LIVING WITH BREAST CANCER; SRI LANKAN RURAL

WOMEN’S REFLEXIVE RESPONSES TO SOCIAL AND

EMOTIONAL CHALLENGES

By

KUMARASINHE HPNI

CPM: 14746

MC: 80222

An Independent Research Report

Submitted to the University of Sri Jayewardenepura

In Partial Fulfillment of the Requirements for the

B.Sc. Human Resource Management (Special) Degree Program

Department of Human Resource Management

Faculty of Management Studies and Commerce

University of Sri Jayewardenepura

Sri Lanka

November 2019
 Certification

I hereby recommend that the research project was prepared under my supervision by

Name: H.P.N.I.Kumarasinghe

CPM: 14746

MC: 80222

Entitled Topic: Living with Breast Cancer; Sri Lankan Rural Women’s Reflexive
Responses to Social and Emotional Challenges.

Accepted in partial fulfillment of the requirements for the Bsc. Human Resource
Management (Special) Degree.

………………………………………

Dr.(Mrs.) U. K Thalgaspitiya

Research Supervisor

II
 Acknowledgement

This research paper was made possible through the guidance of my research supervisor Dr.
(Mrs.) U. K Thalgaspitiya, Senior Lecturer, Department of Human Resource Management.
She had been a source of encouragement at all the times and would like to express my
profound gratitude, for her valuable guidance and support throughout this study. Also other
special thanks goes to Dr. N.W.K.D.K.Dayarathne, Research Coordinator of Department
of Human Resources Management, University of Sri Jayewardenepura.

My sincere gratitude goes to Head and all lecturers of Department of Human Resource
Management for numerous support and guidance rendered for me in completion of this
research study, and also Dean and all members of faculty board for granting this precious
opportunity to enhance my skills and knowledge.

I extent my deep gratitude to the entire respondents who provided information and
immense support, by participating to interviews from different rural areas of Sri Lanka,
sharing their valuable time and effort to make this research a success. They provided
information to complete this dissertation in a timely and proper manner. I wish them soon
recovery and healthy life forever.

Finally, and most importantly I would like to express my heartfelt gratitude to my loving
parents, friends and seniors for the tremendous support and encouragement provided
throughout this study. And I would like to express my special thanks to all who were not
mentioned here for giving me the possibility to complete this research study.

III
 Abstract
Cancer has been a burden health issue worldwide now. Breast cancer can be identified as
the common chronic disease among women. It brings variety of physical, social and
emotional challenges to all most all the rural women living with breast cancer in Sri Lanka.
So, this study mainly focuses to identify the reflexive responses of Sri Lankan rural women
living with breast cancer to social and emotional challenges after diagnosis. Specifically,
this research examines the responses related to six main themes of social and emotional
challenges including stress and depression, family and community support, accessing to
medical support and information, feeling isolation, coping with financial burden and
spiritual directions. The research adopts a qualitative approach and data collected through
semi-structured in-depth interviews from self-selected 10 rural women who are living with
breast cancer more than period of one and half years to fifteen years. Six participants were
direct patients and four participants were closest relatives of the patient. First-level
analytical coding approach was used to derive themes and thematic analysis was used in
analysis of collected data.

Among the major findings, most of the women in the unit of analysis are stressed and
feared more at the very first beginning of the breast cancer diagnosis and also in later
periods too due to lack of proper support and other challenges like difficulty in accessing
to medical treatments and financial burden. As a positive note no one could identify with
depression conditions. Majority of women has good support from the family and
community in many circumstances. Accessing to medical support and information is/was
a biggest challenge due to long distance travelling and no proper way of accessing to
information prior to diagnosis. Feeling isolation could identify with reduced social
interaction mostly in younger women rather than elder women. Finally, greater extent of
spiritual directions could reveal through nine women except one after the diagnosis of
breast cancer as a coping mechanism of this illness and psychological well-being.

Key words: Breast Cancer, Rural Women, Social Challenges, Emotional Challenges,
Stress, Depression, Health Services, Health Information, Family Support, Community
Support, Isolation, Spiritual Directions
IV
 Abbreviations

WHO World Health Organization

IARC International Agency for Research on Cancer

NCD Non-communicable Diseases

GLOBOCAN Global Cancer Incidence, Mortality and Prevalence

MOH Medical Officer of Health

WCRF World Cancer Research Fund

AICR American Institute for Cancer Research

ESRC Economic and Social Research Council

SLTB Sri Lanka Transport Board

V
 Table of contents

Chapter 01 ........................................................................................................................... 1

Introduction ......................................................................................................................... 1

1.1 Background of the study ........................................................................................... 1

1.2 Problem of the study ................................................................................................. 3

1.3 Research questions .................................................................................................... 3

1.4 Objectives of the study .............................................................................................. 3

1.5 Significance of the study ........................................................................................... 4

1.6 Research Methodology .............................................................................................. 5

1.7 Structure of the report ............................................................................................... 6

1.8 Limitations to the study ............................................................................................. 7

Chapter 02 ........................................................................................................................... 8

Literature review ................................................................................................................. 8

2.1 Introduction ............................................................................................................... 8

2.2 Cancer........................................................................................................................ 8

2.3 Breast Cancer .......................................................................................................... 10

2.4 Theories related to breast cancer ............................................................................. 12

2.4.1. Attribution Theory ........................................................................................... 12

2.4.1.1. Biological Attributions ............................................................................. 13

2.4.1.2. Environmental Attributions ...................................................................... 14

2.4.1.3. Reproductive History, Breast Feeding, and Hormones ............................ 14

2.4.1.4. Lifestyle .................................................................................................... 15

2.5 Rural Population in Sri Lanka ................................................................................. 16

2.6 Rural women with Breast Cancer............................................................................ 16

VI
 2.7 Social Challenges .................................................................................................... 17

2.8 Emotional Challenges ............................................................................................. 18

2.9 Social and Emotional challenges associated with rural women with breast cancer
and their responses ........................................................................................................ 19

2.9.1 Stress and Depression ....................................................................................... 20

2.9.2. Family and Community support ...................................................................... 21

2.9.3 Accessing to medical support and information ................................................ 22

2.9.5 Coping with Financial Burden .......................................................................... 24

2.9.6. Spiritual Directions .......................................................................................... 25

2.10 Summary ............................................................................................................... 26

Chapter 03 ......................................................................................................................... 27

Methodology ..................................................................................................................... 27

3.1 Introduction ............................................................................................................. 27

