy. Also, according to Yokota et al. (2009), constipation after prostatectomy can be attributed to disorder of gastrointestinal transit due to rectal stenosis (Yokota et al., 2009). Although, this is possible in participants who experienced constipation in this study, it was not clinically verified. One possibility of constipation among participants could be an alteration in their eating habit. It will be imperative to educate prostate cancer survivors about the possibility of experiencing constipation, and be taught dietary habits and lifestyle modifications that will prevent constipation. Nutritional assessment may go a long way to help men diagnosed of prostate cancer who had received any form of treatment (Stenberg, Cvancarova, Ekstedt, Olsson, & Ruland, 2014). 63 University of Ghana http://ugspace.ug.edu.gh Findings from this study is in agreement with Overgard et al. (2008), which posited that urinary incontinence after radical prostatectomy is a common problem and may lead to a reduced quality of life (Overgård, Angelsen, Lydersen, & Mørkved, 2008). Participants in this study reported experiencing urinary incontinence after undergoing prostatectomy. This had a negative effect on their quality of life as most of them had to live life with urethral catheter passed to enable them urinate. Even with the urethral catheter in situ, most of the participants mentioned that urine still drips into their panties. 5.3 Social wellbeing of men post prostatectomy The social wellbeing of men post prostatectomy recorded isolation, financial burden, employment, secrecy and spousal support. The practice of isolation among men diagnosed with prostate cancer and had undergone prostatectomy is reported in several other studies (Andrew, Weinberger, & Nelson, 2008; Dorey, 2007; Kovaleva, Spangler, Clevenger, & Hepburn, 2018). The phenomenon of isolation among these category of patients stem from concerns such as leaking urine in public as a result of urinary incontinence (Dorey, 2007). Some participants reported that they stayed away from social events due to the fear of getting embarrassed by the sudden onset of pain or urine leakage (Ettridge et al., 2018). Thus, they felt a sense of inactivity in their lives and out of touch with society (Kovaleva et al., 2018). After prostatectomy, men may worry about issues regarding the continuous presence of urethral catheter and the incidence of urine leakage. There are men who avoided any form of social interaction because of these problems (Andrew et al., 2008). In situations where participants in this study did not report isolation, it was largely due to the fact that they felt obliged to be present at social events by virtue of their societal or cultural dictates. Some ostensibly attended social events as a way of swaying peoples’ mind from their health status. They perceived isolation as a conduit through which people may begin to inquire about their health status. In other cases, participants in this study chose to mingle with people as a way 64 University of Ghana http://ugspace.ug.edu.gh of fighting boredom and to enable them take their minds off the dreaded consequences of cancer (Mazza, 2015). Financial burden was reported in this study. Participants linked the financial burden to the protracted nature of the treatment, expensive drugs and high cost of treatment (Lai, 2012). In the socio-cultural context of Ghana, the costs of cancer treatments are borne by patients by direct out-of-pocket payment (van Eechoud et al., 2016). Participants in this study mentioned that the medications they buy on monthly basis are expensive. As a result of the skyrocketing expenses, patients with insurance may require financial bailout from the National Health Insurance Scheme to guarantee access to therapy and to lessen the financial burden of cancer care (Rajurkar, Presant, Bosserman, & McNatt, 2011). In the Ghanaian context, the significant burden of cost of therapy for prostate cancer lies on the patient and his relatives. In the course of such treatments, participants and family members are the immediate source of financial support. As such, participants in this study bemoaned the fact that they used their savings to pay very high medical bills (Nayak, George, Vidyasagar, & Kamath, 2014). Participants mentioned challenges they encountered with their employment status and a decline in work output after being diagnosed of prostate cancer and having undergone prostatectomy (Heinesen et al., 2018) . Though prostatectomy does not have a meaningful bearing on the work status in most men, approximately one third of them confront challenges in their employment due to negative effects linked to prostatectomy and/or additional post prostatectomy anti-cancer therapy (Dahl et al., 2015). Participants in this study stated that, alterations to their work and employment status was as a result of pain and easy fatigability. A high number of prostate cancer patients on treatment or who had undergone treatment experienced changes in their employment status due to fatigue (Vayr et al., 2019). 65 University of Ghana http://ugspace.ug.edu.gh Additionally, patients needed to hire additional hands to shore up productivity at their work places (Curt et al., 2000). Some participants in this study narrated that they had to lessen the level of exertions required of them at their work places due to their current health status. Others who are self-employed stated that their health mishaps compelled them to hire extra labour to make up for the shortcomings in their productivity level or work output. In some instances, some participants in this study had to stop work entirely. There is therefore, the need to review current labour law that will reduce labour market challenges for cancer survivors (Heinesen et al., 2018). Participants had challenges in fulfilling their sexual roles as men after they had undergone prostatectomy. This occurrence buttresses findings by Haglind et al. (2015) that majority of men after prostatectomy experienced negative effects on their sexual health (Haglind et al., 2015). Erectile dysfunction was mostly mentioned by participants in this study. This tendency is in agreement with findings by Ficarra et al. (2012) in a systematic review and meta-analysis of studies reporting potency rates after radical prostatectomy; which concluded that erectile dysfunction is a significant complication of radical prostatectomy (Ficarra, Novara, Ahlering, et al., 2012). Erectile dysfunction is a fearful functional effect of surgery for prostate cancer (Whalen, 2018). There are myriad of probable causes of erectile dysfunction among participants in this study. The most probable cause could be the technique adopted during prostatectomy. Recent research has documented that the morphology of cavernous nerve fibres is far sophisticated than previously thought, and partial nerve sparing is probably a major contributor to erectile dysfunction (Walz et al., 2010). There also can be additional trauma to the nerves during surgery through stretching, heating, and local ischemia and inflammation (Masterson, Serio, Mulhall, Vickers, & Eastham, 2008) This is believed to cause a temporary block of nerve transmission even in anatomically intact fibres This however, cannot be independently 66 University of Ghana http://ugspace.ug.edu.gh ascertained by this study since it did not seek to determine the end point of prostatectomy, but rather the wellbeing of men after undergoing prostatectomy. Participants’ age, smoking status, history of cardiovascular disease among others could be reasons for men experiencing erectile dysfunction after prostatectomy. In addition, the occurrence of erectile dysfunction among participants could be purely psychological. It has been proven that a prostate cancer diagnosis might be enough to influence sexual function (Saitz, Serefoglu, Trost, Thomas, & Hellstrom, 2013). The subsequent hospital visits and therapies are known sources of psychological strain and can cause problems such as loss of masculine identity, low self-esteem, and anxiety (Messaoudi, Menard, Ripert, Parquet, & Staerman, 2011). In-depth counselling of patient prior to surgery and during the period of rehabilitation will go a long way to prepare men psychological to confront the challenge of erectile dysfunction after prostatectomy. Efforts must also be made to train urologists in the current surgical advances in prostatectomy so as the minimize erectile dysfunctions that could be attributed to surgical mishaps. Also, urinary incontinence negatively impacts various domains of sexual function regardless of incontinence types (Bekker et al., 2010). Most participants in this study who could not attain optimum sexual function were as a result of having urethral catheter passed for them due to issues of urinary incontinence. This made it practically impossible for them to have any form of penetrative sex so long as the urethral catheter remains. Existing research clearly demonstrates that individuals suffering from urinary incontinence are vulnerable to sexual problems, especially since the topic is highly emotional and characterized by feelings of shame (Hayder et al., 2009; Lasserre et al., 2009). The existence of secrecy among prostate cancer patients is established in societal misconceptions and stigmatization associated with cancers (Holland et al., 2010). 67 University of Ghana http://ugspace.ug.edu.gh Participants cover up their health conditions from extended family members and friends. They stated that divulging their health status to extended family members might expose them to gossip. Others chose to guard their health status as a top secret due to mistrust and the superstitious believe that someone close to them could be the cause of their disease state. Thus, cultural perceptions about an illness influences one’s decisions regarding the illness (Michael, O’Callaghan, Baird, Hiscock, & Clayton, 2014). However, other participants indicated that they revealed their health status to others in anticipation of getting positive feedbacks regarding a panacea. This is indicative that perhaps participants may have heard testimonies about others having been cured of prostate cancer. Thus, they were ready to speak to anyone who could assist them in finding a cure for their condition (Mwangome, Geubbels, Klatser, & Dieleman, 2016). 5.4 Psychological wellbeing of men post prostatectomy The third objective of this study set out to explore the psychological wellbeing of men after they had undergone prostatectomy. This bothered on issues of anxiety, fear and depression. Men who survived prostate cancer were anxious for various reasons. Participants in this study became anxious due to the uncertainty surrounding prostate cancer and its available treatments including prostatectomy. The diagnosis and treatment of cancer may result in various types of emotional distress in patients, including general anxiety (Linden, Vodermaier, MacKenzie, & Greig, 2012; Tavlarides et al., 2013; Watts et al., 2015). The prevalence of anxiety among participants is in agreement with findings from other studies (Chien et al., 2018; Şahan et al., 2018; Tan, Beck, Li, Lim, & Krishna, 2014). According to a systematic literature review report by Dale et al. (2005), anxiety has been identified in 10–36% of short- and long-term prostate cancer survivors (Dale, Bilir, Han, & 68 University of Ghana http://ugspace.ug.edu.gh Meltzer, 2005). Two recent studies in ambulatory prostate cancer patients and patients with localised prostate cancer following prostatectomy demonstrated high degrees of anxiety in 13% and 15% of men (Namiki et al., 2007; Roth et al., 2006). Some participants became anxious because they dreaded what the future holds for them in the face of prostate cancer. Fear of cancer recurrence has been shown to predict anxiety in prostate cancer patients and is one of the primary concerns of long-term prostate cancer survivors (Deimling, Bowman, Sterns, Wagner, & Kahana, 2016). Participants were sceptical about being disease-free after undergoing prostatectomy. Also, participants were unsure about what the future holds for their loved ones in the event of their death. Perhaps, the main reason why participants became anxious in the course of living after the diagnosis of prostate cancer seem to stem from inadequate counselling they might have received prior to the diagnosis and treatment for prostate cancer. The use of corticosteroids, hormone deprivation treatment, and some conventional chemotherapeutic agents are known to bring about anxiety in cancer patients (Wick, Hertenstein, & Platten, 2016). Participants in this study, however, cannot be independently confirmed to have received any adjuvant treatment after undergoing prostatectomy. Prostate cancer related anxiety persisted many years post prostatectomy and was influenced by younger age, psychological status, rising prostate specific antigen (PSA) level, and shorter time since initial treatment (Meissner, Herkommer, Marten-Mittag, Gschwend, & Dinkel, 2017). The closest this study could come in justifying the incidence of anxiety as has been reported by participants could be anchored to the psychological status of participants during diagnosis, through to the period of surgery and to the aftermath of surgery. Participants without enough information about their condition are likely to exhibit great anxiety in the course living post cancer treatment (Howlader et al., 2013) . A comprehensive and continuous counselling session for participants may go a 69 University of Ghana http://ugspace.ug.edu.gh long way to help them overcome the anxiety that comes with having been diagnosed with prostate cancer (McReynolds & Connors, 2019). Also, participants reported suffering depression in the course of prostate cancer trajectory. This revelation is in line with a meta-analysis