The Cultural Adaptation and Pilot Feasibility Testing of Helping Her Heal (HHH), an Educational Counseling Intervention for Spouse Caregivers of Women with Breast Cancer in Ghana

Abstract

Background. Breast cancer is the leading cancer in Ghana and accounts for 31.8% of cancers in women. In partnered relationships spouses are the primary caregivers and assist wives experiencing breast cancer with activities of daily living, supporting their wives financially and emotionally. Caregiving places burden and strain on spouses. Spouse caregivers are known to have anxiety, depressed mood and sometimes have higher levels of depressed mood than wives. There is therefore a need for an intervention to help spouse caregivers cope better with their wives’ breast cancer and caregiving.Purpose. The overall purpose of this dissertation is to advance the science in spouse caregiving of women with breast cancer in Ghana. In Study 1 (Chapter 2), a three-phase approach and the Ecological Validity Framework (EVF) was employed to culturally adapt Helping Her Heal (HHH), an educational counseling intervention for spouse caregivers of women with breast cancer. The purpose of Study 2 (Chapter 3) was to conduct a field test to assess the appropriateness of the adapted draft HHH-Ghana. The purpose of Study 3 (Chapter 4) was to conduct a pilot study to ascertain the feasibility and short-term impact of the adapted HHH-Ghana. Methods. Both qualitative and quantitative research approaches were utilized in this dissertation. Spouse caregivers were included in all three studies if they could speak and read English, living with their wives or partners for at least 6 months and if their wives had Stages I, II or III breast cancer. Participants from Studies 1 and 2 were the same. In Studies 1 and 2, a single occasion in-depth interview was used to elicit feedback on the intervention manuals from breast cancer nurses and spouse caregivers. The interviews were audio recorded and transcribed verbatim. Both deductive and inductive content analysis were carried out in analyzing the interview data from Study 1. Deductive analysis was conducted for Study 2, a single group pre-post design was employed in Study 3 to ascertain the feasibility and short-term impact of the adapted HHH-Ghana. Five standardized instruments (STAI-Y, CES-D, MIS, CASE and Spouse Skills Checklist) were used to measure the outcome variables of interest. The Wilcoxon Signed Ranked Test was used to assess the short-term impact of the intervention in spouse caregivers of women with breast cancer in Ghana. Exit interviews were conducted with participants at the end of Study 3 to assess what spouse caregivers thought they had gained by participating in the study. Results. Studies 1 and 2 included two breast cancer nurses and four spouse caregivers. Fourteen spouse caregivers participated in Study 2. In Study 1, participants found the intervention to be acceptable and understandable but recommended some changes to be made. A spouse participant said he perfectly understood all the tasks and assignments in the intervention manual while another suggested the inclusion of faith-based activities as a strategy to unwind. In Study 2, participants said the adapted draft HHH-Ghana reflected their feedback and was relevant. A spouse indicated that the adapted draft intervention was relevant because writing a letter to their wives as a way of appreciating them had been modified to verbally expressing appreciation for their wives because it was not in the Ghanaian culture to write letters to their partners. Study 3 showed that the intervention was feasible as recruitment strategies were adequate in enrolling participants, the retention was 87.5% and spouse participants engaged actively in intervention sessions by responding to questions, providing answers, and completing at home assignments with wives. Significant results were achieved in all the outcome variables except one. There was significant improvement in anxiety, depressed mood, spouse self-efficacy, self-care skills and communication. The measure for communication among the couple (MIS) did not record significant change but communication did not get worse. This finding was contrary to the report from the interview data where participants indicated that they were communicating better because of participating in the study. Conclusion. The three-phase approach and the EVF were useful in culturally adapting the HHH. Participants from Study 1 and 2 found the HHH to be acceptable and understandable and made suggestions for change to make it more acceptable and relevant to spouse caregivers of women with breast cancer in Ghana. Study 3 showed that the HHH was feasible and improved anxiety, depressed mood, self-efficacy, and spouse skills in taking care of themselves and their wives. A larger clinical trial can be conducted to ascertain the efficacy of HHH in spouse caregivers of women with breast cancer in Ghana. The HHH-Ghana can be implemented and evaluated at the breast unit of the Korle-Bu Teaching Hospital where the study was conducted. Results from this evaluation will inform policy making regarding the inclusion of HHH in the usual care of women with breast cancer.