3.2 Rationale for the methodology ................................................................................ 27

3.3 Research Approach ................................................................................................. 29

3.4 Research Design ...................................................................................................... 29

3.4.1 Choice of method.............................................................................................. 30

3.4.2 Study context .................................................................................................... 30

3.4.3 Data collection .................................................................................................. 30

3.4.3.1 Sample size ................................................................................................ 31

3.4.3.2 Sampling strategy....................................................................................... 31

3.4.3.3 Unit of analysis .......................................................................................... 32

3.4.3.4 Sample profile ............................................................................................ 32

3.4.3.5 Interview guide .......................................................................................... 32

3.4.3.6 Field notes .................................................................................................. 33

VII
 3.4.3.7 Voice recordings ........................................................................................ 33

3.4.3.8 Observations .............................................................................................. 33

3.4.3.9 Interview procedure ................................................................................... 33

3.4.3.10 Duration of interviews ............................................................................. 34

3.4.3.11 Language of interviews ............................................................................ 34

3.4.4 Data preparation and management ................................................................... 35

3.4.5 Data analysis ..................................................................................................... 35

3.4.5.1 Thematic Analysis ..................................................................................... 36

3.4.5.2 Codes.......................................................................................................... 36

3.5 Rigor of the study .................................................................................................... 37

3.5.1 Credibility ......................................................................................................... 38

3.5.2 Transferability .................................................................................................. 38

3.5.3 Dependability.................................................................................................... 38

3.5.4 Confirmability .................................................................................................. 38

3.5.5 Integrity ............................................................................................................ 39

3.6 Methodological Limitations .................................................................................... 39

3.7 Ethics ....................................................................................................................... 39

3.8 Summary ................................................................................................................. 40

Chapter 04 ......................................................................................................................... 41

Findings............................................................................................................................. 41

4.1 Introduction ............................................................................................................. 41

4.2 Study context ........................................................................................................... 41

4.3 Participant Coding system....................................................................................... 43

4.4 Sample Profile ......................................................................................................... 43

4.5 Stress and Depression.............................................................................................. 45

VIII
 4.5.1 Changes in feelings when being diagnosed as a breast cancer patient ............. 45

4.5.2 Way of coping with stress and depression........................................................ 47

4.6 Family and Community support.............................................................................. 48

4.6.1 Support from the family ................................................................................... 49

4.6.2 Support through social relations ....................................................................... 50

4.7 Accessing to medical support and information ....................................................... 51

4.7.1 Difficulties in accessing health services ........................................................... 51

4.7.2 Availability of accessing to information .......................................................... 52

4.8 Coping with financial burden .................................................................................. 54

4.8.1 Financial difficulties and Income level of the patient and the family .............. 54

4.8.2 Financial support by outside parties ................................................................. 55

4.9 Feeling isolation ...................................................................................................... 56

4.9.1 Felling helplessness .......................................................................................... 57

4.9.2 Changes in social interactions .......................................................................... 58

4.10 Spiritual directions ................................................................................................ 59

4.10.1 Extent of engage in religious activities........................................................... 59

4.10.2 Impact for Psychological Relief ..................................................................... 61

4.11 Conclusion............................................................................................................. 62

Chapter 05 ......................................................................................................................... 63

Discussion of findings....................................................................................................... 63

5.1 Introduction ............................................................................................................. 63

5.2 Stress and Depression.............................................................................................. 63

5.2.1 Changes in feelings when being diagnosed as a breast cancer patient ............. 63

5.2.2 Way of coping with stress and depression........................................................ 64

5.3 Family and Community Support............................................................................. 65

IX
 5.3.1 Family Support ................................................................................................. 65

5.3.2 Support through Social relations ...................................................................... 66

5.4 Accessing to medical support and information ....................................................... 66

5.4.1 Accessing to health services ............................................................................. 67

5.4.2 Accessing to information .................................................................................. 68

5.5 Coping with financial burden .................................................................................. 68

5.5.1 Financial difficulties and Income level of the patient and the family .............. 68

5.5.2 Financial support by outside parties. ................................................................ 69

5.6 Feeling isolation ...................................................................................................... 69

5.6.1 Feeling helplessness ......................................................................................... 69

5.6.2 Changes in social interactions .......................................................................... 70

5.7 Spiritual Directions ................................................................................................. 70

5.7.1 Extent of engage in religious activities............................................................. 70

5.7.2 Impact for Psychological Relief ....................................................................... 71

5.8 Conclusion............................................................................................................... 71

Chapter 06 ......................................................................................................................... 72

Conclusion and Recommendations ................................................................................... 72

6.1 Introduction ............................................................................................................. 72

6.1 Conclusion............................................................................................................... 72

6.3 Implications and recommendations ......................................................................... 74

6.4. Summary ................................................................................................................ 75

References ...................................................................................................................... XVI

X
List of Tables

Table 2. 1: New cases and deaths for 36 cancers and all cancers combined in 2018……10

Table 2. 2: Unhealthy stress symptoms experienced by breast cancer patients…………..20

Table 3.1: Themes and codes…………………………………………………………….37

Table 4.1: Participants' coding system………………………………………………...…43

Table 4.2: Sample profile………………………………………………………………...44

List of Figures

Figure 2.1: Percentage distribution of population by province and sector………………16

Figure 2.2: Unmet needs of rural women with breast cancer……………………………23

XI
 Chapter 01

Introduction

1.1 Background of the study

The burden of cancer is rapidly increasing and is leading cause of death worldwide. Among
them, breast cancer is the major health problem and cause of death worldwide (World
Health Organization, 2012). Among female, breast cancer is the most frequently diagnosed
cancer and the leading cause of cancer mortality in developed and developing countries. A
gradual but a significant increase in the incidence of female breast cancer is observed in
Sri Lanka (Fernando, et al., 2018). A rapid rise in the breast cancer incidence among post-
menopausal women appears to be the major contributor towards this increase. Improving
cancer data collection appears to have been a contributor to the observed increase.
However, an inherent increase is also likely as differential rates of increase were observed
by age groups (Fernando, et al., 2018).