including 27 studies with a pooled sample size of over 4,000 prostate cancer patients, with either localized or advanced disease, which estimated a prevalence rate of clinically significant depression between 15% and 18% (Watts et al., 2014). The underlying reasons for depression among participants in this study may be multi-fold and can include the psychological distress related to the diagnosis both in the short term and long-term, physical symptoms, side effects of treatment, family and social concerns, as well as the cancer pathophysiology itself (Pitman et al., 2018). Participants mentioned that, the thought of being diagnosed of prostate cancer alone was enough to scare them. This made them to think a lot about their condition to the point that they shed tears on some occasions. Men diagnosed of prostate cancer are reported to be at an increased risk of death by suicide (Fall et al., 2009; Smith et al., 2018). Participants in this study however did not mentioned having experienced any instance of suicide ideation. This could be due to their African traditional orientation and religious affiliations which frowns on suicide as an abomination (Straight, Pike, Hilton, & Oesterle, 2015). A probable cause of depression among participants in this study could be the incidence of various degrees of pain they reported to have experienced (Laird, Boyd, Colvin, & Fallon, 2009). Pain is known to have a positive association with depression among cancer patients (Shaygan & Shayegan, 2019). 5.5 Spiritual wellbeing of men post prostatectomy Issues on spiritual wellbeing of men post prostatectomy in this study revolved around meaning, religiosity, hope and uncertainty. Participants sought meaning to their 70 University of Ghana http://ugspace.ug.edu.gh condition as reported in this study. They reported that, in their quest to understand why they had to be diagnosed with prostate cancer, they questioned God. Some indicated that they wondered why they should be suffering or had to undergo limitations in their daily activities due to prostate cancer. This finding is in line with findings from (Gall, 2009) in a cross- sectional study of 34 prostate cancer patients where participants questioned God about why they had to be diagnosed of prostate cancer. Some believed their prostate cancer diagnosis was as a result of God’s anger towards them (Gall, 2009). Findings from this study indicated that, religiosity was adopted as a coping mechanism by the participants (Clayton-Jones & Haglund, 2016). Most participants in this study mentioned that they increased their closeness to God after being diagnosed of prostate cancer. The increase in religiosity among participants agrees to Caplan et al (2014) in their hypothesis from a longitudinal analysis of cancer diagnoses and religiosity in the University of Alabama that a cancer diagnosis would lead to increased religiosity in the majority of cancer patients (Caplan et al., 2014). This increased in religiosity could perhaps be attributed to the general religiosity that Africans are noted for (Weeden & Kurzban, 2013). Religiosity was characterized by increased in attendance to church services, frequency of going to prayer camps and crusades, increased association with pastors and Mallams, and praying about their health which was meant to be a way of drawing closer to God (Ross, Hall, Fairley, Taylor, & Howard, 2008). Participants believed in getting the cure for cancer through their close association with God. A better understanding of patients’ religiosity and existential beliefs will guide health professionals in adopting the holistic approach in caring for prostate cancer survivors and those undergoing active treatment such as prostatectomy (Pearce, Coan, Herndon, Koenig, & Abernethy, 2012; Rudolfsson, Berggren, & da Silva, 2014) 71 University of Ghana http://ugspace.ug.edu.gh The participants in this study exuded hope by virtue of having a feeling of an optimistic future (Chang, Yu, & Hirsch, 2013). In the face of daily situations with prostate cancer, people tend to anchor their hope on issues that are significant to them, either external, such as family, friends or something supernatural; as well as internal, when people deposit their hopes on themselves, thinking about their life and the possibility of personal achievements (Du & King, 2013). From the study, participants mentioned that they had hope that things will turn out well for them concerning their health. This tendency of optimism could be attributed to their overwhelming believe in a supernatural power that they perceive to have a solution to issues that are beyond the comprehension of mortals (Rustøen et al., 2010). The portraying of hope among participants in this study perhaps could be as a result of the fact that most of the participants fall within the age bracket (less than 65 years) that have be noted to exhibit greater sense of hope when confronted with cancer (Centeno, Carranza, Zuriarrain, Portela, & Larumbe, 2013). 5.6 Spousal Support The diagnosis of cancer and its therapies has major implications for both patients and their family (Li & Loke, 2014). This is assertion is more profound when the main caregiver is the patient’s wife, who plays a central role in decision making concerning treatment choices and gives emotional support to the patient (Hagedoorn, Sanderman, Bolks, Tuinstra, & Coyne, 2008). Cancer survival is linked to marital status, with married persons regarded as having an advantage to live longer and able to face challenges better (Fosså et al., 2011; Pinquart & Duberstein, 2010). Participants in this study stated that they enjoyed varied levels of support from their spouses in the course of their diagnosis, through treatment to living in the aftermath of treatment. Some stated that, they became psychologically strong due to the support they got from their spouses. Married men may experience healthier lifestyles and behaviours (Sarah, Steptoe, & Wardle, 2015), and 72 University of Ghana http://ugspace.ug.edu.gh therefore enhanced overall health at diagnosis, an occurrence favourable for withstanding cancer treatment and thus enhancing longevity. Being married enhances the decision to seek for timely medical advice routinely and particularly when one suspects (Seo & Lee, 2010). This brings about the situation where married patients comes forth with an initial stage at diagnosis and thereby having a more favourable outcome (Lai & Stotler, 2010). From this study, some participants admitted to the tremendous assistance they enjoyed from their wives; some were supported with money to purchase their medication, others were reassured about the prognosis of their condition and lastly some took their husbands to prayer camps and faith healers for solutions. This trend could be rooted in the African tradition which by default bestowed a supportive obligation on women in the domain of marriage (Ndulo, 2011). Women by culture are expected to be supportive of their husbands in any circumstance. The “for better, for worse” maxim seem to be manifested based on the testimonies of men in this study. 5.7 Alternative/complementary sources of treatment Alternative and complementary sources of treatment among men who had undergone prostatectomy were emerging findings not consistent with Ferrell’s Quality of life model. Men resorted to spiritual and herbal sources in search of remedies to their health problems. About 40% of cancer patients globally are known to use alternative and complementary sources of treatment (Horneber et al., 2012). This is attributable to the inborn tendency among humans to experiment with new and alternative means of remedy, especially in instances where orthodox remedy falls short to give desired respite (Aliyu et al., 2017). Some participants in this study alluded to instances where they visited various spiritualists in search of solutions to the problems that prostate cancer has brought on them. This tendency could be attributed to the cultural belief that the roots of an illness can be traced to supernatural causes (Kahissay, Fenta, & Boon, 2017). Participants may have 73 University of Ghana http://ugspace.ug.edu.gh sought cure from spiritualists and prophets probably because of their religious background (Ching et al., 2015). It is also possible that participants may have seen or heard people healed of diverse illnesses on religious television programmes or on the radio. Also, friends and close associates of participants may have testified about receiving healing from such sources of treatment (Ondicho, Ochora, Matu, & Mutai, 2016). Furthermore, perhaps, they probably did not believe that orthodox medicine could cure cancer (Silvanathan & Low, 2015). 5.8 Life satisfaction Another theme that came to the fore in this study which is not consistent with the Betty Ferrell quality of life model for cancer survivors is life satisfaction as a way of self- fulfilment among prostate cancer patients. Life satisfaction is a variable that positive psychology frequently associates with measures of healthy psychological functioning, such as self-fulfilment and happiness. Furthermore, it seems to operate as a facilitator of adaptive coping (Brandstätter et al., 2014; Park et al., 2010; Wnuk et al., 2012), functioning as a tool that allows for greater resistance to suffering and a better adaptation to the disease (Sherman & Simonton, 2012; Vehling et al., 2011). Participants from this study derived happiness and strength from things they deemed as accomplishments in life. Some participants took solace in the houses they had put up and the viable businesses they are running. Others also felt a sense of life satisfaction by virtue of their ability to cater for their family and the progress being made by their children in various endeavours. The innate satisfaction which participants derived from things they mentioned could be attributed to the fact that across diverse socio-cultural contexts which places premium on one’s ability to fend for his/her family as a mark of accomplishment (Benzies & Mychasiuk, 2009). Also, the acquisition of real estates is highly recognized as an indicator of a worthy life by the African at large. These are seen as a preserve of the wealthy in the African society. Participants who 74 University of Ghana http://ugspace.ug.edu.gh seemingly were satisfied with life achievements were able to confront their cancer diagnosis better (Wnuk et al., 2012). 5.9 Evaluation of the Quality of life model applied to cancer survivors The quality of life model by Ferrell was the underpinning framework for this study. It guided the researcher in exploring the wellbeing of men post prostatectomy. The physical, social, psychological and spiritual domains were used to formulate the research objectives. Also, the interview guide was based on the constructs of the model. The physical domain had one major theme as physical wellbeing. A major theme identified from this study was physical wellbeing. This theme was in agreement with the physical domain of the model. Fatigue, sleep disruption, function, nausea, appetite, constipation and aches/pain were subthemes that made up the physical domain in the model. Four subthemes identified from this study were consistent with the model. These were pain, fatigue, sleep disruption and constipation. Nausea, loss of appetite and function were not identified in this study. A new theme: impaired bladder control, which may fit into the physical domain of the model emerged. The psychological domain of the model had psychological wellbeing as its main theme. This was consistent with the psychological domain of the model. The Psychological domain also had anxiety, depression, helplessness, difficulty coping, fear, uselessness, concentration, control and distress as subthemes. These subthemes assisted in eliciting responses about the psychological state of health of the participants in this study. However, from the subthemes that were identified in this study, helplessness, difficulty coping, uselessness, concentration, distress and control were not identified. Nevertheless, a new subtheme: meaning in life emerged which is related to the psychological domain. 75 University of Ghana http://ugspace.ug.edu.gh The model had social wellbeing as its main theme in the social domain. Social wellbeing was identified as a major theme from this study which agrees with the model. The social domain of the model has a total of eight subthemes namely; isolation, role adjustment, financial burden, roles/relationships, affection/ sexual function, leisure activities, burden and employment. Apart from three of these subthemes comprising isolation, financial burden and employment which were identified as subthemes from the data analyzed from this study; the other concepts were not relevant to this study. However, secrecy and spousal support were new themes that emerged from the analysis of the data in this study. These new themes were related to the social domain of the model. Regarding the spiritual domain of the QoL model, spiritual wellbeing was its major theme. Also, a major theme that was identified from the findings of this study was spiritual wellbeing. This was in agreement with the model. The spiritual domain of the model had concepts such as meaning, uncertainty, hope, religiosity, transcendence and positive change as its subthemes. However, the subthemes that were identified from this study and were consistent with the model were meaning, religiosity, uncertainty and hope. In all, six major themes emerged from the data but only four were consistent with the model. The four themes include physical wellbeing, psychological wellbeing, social wellbeing and spiritual wellbeing. The three additional themes include:  Spousal support  Alternative and complementary sources of treatment  Life satisfaction 76 University of Ghana http://ugspace.ug.edu.gh 5.10 Suggestions to the model. The researcher suggests that the QoL model applied to cancer survivors should incorporate impaired bladder control into the physical domain of the model, secrecy and spousal support into the social domain of the model and also life satisfaction into the psychological domain of the model. In addition, the social domain could further be broadened to include alternative and complementary sources of treatment. Lastly, traditional and cultural beliefs should be considered under either the spiritual or social domain. 