It is no doubt that Breast cancer is a most common women cancer in the world that
everyone is aware. Breast cancer is second most prevalent type of cancer and is equally
common in developing as well as developed countries (American Cancer Society, 2013).
The global incidence of breast cancer (that is, the number of women diagnosed with breast
cancer) is nearly three times higher than the next, colorectal cancer. It is also the biggest
cause of cancer in women. Sri Lanka is no different. According to WHO estimates
approximately 4000 Sri Lankan women are diagnosed with breast and almost a third of this
number succumb to breast cancer each year (S.Senevirathne, 2016). Over the last several
decades, the incidence of breast cancer has risen globally, and this is estimated to increase
by another 25% by year 2020 (Fernando, et al., 2018). So, the breast cancer can be
identified as rising threat to women all around the world that should concern highly.
According to data from the International Agency for Research on Cancer (IARC), a
disproportionately high number of breast cancer deaths occur in developing countries due
to lower cancer specific survival rates. Studies have shown that the greatest increase will
1
be among women in developing countries, a majority of whom live in the Asian region and
most studies on incidence and trends in breast cancer incidence have been reported in
developed countries, while analyzes of these trends and patterns in developing countries,
including Sri Lanka, are limited. (Fernando, et al., 2018)

The experience of breast cancer presents significant social and psychological challenges
for women. Yet, many breast cancer patients function well, while others with identical
diagnosis and treatment have poorer psychological outcomes (Holland & Holahan, 2003).
With breast cancer, women are confronted with number of physical and psychological
challenges. They face a life-threatening disease, as well as the experience and side effects
of surgical and other treatments.

Women commonly experience number of negative psychological and behavioral reactions

to diagnosis and treatment for breast cancer. These reactions may include anxiety and
depression, anger or hostility, inability to concentrate, feelings of shame and worthlessness,
and suicidal thoughts, as well as insomnia, loss of appetite, disruption of daily activities,
and increased use of tranquilizers and alcohol (Holland & Holahan, 2003).

Studies of social support and adjustment to breast cancer have examined support from
several sources. For example, Bloom and Spiegel (1984) found that emotional support from
the family and opportunities for social interaction were related to adjustment in a sample
of women with advanced breast cancer (Holland & Holahan, 2003). Although social
support has been shown to improve patients’ emotional well-being, the process through
which social support influences emotional well-being has not been adequately explored.
Women living with breast cancer suffer lot with many of social and emotional challenges.
But sometimes people around them or people commonly in the society cannot understand
their responses. Firstly, not only the doctors, physicians but also the closest relatives around
them should aware about the social, physical and psychological issues and challenges
which the patients are facing. Unless they cannot understand their responses to those issues
and challenges. So basically, it is important to identify the social and emotional challenges
of women living with breast cancer.

2
The responses of women living with breast in Sri Lanka to social and emotional challenges
will be discussed and analyzed through this study. It will be beneficial for identify the ways
they responses to their issues and challenges and to introduce coping strategies for them as
well.

1.2 Problem of the study

According to the background analysis of the research study, women living with breast
cancer experience many social, psychological and physical challenges throughout the life.
So, basically the research is going to identify what are the social and emotional challenges
and how breast cancer patients’ response to those challenges.

Therefore, the study focused on how women living with breast cancer response to their
social and emotional challenges. Hence, the below specific research questions will be
addresses to achieve the research objectives.

1.3 Research questions

1 What are the social challenges of rural women living with breast cancer?

2 How do rural women live with breast cancer response to social challenges?

3 What are the emotional challenges of rural women living with breast cancer?

4 How do rural women live with breast cancer response to emotional challenges?

1.4 Objectives of the study

Number of researches, studies have been done on major psychological and social
challenges of breast cancer patients in the world while no considerable number of studies
done in Sri Lanka. And their responses to those challenges have not been discussed and
analyzed mostly. Therefore, the main objective of this study is to examine the responses to
the social and emotional challenges of women living with breast cancer in Sri Lanka.

1. To identify major social and emotional challenges faced by Sri Lankan rural women
living with breast cancer.

3
 2. To identify how Sri Lankan women with breast cancer response to social
challenges.
3. To identify major emotional challenges faced by Sri Lankan rural women living
with breast cancer.
4. To identify how Sri Lankan women with breast cancer response to social
challenges.

1.5 Significance of the study

Cancers specially like breast cancer is widening all over the world in recent years. Hence
a massive number of patients are suffering with such illnesses in their rest of life. There
seemed to be no a considerable number of studies in line with breast cancer and its
challenges and responses in Sri Lanka. So, it is important to identify their responses to
challenges for building up coping strategies in counseling and psychology.

Although the women with breast cancer gets recovered, they must live the rest of the life
with many side effects of socially, psychologically and physically as well. So, their
challenges remain with their life. Hence it is important to know how they react and response
to those challenges for themselves to build and rise again in their lives.

From the perspective of women, breast cancer and its treatments can impact to occur
changes in their roles and relationships within the family and in the society. Diagnosis and
treatment can rob people of family and social roles, which causes emotional distress for all
involved (Wyk & Carbonatto, 2016). A person’s ability to fulfil certain roles is linked to
self-worth; so, a woman’s self-worth is adversely influenced when she is unable to fulfil
her roles in the family and society (Brennan, 2004). Women’s social functioning is worse
when they use escape-avoidance coping or feel that cancer keeps them from doing what
they want to do, and that cancer threatens their self-esteem (Bourjolly, et al., 1999). The
patient experience of breast cancer focused on the range of emotions felt throughout the
illness trajectory, the importance of religion and family support on coping strategies
employed to manage the side effects of chemotherapy and financial concerns (Banning , et
al., 2009). Rural participants mentioned their friends as source of support and
encouragement and felt better prepared for the side-effects of treatment as a result (Sawin,

4
2002). So, it is important to know their responses by the closest people around them to
support her socially and emotionally.

Not by themselves and closest people around them, but also knowing the responses for
social and emotional challenges of women living with breast cancer are significant for the
doctors, physicians, psychologists, counsellors and etc. who move around with those kinds
of patients to build coping strategies for them.

1.6 Research Methodology

The research methodology includes research approach, data collection methods and
approach, sampling techniques, reliability and validity of data and analysis of data.

Research Design

In this study, the researcher used qualitative research method and collected qualitative form
data from the sample and did interpretation and discussion for conclude this study.

Population

Population means the whole group of people and everything that related to the researcher
hope to examine. This research considers the all the rural women living with breast in Sri
Lanka.

Sample

Self-selected 10 rural women living with breast cancer in different rural areas in Sri Lanka
has been the sample of this research study.

Data Collection

In this research, researcher used primary data collected directly from patients and relatives
of some patients. semi- structured voluntary interviews of 10 – 20 minutes of time to
gathered primary data. Language of the interviews is Sinhala.

Data Analysis

5
Even though all qualitative studies are inductive, different strategies have been developed
for data analysis such as grounded theory, analytic induction, narrative analysis,
conversation analysis, interpretive phenomenological analysis and thematic analysis.
Thematic analysis is seemed as the most appropriate approach for data analysis of this
study as it offers an accessible and flexible approach.

1.7 Structure of the report

This report consists 6 chapters.

Chapter 01- Introduction

This chapter provides clear guidance to begin the research. It consists background of
research, research problem, research objectives, significant to the study, research
methodology and anticipated limitations.

Chapter 02- Literature Review

This chapter explains related literature available regarding the research study.

Chapter 03-Research Methodology

This chapter presents the methodological analysis to carry out the survey to identify the
social and emotional challenges and the responses of rural women living with breast cancer
to those challenges. It presents the process followed in the study including the population
and sampling design, data collection and data analysis methods, furthermore, this chapter
discuss the methodology of the study, method of survey, research method, time horizon,
data collection method and technique for data analyzing.

Chapter 04- Findings

This chapter includes the analysis of collected data through interviews.

Chapter 05 – Discussion of findings

Findings will be discussed by comparing with the current literature.

Chapter 06- Conclusion and Recommendation

6
It includes overall summery of the findings. Mentioned whether can achieve the objective
of the study. It includes the discussion of the challenges of rural women living with breast
cancer and their responses to those. In this chapter researcher is expecting to give
recommendation to future researcher and finally give limitation of the present research
study.

1.8 Limitations to the study

There were some limitations while doing this research study as follows.

1. Limitation of time and budget.

2. It is difficult to collect in-depth data from patients who are under treatments.

3. Some patients may not like to express their true ideas.

4. Difficult to access to rural areas to meet patients.

5. Cannot consider all the rural women living with breast cancer Sri Lanka.

7
 Chapter 02

Literature review
2.1 Introduction
This chapter reviews an extensive part in existing literature on how rural women with
breast cancer response to social and emotional challenges. Themes like family and
community support, spiritual directions (religious prayers) and accessing to medical
support will be reviewed under social challenges while stress/depression, feeling isolation
and coping with financial burden will be reviewed under the emotional challenges in this
chapter.

2.2 Cancer
Noncommunicable diseases (NCDs) are now responsible for majority of global deaths, and
cancer is expected to rank as the leading cause of death and the single most important
barrier to increasing life expectancy in every country of the world in the 21st century (Bray,
et al., 2018). For many cancers, incidence rates could increase substantially in the future,
with up to 15 million new cases in 2020, most of which will be in developing countries
(Kanavos, 2006).

Cancer is a generic term for a large group of diseases that can affect any part of the body.
According to data published by the World Health Organization (WHO), cancer is one of
the leading causes of death in the world. An estimated 9.6 million deaths in 2018.
Worldwide, about one in six deaths is due to cancer. The most common causes of cancer
deaths are lung cancer, colorectal cancer, breast cancer, liver cancer and stomach cancer.
About 70% of cancer deaths occur in low- and middle-income countries.

According to the data gathered by Bray et al; Lung cancer remains the leading cause of
cancer incidence and mortality, with 2.1 million new lung cancer cases and 1.8 million
deaths predicted in 2018, representing close to 1 in 5 (18.4%) cancer deaths in worldwide
over 1.8 million new colorectal cancer cases and 881,000 deaths are estimated to occur in
2018, accounting for about 1 in 10 cancer cases and deaths, there will be about 2.1 million
newly diagnosed female breast cancer cases in 2018, accounting for almost 1 in 4 cancer
cases among women in worldwide, Liver cancer is predicted to be the sixth most commonly

8
diagnosed cancer and the fourth leading cause of cancer death worldwide in 2018, with
about 841,000 new cases and 782,000 deaths annually, and Stomach cancer (cardia and
non-cardia gastric cancer combined) remains an important cancer worldwide and is
responsible for over 1,000,000 new cases in 2018 and an estimated 783,000 deaths
(equating to 1 in every 12 deaths globally), making it the fifth most frequently diagnosed
cancer and the third leading cause of cancer death (Bray, et al., 2018).

According to Global Cancer Incidence, Mortality and Prevalence (GLOBOCAN),

following table indicates new cases and deaths for 36 cancers and all cancers combined in
2018.

Table 2. 3 : New cases and deaths for 36 cancers and all cancers combined in 2018

Cancer site No. Of new cases (% of all No. Of deaths (% of all

sites) sites)
Lung 2,093,876 (11.6) 1,761,007 (18.4)
Breast 2,088,849 (11.6) 626,679 (6.6)
Prostate 1,276,106 (7.1) 358,989 (3.8)
Colon 1,096,601 (6.1) 551,269 (5.8)
Nonmelanoma of skin 1,042,056 (5.8) 65,155 (0.7)
Stomach 1,033,701 (5.7) 782,685 (8.2)
Liver 841,080 (4.7) 781,631 (8.2)
Rectum 704,376 (3.9) 310,394 (3.2)
Esophagus 572,034 (3.2) 508,585 (5.3)
Cervix uteri 569,847 (3.2) 311,365 (3.3)
Thyroid 567,233 (3.1) 41,071 (0.4)
Bladder 549,393 (3.0) 199,922 (2.1)
Non-Hodgkin lymphoma 509,590 (2.8) 248,724 (2.6)
Pancreas 458,918 (2.5) 432,242 (4.5)
Leukemia 437,033 (2.4) 309,006 (3.2)
Kidney 403,262 (2.2) 175,098 (1.8)
Corpus uteri 382,069 (2.1) 89,929 (0.9)

9
 Lip, oral cavity 354,864 (2.0) 177,384 (1.9)
Brain, nervous system 296,851 (1.6) 241,037 (2.5)
Ovary 295,414 (1.6) 184,799 (1.9)
Melanoma of skin 287,723 (1.6) 60,712 (0.6)
Gallbladder 219,420 (1.2) 165,087 (1.7)
Larynx 177,422 (1.0) 94,771 (1.0)
Multiple myeloma 159,985 (0.9) 106,105 (1.1)
Nasopharynx 129,079 (0.7) 72,987 (0.8)
Oropharynx 92,887 (0.5) 51,005 (0.5)
Hypopharynx 80,608 (0.4) 34,984 (0.4)
Hodgkin lymphoma 79,990 (0.4) 26,167 (0.3)
Testis 71,105 (0.4) 9,507 (0.1)
Salivary glands 52,799 (0.3) 22,176 (0.2)
Anus 48,541 (0.3) 19,129 (0.2)
Vulva 44,235 (0.2) 15,222 (0.2)
Kaposi sarcoma 41,799 (0.2) 19,902 (0.2)
Penis 34,475 (0.2) 15,138 (0.2)
Mesothelioma 30,443 (0.2) 25,576 (0.3)
Vagina 17,600 (0.1) 8,062 (0.1)
All sites excluding skin 17,036,901 9,489,872
All sites 18,078,957 9,555,027
Source: GLOBOCAN 2018

2.3 Breast Cancer

Breast cancer can be identified as a common disease in worldwide within women which is
still rising rate with the years mostly in developing countries as well as in low- and middle-
income countries including Sri Lanka. According to the prior researches done by various
scholars, breast cancer is a challenging disease which rural women are coping with many
social and psychological challenges more than the cancer.