77 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX SUMMARY, IMPLICATION, LIMITATION, CONCLUSION AND RECOMMENDATION 6.0 Introduction This chapter outlines the summary of the study, the implications of the findings for nursing practice, research, administration and education. The limitation, conclusion and recommendations of the study are also presented. 6.1 Summary of the study The incidence of prostate cancer is on the ascendency globally, and similar observations are made in Ghana (Chu et al., 2011). Although there are several interventions meant to ameliorate the effect of prostate cancer, prostatectomy remains the most used surgical intervention in the Ghanaian context (Kyei et al., 2013). Men who undergo prostatectomy have challenges to confront in every sphere of their lives. How they cope or overcome such challenges remains an individualized issue. This study sets out to explore the wellbeing of men post prostatectomy. The study employed a qualitative exploratory descriptive design. A semi- structured interview guide was designed based on the objectives of the study using the QoL model applied to cancer by Betty Ferrell (1995). The study was undertaken within the Ho municipality and participants were recruited from the urology clinic of the Volta Regional hospital. Data collection started after ethical approval from the Ghana Health Service Ethics Committee, University of Ghana and the Volta Regional hospital. Participants were purposively sampled and saturation was reached at the 13th participant. The interview guide was pretested at the Sogakope District hospital to ensure that it was understood and was able to bring out the 78 University of Ghana http://ugspace.ug.edu.gh required responses that would answer the research questions. Participants who agreed to participate in the study signed a consent form. Interviews were audio-taped and verbatim transcription of interviews occurred alongside. Data were analyzed using thematic content analysis. The key findings brought to the fore that men who had undergone prostatectomy physically experienced pain in different parts of their bodies. Pain disrupted their day to day activities with a negative bearing on the various work/employment They had issues with urinary incontinence which disrupts their sleep since they had to wake up several times during the night to micturate or to empty their urine bags. Also, they got easily fatigued whenever they engaged in activities of daily living. This affected their productivity at their various places of work. Furthermore, constipation was an issue of concern to them. They noticed that they had to strain to empty their bowels. Others stayed several days without the urge to empty their bowel. Most prostate cancer survivors could not honour invitations to social gatherings because they fear being embarrassed with a sudden onset of pain or urine dripping into their clothes. They feared suffering stigmatization as a result of their conditions, hence the decision not to patronize social gatherings. They had pressing financial burdens as a result of the expensive medication they buy every month. The cost of the surgery was also a financial albatross of men who had prostatectomy. Some men were fortunate to get some financial bailouts from their spouses. Also, most men kept their conditions a top secret from friends and relatives for fear of stigmatization. Men who survived prostate cancer experienced anxiety due to the obvious changes they noticed about their day to day lives. In addition, the lack of clarity about the outcome of their condition brought about a feeling of uncertainty into them. Some men experienced 79 University of Ghana http://ugspace.ug.edu.gh depression. They entertained the thought that they could die from the debilitating effects of cancer. This made some men to cry whilst others isolated themselves just to ponder over what the uncertain future holds for them. Nevertheless, some other men had tremendous support from their spouses in the course of their day to day lives with prostate cancer survival. In the face of all these, they had the hope that things could turn out for good. Participants adopted diverse spiritual approaches as a means of seeking redress to their health problems. Men questioned God as to why they had to suffer from prostate cancer. They posited that it was the will of God to suffer from prostate cancer. Most men who had prostatectomy drew closer to God and prayed for the healing. They patronized prayer camps and spiritualists in search of help. In contrast, two participants stayed away from God since to them, they do not see why they should be so close to God and still suffer from prostate cancer. Most prostate cancer survivors sought alternative and complementary sources of treatment for their conditions; in addition to traditional orthodox medicine. Most participants sought spiritual healing by visiting prophets and spiritualists at prayer camps for prayers for healing. Several men got herbal medication from herbalists to administer with the hope of getting healing through them. Some traveled several distances just to see herbalist for solutions to their health needs. 6.2 Implications for Nursing The findings from this study have implications that require attention. These implications yield themselves to nursing research, nursing education, nursing administration and nursing practice. 80 University of Ghana http://ugspace.ug.edu.gh 6.2.1 Nursing Research/Avenues for future Research Men who had prostatectomy experienced varied degrees of alterations in their general wellbeing. They experienced physical, social, psychological and spiritual challenges in the course of living after prostatectomy. Future studies could focus on experiences of care givers of men who had undergone prostatectomy, wellbeing of family after the death of a sick prostate cancer relative, experiences of spouses of men who had undergone prostatectomy, the impact of spirituality on preferred treatment choices of men who had prostate cancer, complementary and alternative treatment use in men diagnosed with prostate cancer and the patronage of prostate cancer screening in men. 6.2.2 Nursing Education The curriculum for the training of nurses should be revised to include Oncology nursing. This training will provide nurses with specialized skills to give holistic and evident based care to patients with prostate cancer and their family members. Tutors in health training institutions must be taken thorough in-service training to equip them to teach modern trends in the holistic approach to cancer management and treatment. In addition, findings from this study revealed that, the physical and social wellbeing of men who had prostatectomy were compromised. This requires the development of curriculum for palliative nursing programme for the training of palliative care nurses to provide specialized care for patients with advanced cancer. This will go a long way to ameliorate the physical and social wellbeing challenges faced by prostate cancer survivors. Finally, healthcare for prostate cancer survivors must embrace a family centered care approach, to enable care to be centered on the entire family and not only the sick person. 