Breast cancer is a global concern. More than in developed countries, breast cancer rapidly
rises in low- and middle-income countries and developing countries. It has become a

10
burden for rural women with breast cancer. Today, breast cancer has been a common cancer
affecting to women in worldwide. It leads to many social and psychological issues with
breast cancer patients. So, it is very important to identify how they react or response to
those challenges. It is a disease that is not restricted by culture, religious belief, social class
or economic status (Banning , et al., 2009).

Breast cancer is a most common women cancer in the world that everyone is aware now.
It is second most prevalent type of cancer and is equally common in developing as well as
developed countries (American Cancer Society, 2013). The global incidence of breast
cancer (that is, the number of women diagnosed with breast cancer) is nearly three times
higher than the next, colorectal cancer. It is also the biggest cause of cancer in women. Sri
Lanka is no different. According to WHO estimates approximately 4000 Sri Lankan
women are diagnosed with breast and almost a third of this number succumb to breast
cancer each year (S.Senevirathne, 2016). Over the last several decades, the incidence of
breast cancer has risen globally, and this is estimated to increase by another 25% by year
2020 (Fernando, et al., 2018). So, the breast cancer can be identified as rising threat to
women all around the world that should concern highly. According to data from the
International Agency for Research on Cancer (IARC), a disproportionately high number of
breast cancer deaths occur in developing countries due to lower cancer specific survival
rates. Studies have shown that the greatest increase will be among women in developing
countries, a majority of whom live in the Asian region and most studies on incidence and
trends in breast cancer incidence have been reported in developed countries, while analyzes
of these trends and patterns in developing countries, including Sri Lanka, are limited.
(Fernando, et al., 2018).

Breast cancer screening services are provided through network of medical institutions and
mainly preventive health units which are managed by Medical Officer of Health (MOH) in
respective MOH areas in Sri Lanka.

11
2.4 Theories related to breast cancer
Many causes or attributions of breast cancer can be identified through medical information
and also from prior literatures. So, under attribution theory those can be discussed as
follow.

2.4.1. Attribution Theory

“Attribution theory” in psychology refers to the process by which people attempt to explain
the causes of an outcome. Thirty years ago, when women were asked what caused their
own breast cancer, most women identified God, fate, chance, or stress, and exposure to
carcinogenic substances (Dumalaon-Canaria, et al., 2014). Since then, several studies have
been conducted on causal attributions for breast cancer among affected women. Results of
these studies are less well synthesized but even recent studies indicate that women with a
previous diagnosis of breast cancer continue to ascribe their own experience to forces
outside of their volition (Dumalaon-Canaria, et al., 2014). In contrast, published scientific
evidence on risk factors for breast cancer report the importance of modifiable lifestyle
behaviors in controlling and modifying cancer risk. Parkin, et al (2011) estimated that
26.8% of all new cases of breast cancer diagnosed in the United Kingdom in 2010 could
be attributed partly to lifestyle factors. Similarly, preventability estimates on breast cancer
report that up to 23.0% of (post-menopausal) breast cancer cases can be accounted for by
obesity. Physical inactivity accounts for up to16.5% and alcohol use up to 7.0% of breast
cancer cases (Parkin , et al., 2011).

According to the research study of Dumalaon-Canaria, et al (2014), risk factors or

attributions are organized into the following categories: biological, environmental,
reproductive history and hormones, and lifestyle. Other causal attributions identified, but
not validated by expert consensus, such as stress, existential influences, and other health
conditions are also reported.

12
2.4.1.1. Biological Attributions

Family history/genetics

Based on established evidence it is estimated that those with a first-degree relative with a
history of breast cancer have greater probability of developing breast cancer compared to
women without such a history. Risk varies according to the number of relatives with breast
cancer and the age at which relatives were diagnosed (Dumalaon-Canaria, et al., 2014).

Age

Age is a strong risk factor for breast cancer in women. According to the prior studies, that
the greatest rate of increased risk for breast cancer occurs among post-menopausal women,
where risk starts to double with each decade of life up to 80 years of age ( Newcomb &
Wernli , 2010).

Breast conditions

High breast density as evident in a mammogram is one of the strongest risk factors for
breast cancer. It is estimated that for women with more than 75% breast density, the risk
of breast cancer is four times greater than those with less dense breast tissue. Moreover,
women with a history of benign breast disease, who have not been diagnosed with
hyperplasia, have a 1.5-fold increased risk of breast cancer compared to women without
benign breast disease ( Newcomb & Wernli , 2010).

Height

There is scientific evidence that taller height is associated with increased risk of breast
cancer especially among post-menopausal women (Dumalaon-Canaria, et al., 2014). But
height was not identified as a cause of breast cancer by any of the respondents in the studies
reviewed by the researcher.

Other demographic factors

Women may be at greater risk of breast cancer if they belong to higher socio-economic
groups as indicated by level of income and education, as well as geographic locale.
13
Caucasian white women have a higher risk for breast cancer, followed by African-
American women, Hispanic women, and with the lowest rates in Asian women ( Newcomb
& Wernli , 2010). There were no studies reviewed which identified demographic factors
such as socio-economic status, race, level of income and/or education as risk factors for
breast cancer (Dumalaon-Canaria, et al., 2014).

2.4.1.2. Environmental Attributions

Environmental factors.

Expert evidence suggests that the following environmental risk factors are associated with
increased breast cancer risk: exposure to pesticide agents heavy metal cadmium, and
greater exposure to traffic emissions at the time of menarche for pre-menopausal women (
Newcomb & Wernli , 2010). Radiation exposure is also classified as a carcinogenic agent
with enough evidence in humans. Expert guidelines indicate that many other aspects of the
environment are still being tested (Dumalaon-Canaria, et al., 2014).

2.4.1.3. Reproductive History, Breast Feeding, and Hormones

Several factors affecting hormonal status have been associated with increased risk of breast
cancer; lifetime exposure to estrogen influencing early menarche, having a late natural
menopause, not bearing children, a late first pregnancy (over the age of 30), or not
breastfeeding are all described by the WCRF/AICR as breast cancer risk factors with
convincing evidence ( World Cancer Research Fund/American Institute for Cancer
Research, 2007). There is also convincing evidence that hormone replacement therapy
increases the risk of breast cancer. Other data indicate oral contraceptives containing both
estrogen and progesterone cause a small, transient, increased risk of breast cancer. IARC
classified diethylstilbestrol, a synthetic nonsteroidal estrogen, and oral contraceptives, as
carcinogenic agents with enough evidence in humans (The International Agency for
Research on Cancer, 2010).

14
2.4.1.4. Lifestyle

Physical activity.

According to WCRF/AICR ( World Cancer Research Fund/American Institute for Cancer

Research, 2007) there is convincing evidence that physical activity is protective against
breast cancer for post-menopausal women. However, for pre-menopausal women there is
limited evidence that it is protective against breast cancer. Physical inactivity has also been
estimated to be responsible for approximately 10% of breast cancer mortality ( World
Cancer Research Fund/American Institute for Cancer Research, 2007).

Diet

Research has evaluated the relationship between dietary factors and breast cancer risk.
According to the WCRF/AICR only a high fat diet has been shown to play a causal role in
increasing breast cancer risk among post-menopausal women, however, current evidence
remains limited in this area ( World Cancer Research Fund/American Institute for Cancer
Research, 2007).

Body size

Although evidence of a link between diet and breast cancer risk has not been consistent or
strong there is strong and convincing scientific evidence that weight gain in adulthood and
abdominal body fat are associated with increased risk for breast cancer, particularly in post-
menopausal women ( World Cancer Research Fund/American Institute for Cancer
Research, 2007). IARC also state that overweight and obesity are responsible for 9.0% of
breast-cancer related deaths (The International Agency for Research on Cancer, 2010).

Alcohol

There is convincing evidence in humans that the consumption of alcoholic drinks or

beverages is a carcinogenic agent that increases breast cancer risk ( World Cancer Research
Fund/American Institute for Cancer Research, 2007). The IARC conclude that
consumption of alcohol is responsible for 5.0% of breast cancer-related deaths (The
International Agency for Research on Cancer, 2010).
15
2.5 Rural Population in Sri Lanka
Rural population (% of total population) in Sri Lanka was reported at 81.59 % in 2016,
according to the World Bank collection of development indicators, compiled from
officially recognized sources Figure 2.1 presents the distribution of population by province
and sector. According to the Figure 2.1, majority of population in Sri Lanka is in rural
sector (77.4%). Urban population share of the country is 18.2 percent while the estate
population consists of 4.4 percent. In addition, data present in the Figure 2.1 shows,
urbanization is relatively high in Western province (38.8 %) and very low in North Central
(4.0%) and North Western (4.1%) provinces. The highest rural population is reported from
North Central province (96.0%) and the highest estate population is reported from Central
province. No estate population is reported from Northern and Eastern provinces.

Figure 2.1: Percentage distribution of population by province and sector

Source: Census of Population and Housing Sri Lanka 2012

2.6 Rural women with Breast Cancer

Rural population refers to people living in rural areas defined by national statistic offices.
So, rural women with breast cancer face many difficulties rather than in urban areas.
Alongside the trauma of diagnosis, and the difficulties of living with breast cancer, rural
women may experience specific concerns because of their geographical location (Rogers-

16
Clark, 2002-2003). These concerns relate to their remoteness from metropolitan areas and
specialized health services: and to the specific difficulties of rural life, including rural
unemployment, declining farm incomes, drought, declining population, closing of
businesses and services and the loss of farms by families who had been living for a long
time (Coakes & Kelly, 1997). In relation to rural women with a history of breast cancer, it
is vital that any interventions seek to build on the strength of rural communities in relation
to lifestyle and support, rather that assuming that rural communities are defined by their
absence of specialized services. (Rogers-Clark, 2002-2003).

Rural women may have decreased access to their primary care practitioner because there
are low healthcare providers in rural areas, translating to a lower rate of clinical breast
examinations (Sawin, 2002). Moderate but notable differences in women's preventive
screening rates between rural and urban physicians highlight the need for practical
solutions that increase the use of testing services and reduce barriers to services in rural
areas (Orwat, et al., 2017). Rural women have decreased access to state-of- the- art
treatment, with less access to breast conserving treatment; the rates of access decrease as
women become more rural (Sawin, 2002).

2.7 Social Challenges

Social functioning can be a burden for some breast cancer women if it does not function
well; unsupportive partner, being a topic to gossip within surrounded people, not having
supportive family and friends, not believe in or not having spiritual (religious) support and
less access to medical support and related information while at the same time it can be a
huge support to rural women with breast cancer if the social functioning occurs well as a
support to her; supportive partner, family and friends, good spiritual support from religious
places and having proper access to medical support and relevant information. Most of
rural women with breast cancer are struggle most with accessing to proper medical support
and information.

Studies have found that social support is associated with better adjustment to disease and
better quality of life; however, the subjective appropriateness of the offered is important
(Leung, et al., 2014). (Silberfarb, et al., 1980) compared the social support available to
women with varying stages of breast cancer and found that women with recurrent breast

17
cancer experienced increased social isolation and dissatisfaction with their physicians in
comparison to other women. Social functioning from a social work perspective means the
fulfilment of an individual’s roles that exit as result of the individual’s interactions with
his/her own self, family, society and environment with the purpose of performing tasks
essential for daily living. (Wyk & Carbonatto, 2016). Some other researchers also haven
the similar ideas regarding social functioning. According to Bourjolly and others, social
functioning is related to functional status, which a person’s performance of activities
associated with their roles and for women with breast cancer these activities include
household, family, social, community, self-care and occupational activities (Bourjolly, et
al., 1999). Although social support is associated with positive adjustment to breast cancer,
there is reason to believe that women may not always receive social support when it is most
needed (Brady & Helgeson, 1999).