81 University of Ghana http://ugspace.ug.edu.gh 6.2.3 Nursing Administration. Findings from this study revealed that, men who suffered from prostate cancer were most non- compliant to treatment regimen. They sought for treatment from several sources in an uncoordinated manner. Some used herbal medication concomitantly with the orthodox treatment being received from the hospital. A modification of the policy on public education is therefore imperative. This will make the education on prostate cancer acceptable and easily accessible and further enhance the choice of treatment modalities of prostate cancer patients and the entire populace. 6.2.4 Nursing Practice Findings from this study revealed that, the psychological wellbeing of men who had undergone prostatectomy was highly compromised. They haboured a lot of uncertainty and fear about the prognosis of their conditions which made most of them to be depressed. Therefore, counselling needs to be provided for prostate cancer survivors to help them to cope better with their day to day lives. 6.3 Insight Gained The researcher noted that, pain remained a major setback to men who had prostatectomy, inspite of the believe that pain diminishes once there is no evidence of cancer metastasis prior to prostatectomy. Men who had prostatectomy did not receive adequate education from health professionals. They mostly depended on information from the mass media, family and friends. What they got from the hospital can only stand as assurances about their condition getting better after undergoing prostatectomy. Some prostate cancer survivors combined orthodox medicine with scientifically unproven herbal medicines based on the recommendation of friends and relatives. The psychological health of prostate cancer patients was regrettably compromised. 82 University of Ghana http://ugspace.ug.edu.gh 6.4 Limitation The study was conducted in the Volta region of Ghana. The participants in this study were all Christians except three. The study may be conducted in an Islamic community using Muslims because of differences in the religious beliefs and the findings compared. The fact that all the participants had their prostatectomy at one hospital may hinder the researcher’s tenacity to draw a relationship between the successes of the surgical procedure to some of the challenges that the participants narrated. A study may be conducted drawing participants from various hospitals to enable the researcher study the trend of complaints from these participants. This will help rule out complaints that are as a result of a not too successful prostatectomy. 6.5 Conclusion Prostate cancer is on the ascendency and prostatectomy remain the treatment of choice in Ghana. Most patients who had prostatectomy had to live their lives in the face of several challenges they encounter as a result of their condition. Health facilities do not have adequate capacity to nurse these patients. Patients and their families are saddled with responsibilities of caring for themselves vis-à-vis the high cost of treatment for prostate cancer. The physical, social, psychological and spiritual wellbeing of prostate cancer survivors in Ghana are compromised. It is necessary that policy makers put measures in place to address the health needs of prostate cancer patients. The first step is to establish a functioning cancer registry at various facilities in Ghana to give an in-depth account on cancer patients in Ghana. Educational materials should be tailored towards the need of cancer patients and their families. Health professionals at schools and institutions should be made to embrace oncology as an integral part of the training they receive to become practicing nurses. The Ministry of Health together with other stakeholders should lobby for the absorption of the cost of treatment for prostate cancer fully by the national health 83 University of Ghana http://ugspace.ug.edu.gh insurance scheme. This will ease the financial burden on patients and their families. With these measures, men who had prostate cancer will be in a better position to live a normal life in the face of cancer. 6.6 Recommendations Based on the findings of this study, the following recommendations have been made to the Ministry of Health and the Volta Regional hospital. 6.6.1 Ministry of Health  The policy on public education on prostate cancer should be modified by the Ministry of Health and other stakeholders. Health education on prostate cancer should be intensified. This will make the education on prostate cancer acceptable and easily accessible.  The Ministry of Health and other stakeholders should lobby the government to cover the treatment of prostate cancer completely by the National Health Insurance Scheme.  Policy should be made to include prostate cancer screening in men a routine investigation that should come at no cost to men.  The Ministry and other stakeholders should explore and train surgeons in other treatment options for prostate cancer so, as to arrive at the most appropriate for each prostate cancer patient. 6.6.2 The Volta Regional Hospital  The management of the hospital should prepare educational materials touching on prostatectomy and other cancers to be distributed at the outpatient department (OPD). 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Automatically identifying social isolation from clinical narratives for 111 University of Ghana http://ugspace.ug.edu.gh patients with prostate Cancer. BMC medical informatics and decision making, 19(1), 43. Zullig, K. J., Valois, R. F., Huebner, E. S., & Drane, J. W. (2005). Adolescent health- related quality of life and perceived satisfaction with life. Quality of Life Research, 14(6), 1573-1584. 112 University of Ghana http://ugspace.ug.edu.gh APPENDICES APPENDIX A: BACKGROUND INFORMATION FORM A. Demographic Information Code number………………… 1. Age (years)……………………………………………………………………………… 2. Level of Education……………………………………………………………………… 3. Occupation……………………………………………………………………………... 4. Place of residence………………………………………………………………………. 5. Marital status………………… ………………………………………………………... 