2.8 Emotional Challenges

Emotional challenges are threats for rural women to cope with life more than the breast
cancer. Stress and depression are a common problem that can identify with almost all kind
of cancer patients. But it is harder for women with breast cancer because they are dealing
with many problems like changing the self-image, sexual problems, feeling gossiped about,
etc. According to research evidences, most of the women feel isolation and do not like to
meet people. It is a big psychological problem that can leads to more stress and depression
too. In addition, coping with financial burden is also affect to emotionally unwell. Because
these rural women must incur big cost for treatments, travelling cost since they have not
proper medical support and information in rural setting, cost for accommodation, etc. So,
the breadwinner should spend almost all the income he/she earn for cancer recovery. So, it
affects psychologically to the women with breast cancer.

The issue of breast cancer is an emotional one that instigates numerous responses and
reactions from women (Banning , et al., n.d.). Emotional functioning, which influences the
ability to enjoy life, is affected and this causes emotional reactions such as being bad-
tempered, depression, lack of tolerance, bitterness, and fear of pain and death (Luoma &
Hakamies-Blomqvist, 2004). For many women, the psychological dimension of breast
cancer is an important aspect of the disease. As it may not only increase her body

18
consciousness which can result in loss of self-esteem, but it can also have an emotional
effect (Banning , et al., n.d.). Briefly women who experience greater psychological and
physical problems as result of breast cancer may have greater difficulty in coping (Brady
& Helgeson, 1999).

Research has shown that psychological morbidity such as helplessness / hopelessness,

hostility and guilt, chronic stress, extroversions and cognitive disorders, lack of joy and
negative mood, stressful life events , lack of perceived social support, obsessive-
compulsive symptoms, coping problems one-third of women in the first two years after
treatment (Malik & Kiran, 2013). Emotional support appears to be most important from a
partner, while informational support to be most important from a physician (Brady &
Helgeson, 1999). Breast cancer is the most frequently diagnosed cancer and the leading
cause of cancer death in females.

Worldwide, 1.39 million women were diagnosed with breast cancer in 2008 and 458,400
women died from the Disease. Women diagnosed with breast cancer not only have to cope
with the physical burden of their condition, but also with psychological comorbidities
common among breast cancer survivors such as depression and anxiety. For example,
breast cancer patients have described feelings of helplessness and hopelessness, fears of
death and dying, and concerns about how their illness would affect their families and their
finances (Dumalaon-Canaria, et al., 2014).

2.9 Social and Emotional challenges associated with rural women with breast cancer
and their responses
Many physical problems like hair loss, or nausea and vomiting can cause to patients due to
cancer and cancer treatment. Though successful treatment options are available to deal with
breast cancer, pain and suffering associated with available treatment modalities is
significant (Malik & Kiran, 2013). They can also cause to social and emotional issues.
These are problems that affect the patient's feelings or his relationship with his family and
community. They are also can be called psychological problems. Women with breast
cancer experience suffering related to life dimensions: physical pain, spiritual, emotional,
psychological and social forms of suffering (Banning , et al., 2009). Social and emotional
issues can be difficult to understand and discuss for patients. Cancer treatment limits daily

19
activities such as driving, walking, housework, family activities, hobbies and personal care,
as well as changing roles and feelings of helplessness (Luoma & Hakamies-Blomqvist,
2004). Women with breast cancer experience suffering related to life dimensions: physical
pain, spiritual, emotional, psychological and social forms of suffering (Perreault &
Bourbonnais, 2004).

2.9.1 Stress and Depression

Stress and depression can be identified as common psychological/ emotional challenges
that that cancer patients face. Specially it will be a huge burden for rural women to cope
with breast cancer while facing to life challenges. Many women had young children and
were depressed and constantly worried by the uncertainty of treatment outcome and the
future of their children (Banning , et al., 2009). Depression can be seen in every level of
treatment. Depression was found in patient who were in process of receiving chemotherapy
as well as those who completed their chemotherapy. (Malik & Kiran, 2013). Research has
shown that psychological morbidity such as helplessness / hopelessness, hostility and guilt,
chronic stress, extroversions and cognitive disorders, lack of joy and negative mood,
stressful life events , lack of perceived social support, obsessive-compulsive symptoms,
coping problems one-third of women in the first two years after treatment (Malik & Kiran,
2013).

A South African Research has indicated few unhealthy stress symptoms experienced by
breast cancer patients. These symptoms are described in the following table by Lo Castro
and Schlebusch (2006:768-775)

Table 2. 4: Unhealthy stress symptoms experienced by breast cancer patients

• High Blood Pressure

• Sexual Problems
Physical reactions • Dizzy Spells
• Felling physically unwell
• Erratic Bowel function

20

Psychological reactions
Behavioral reactions
(Lo Castro & Schlebusch, 2006)
• Being afraid of cancer
• Lack of self-confidence
• Feeling gossiped about
• Feeling no one wants to work with them
• Depression
• Overly self-critical
• Feeling tense
• Nail biting
• Loss of appetite
• Drop in personal standards
• Poor concentration
• Procrastination
• Emotional outbursts
• Restlessness

According to a research investigation by Malik & Kiran (2013), prevalence of depression

in women under follow up for breast cancer treatment is 29% while prevalence of grade I
anxiety is 2.5%, grade II anxiety is 77%, grade III anxiety is 19% while prevalence of
depression in breast cancer women at completion of treatment is 22.2% and anxiety is
38.4% (Malik & Kiran, 2013). All physical, psychological and social challenges create
stress and/or depression within rural women with breast cancer.

2.9.2. Family and Community support

Family is the closest member of the patient that cares about everything at all. The support
given by the family; husband, children, parents, relatives, friends and community for rural
women with breast cancer is highly affect to her both socially and psychologically.
Researchers have found that women with breast cancer found significant support from
within the informal support networks which are operating in rural areas. These networks
included family, friends and community, and offered significant practical and emotional
support to the woman and her loved ones through the ordeal of breast cancer (McGrath, et

21
al., 1999). Many women gained emotional support from their immediate family, husbands,
children and predominantly female extended family members (Banning , et al., 2009),

From the perspective of women, breast cancer and its treatments can impact to occur
changes in their roles and relationships within the family and in the society. Diagnosis and
treatment can rob people of family and social roles, which causes emotional distress for all
involved (Wyk & Carbonatto, 2016). A person’s ability to fulfil certain roles is linked to
self-worth; so, a woman’s self-worth is adversely influenced when she is unable to fulfil
her roles in the family and society (Brennan, 2004). Women’s social functioning is worse
when they use escape-avoidance coping or feel that cancer keeps them from doing what
they want to do, and that cancer threatens their self-esteem (Bourjolly, et al., 1999). The
patient experience of breast cancer focused on the range of emotions felt throughout the
illness trajectory, the importance of religion and family support on coping strategies
employed to manage the side effects of chemotherapy and financial concerns (Banning , et
al., 2009). Rural participants mentioned their friends as source of support and
encouragement and felt better prepared for the side-effects of treatment as a result (Sawin,
2002).