6. Number of children……………………………………………………………………... 7. Nationality……………………......................................................................................... 8. Religion………………………......................................................................................... 9. Language spoken…………. …………… ……………………………………………… 10. Number of years post prostatectomy…………………………………………………… 113 University of Ghana http://ugspace.ug.edu.gh APPENDIX B: INTERVIEW GUIDE B. GUIDING QUESTIONS 1. Please with me what you do on day to day basis 2. Please share with me your experiences with regards to your physical health Probes:  Fatigue  Aches and pains  Changes in eating  Changes in elimination  Difficulty Sleeping 3. What are some of your experiences with regards to your social health? Probes:  Recreational activities  Social events such as weddings, funerals, naming ceremonies etc  Work related activities  Relationship with spouse/family  Social isolation  Any changes in responsibilities 114 University of Ghana http://ugspace.ug.edu.gh 4. What will you say about your psychological health? Probes:  Fears and worries  Happy and unhappy moments  Forgetfulness  Helplessness  Depression 5. What can you say about your spiritual life? Probes:  Closeness to God  Consultation with prophets/ Mallams/ herbalists  Use of anointing oil/ concoctions/holy water  Hope in God Please, is there anything else you will like to talk about? 115 University of Ghana http://ugspace.ug.edu.gh APPENDIX C: CONSENT FORM Study Title: Exploring the wellbeing of men post prostatectomy in the Ho municipality PARTICIPANTS’ STATEMENT I acknowledge that I have read or have had the purpose and contents of the participants’ Information Sheet read and all questions have been satisfactorily explained to me in a language I understand (English Ewe Twi Ga ). I fully understand the contents and any potential implications as well as my right to change my mind (i.e. withdraw from the research) even after I have signed this form. I voluntarily agree to be part of this research. Name or Initials of Participant……………………………………………….ID Code……………………………… Participant’s Signature……………………OR Thumb Print………………… Date…………………………………………. Permission to audio record the interview. Yes No INTERPRETERS’ STATEMENT I interpreted the purpose and contents of the Participants’’ Information Sheet to the afore named participant to the best of my ability in the (English Ewe Twi Ga ) language to his proper understanding. All questions, appropriate clarifications sort by the participant and answers were also duly interpreted to his satisfaction. Name of Interpreter…………………………………………………………. Signature of Interpreter…………………………………………………….. Date……………………………………….. Contact Details……………………………………………………….. 116 University of Ghana http://ugspace.ug.edu.gh STATEMENT OF WITNESS I was present when the purpose and contents of the Participants’ Information Sheet was read and explained satisfactorily to the participant in the language he understood (English Ewe Twi Ga ). I confirmed that he was given the opportunity tom ask questions/seek clarifications and same were duly answered to his satisfaction before voluntarily agreeing to be part of the research Name………………………………………Signature……………………… OR Thumb Print…………………... Date…………………………………………………… INVESTIGATOR STATEMENT AND SIGNATURE I certify that the participant has been given ample time to read and learn about the study. All questions and clarifications raised by the participant have been addressed. Researcher’s name………………………………………………. Signature……………………………………… Date……………………………………... Participant’s ID Code………………………………… Place………………………………………... 117 University of Ghana http://ugspace.ug.edu.gh PARTICIPANTS’S INFORMATION SHEET SCHOOL OF NURSING AND MIDWIFERY DEPARTMENT OF ADULT HEALTH UNIVERSITY OF GHANA STUDY TITLE: EXPLORING THE WELLBEING OF MEN POST PROSTATECTOMY IN THE HO MUNICIPALITY Introduction Hello. I am Cyril Akator, a Master of science in Nursing student at the School of Nursing and Midwifery, University of Ghana. I invite you to take part in a research project entitled: Exploring the wellbeing of men post prostatectomy in the Ho municipality. Background and purpose of the study I am gathering data on wellbeing of men after they had undergone prostate surgery in the Ho municipality. Data for this study will be collected by me by the use of an interview guide. I will however, want to seek your consent to participate in the study, so what you are about to hear is part of the process of informed consent. This process will give you basic idea on what that research is about and what your participation will involve. Men who had prostate surgery are confronted with several negative health issues, some of which include sexual and urinary problems. Some studies revealed that men have suffered from severe overall distress and activity limitations after prostate surgery. Also, the higher number of Black men diagnosed with prostate cancer also suggests this population must contend with managing the symptoms associated with the disease. An understanding of the negative health issues experienced by Black men living with prostate cancer is needed to in order to positively impact their health outcomes and improve their overall wellbeing. There is no one true definition of the concept of wellbeing. The known definitions range from those with emphasis on the social, emotional and physical well-being to those that pointed to the impact of a person’s health on daily basis. The concept of wellbeing is said to be difficult to define and even harder to measure. There are several theoretical models used to study and or understand wellbeing. However, this study will use Betty Ferrell’s Quality of life model for cancer specific conditions. It focuses on the domains of physical wellbeing, 118 University of Ghana http://ugspace.ug.edu.gh psychological wellbeing, social wellbeing and spiritual wellbeing. Thus, it is important to understand these domains of one’s wellbeing to be able to offer supportive care to them during the period post prostate surgery. This study is a Master of Science (MSc.) degree project work for me. It was reviewed by the Ghana Health Service to be carried out. Participants have been selected to participate in this study are 18 years and above, had undergone prostate surgery and resides in the Ho municipality. The Nature of the study The study will be an exploratory qualitative study on men who have had prostate surgery in the Ho municipality. Data will be collected via an in-depth interview where respondents are expected to answer specific questions pertaining to their wellbeing after prostate surgery. The study will be conducted in June, 2019. In all, 13 people will be interviewed for this study. Participants involvement Duration/What is involved: Series of questions will be asked via an interview guide concerning respondents’ wellbeing after they had prostate surgery. You will be required to give responses to the questions related to your demographic characteristics and on your wellbeing after surgery. You will be expected to spend between 30-45 minutes of your time participating in the study. Potential risks It is not expected that being in this study will be harmful to you, however, you may feel emotional about telling your story. If that happens, then you will be referred a clinical psychologist who will talk to you to relief you of your emotions without any financial cost to you. Benefits Sharing your post-surgery experiences in this study, may lead to further exploration into the care given to patients with prostate cancer in Ghana. This in a long way will guide caregivers to tailor made care to meet the peculiar needs of men who have undergone prostate surgery. 119 University of Ghana http://ugspace.ug.edu.gh Compensation There will be no cash compensation for participating in the study. You will not be paid for participating in the study. However, you will be served snacks after the conversation with the researcher. In the event that the conversation takes place outside your home or workplace, the cost of your transportation will be borne by the Researcher. Confidentiality All information related to you in relation to this study will be kept confidential from any other person except those who are directly involved in the study. The information will be kept under lock and key, filled and put in a cabinet. The softcopy of the data will be stored on a computer and encrypted with password known to the principal investigator alone. Data analysis will be done without disclosing your identity by using false names and codes. Any stakeholder who wishes to use the results of the study to implement a recommendation will sign a consent to keep sensitive parts of the reports strictly confidential and is ready to face any sanction should he/she breach your right to confidentiality. The data collected will be used for only academic purposes. Data will be kept for a period of 5 years, and then transferred to the national archive house of judicious safe keeping or be destroyed if the need arises. Voluntary participation/Withdrawal from the study Participating in this study is voluntary. You are at liberty to withdraw from the study at any point. Such withdrawal will not affect the quality of healthcare service you or your relative will require from health care providers. Also, you are free to decline answering to questions you deem too sensitive or uncomfortable with. Information collected from participants before deciding to withdraw from the study will not be included in the final analysis of the data. Outcome and feedback The data collected will be used for only academic purposes. Data will be kept for 5 years and the transferred to the national archive house for safe keeping. Feedback will be given to the right authorities regarding the results of this study especially when the study results would need publishing. 120 University of Ghana http://ugspace.ug.edu.gh Feedback to participant Since the study is solely for academic purposes, you may not get first hand feedback on the results of this study. However, your caregiver may relay any relevant information to you. Funding information This study is self-sponsored by the principal investigator. Sharing of participants Information/Data The data collected will be used for only academic purposes. Data will be kept for 5 years and then transferred to the national archive house for safe keeping. Since the information obtained is solely for academic purposes, your information will not be shared with the general public but used specifically for the purpose stated. A copy of the findings will be presented to the Ethics Review committee of the Ghana Health Service. Provision of information and consent You will be given copies of the information sheet and consent forms after it had been signed or thumb printed to keep. Contacts for Additional Information on the study If you have a complaint or wish to seek further clarification, kindly contact: Principal Investigator: Akator Cyril, Department of Adult Health, School of Nursing and Midwifery, University of Ghana, P.O. Box LG 43, Legon. Tel:024 2959 290 Email: cyrilakator17@gmail.com 121 University of Ghana http://ugspace.ug.edu.gh Administrator at the Ghana Health Service Ethics Review Committee Office: Madam Hannah Frimpong, between the hours of 8am – 5pm via telephone 0507041223 or email address: Hannah.Frimpong@ghsmail.org Supervisors: Prof. Lydia Aziato, Department of Adult Health, School of Nursing and Midwifery, University of Ghana, P. O. Box LG 43, Legon, Accra, Ghana. Tel: 0244719686 Email: aziatol@yahoo.com Dr. Lillian Akorfa Ohene, Department of Adult Health, School of Nursing and Midwifery, University of Ghana, P.O. Box LG 43, Legon, Accra, Ghana. Tel: 0246395696 Email: lohene@ug.edu.gh Counselor: Mr. Eugene Tornyeava, Comboni Catholic Hospital, Sogakope Tel. 0205850427, Email: telikemugene@gmail.com 122 University of Ghana http://ugspace.ug.edu.gh APPENDIX D: GENERAL PROFILE OF PARTICIPANTS DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS Name Language Age Education Occupation Marital Number Religion Years spoken status of post- (Years) Children surgery Joe Ewe 38 Senior Farmer Married 2 Christianity 2 yrs. High William English 52 Tertiary c. servant Married 4 Christianity 4 Kwame English 43 Tertiary C Servant Married 0 Christian 3 Kwao English 67 Tertiary C. Servant married 3 Christianity 8 months Isaac English 43 Tertiary Farmer married 2 Christianity 3 yrs. Yao English 48 Tertiary Pensioner married 4 Traditional 2 yrs. Kojo English 48 Senior Trader married 3 Christianity 1 yr. High Kofi English 54 Tertiary Teacher married 5 Christianity 2 yrs. Annor English 47 Senior Farmer married 4 Christianity 3 yrs. High James Ewe 50 Senior Mechanic married 3 Christianity 1 yr. High Godwin English 44 Senior Driver married 2 Traditional 3 yrs. High Aziz English 56 Junior Butcher married 3 Islam 2 yrs. High Frederick Ewe 37 Junior Mason married 2 Christianity 1 yr. High 123 University of Ghana http://ugspace.ug.edu.gh APPENDIX E: SUMMARY OF THEMES THEMES SUBTHEMES Physical wellbeing Pain Fatigue Sleep disruption Constipation Impaired bladder control Social wellbeing Isolation Financial burden Employment Affection/Sexual function Secrecy Psychological wellbeing Depression Anxiety Fear and uncertainty Spiritual wellbeing Religiosity Hope Meaning Uncertainty Spousal support Alternative/complementary sources of treatment Herbal medicine Spiritual Life satisfaction 124 University of Ghana http://ugspace.ug.edu.gh APPENDIX F: ETHICAL APPROVAL LETTER 125 University of Ghana http://ugspace.ug.edu.gh APPENDIX G: INTRODUCTORY LETTER 126 University of Ghana http://ugspace.ug.edu.gh APPENDIX H: APPROVAL LETTER FROM THE VOLTA REGIONAL HOSPITAL 127 University of Ghana http://ugspace.ug.edu.gh APPENDIX I: INTRODUCTORY LETTER TO VOLTA REGIONAL HOSPITAL 128