Women turn to intimate partners for support, and the quality of partner support can predict
how a woman copes with breast cancer (Manne, et al., 2004). The presence of a supportive
partner is often assumed when a woman enters cancer treatment (Schmidt , et al.,
2006).Many women are not satisfied with the help that they received from their partner
while dealing with breast cancer (Manne, et al., 2004).Non-supportive partner behavior can
be even more powerful than positive support, leading to emotional distress and maladaptive
coping (Manne & Schnoll, 2001). Community support was an important aspect of support
for these rural women, who were experiencing breast cancer without a supportive intimate
partner (Sawin, 2002).

2.9.3 Accessing to medical support and information

In relation to rural women with a history of breast cancer, it is vital that any interventions
seek to build on the strength of rural communities in relation to lifestyle and support, rather
that assuming that rural communities defined by their absence of specialized services
(Rogers-Clark, 2002-2003). According to literature, rural women with breast cancer are

22
struggling with accessing to medical support and other related information. The issue of
access to local physicians was seen as particularly critical in the rural context, as women
rely more heavily on their physicians in the absence of other informational and professional
options (Gray, et al., 2003). It is plausible to expect that patients living in rural areas may
be more likely to have unmet needs than their urban counterparts due to factors of
geographical isolation and difficulty accessing health services (Girgis, et al., 2000). The
follwing figure indicates several unmet needs of rural women with breast cancer.

Figure 2.2: Unmet needs of rural women with breast cancer

(Girgis, et al., 2000)

Rural women with breast cancer have less access to new data. Lack of data has made it
difficult to (1) clearly identify support needs; (2) assess whether these needs are being met
and (3) decide how best to improve the circumstances of rural women with breast cancer
(Gray, et al., 2003). Rural women are also at a disadvantage because there are less options
of times and locations at which to receive screening (Sawin, 2002). Those women like to
have the easy access to health support. Women often commented that they have access to
supportive care programs run by health professionals or trained peers (Gray, et al., 2003).

23
There is minimal information is available related to cancer screening methods among
female health care workers in Sri Lanka.

2.9.4. Feeling Isolation

Many of the women who participated in focus group discussions described having
struggled with a sense of isolation, both in their home setting and in the urban setting where
they received treatment (Gray, et al., 2003). A problem associated with rural living which
appeared to be more strongly felt by some participants was that of ‘being alone’ with their
experiences (Rogers-Clark, 2002-2003). For some, this was related to the lack of
professional support, whilst others reported that they felt unable to speak of their true
feelings because they wanted to protect loved ones, or because they felt a real lack of
privacy and confidentiality in their communities. (Rogers-Clark, 2002-2003)

Women emphasized the need to be alone, preferred not to talk or discuss issues with people
and experienced a dislike of being surrounded by other people. Women expressed that they
disliked meeting people and family members and preferred not to attend family functions
and weddings (Banning , et al., 2009). According to Gray, et al, isolation continued for
some women who unable to find support. Sometimes this was because of a perceived lack-
of-interest from others, while in other situations women decided to isolate themselves in
order to avoid being the topic of gossip (Gray, et al., 2003).

2.9.5 Coping with Financial Burden

Specially breast cancer is a bigger psychological challenge for rural women as it is difficult
for them to cope with financial burden in different aspects; for medical treatments,
travelling expenses, accommodation costs and expenses for aother needs. this was ver
expensive for families, and often led to financial difficulties with many families using all
their savings to pay for treatment (Banning , et al., 2009). And also accorinding to McGrath
et al, women with breast cancer experienced many socail difficulties as a result of living
in a rural community which leads to financial burden. They reported that rural women had
significant financial burdens related to travel, childcare responsibilities and changes to
work (McGrath, et al., 1999).

24
Rural women travel further for treatment, creating increased stress and financial burden
(Sawin, 2002). Breast cancer created additional financial stress due to time lost from work,
gasoline prices, and the occasional need for lodging (Sawin, 2002). Their distance from
metropolitan areas led to further hardships such as being separated from family and friends
at a time of heightened vulnerability, having to travel long distance for follow-up care, and
additional financial burdens arising from travel and accommodation costs (Rogers-Clark,
2002-2003).

2.9.6. Spiritual Directions

Through spiritual directions, rural women are fighting with the breast cancer to have a
relief psychologically. Spirituality was a source of comfort for women, it reduced their fear
and uncertainty and gave them the strength to fight the disease, tolerate the treatment and
look to the future (Banning , et al., 2009). Seven of the eight participants belong to the
Christian faith and felt a change in their spiritual lives (Wyk & Carbonatto, 2016). Another
participant felt that the spiritual aspects were an important part of coping with cancer and
believes that all people need God in their lives (Wyk & Carbonatto, 2016). As Wyk &
Carbonatto cited from Venter, 2008:27, people can draw strength from their faith or
relationship with God, which positively affects their ability to cope (Wyk & Carbonatto,
2016). This is confirmed research by Venter (2008:27-28), who found that cancer patients
also expressed a deepening in their spiritual and see religion as a way of coping with cancer.

Religion plays a significant role for rural women with breast cancer to cope with it. Rural
women were able to draw on their faith for support and hope and they received support
from their church. This religious aspect gives rural women peace an emotionally and
physically challenging time in their cancer lives. This research study confirms the
importance of religion and how participants able to see the “bigger picture” because of
their relationship with God (Wyk & Carbonatto, 2016).

The data highlight the role of religion and family support as essential coping strategies, but
also highlight issues of isolation, aggression and anger as common responses to
chemotherapy (Banning , et al., 2009). the patient experience of breast cancer focused on
the range of emotions felt throughout the illness trajectory, the importance of religion and
family support on coping strategies employed to manage the side effect of chemotherapy

25
and financial concerns (Banning , et al., 2009). Religious beliefs were viewed as a source
of strength which has a positive impact on their outlook (Taleghani, et al., 2006). Unique
features of this study are women’s need to seek spiritual support for their illness and the
overriding innate characteristics on maternal responsibility (Banning , et al., 2009).

2.10 Summary
In conclusion, what is cancer and breast cancer including attribution theory, rural
population in Sri Lanka, rural women with breast cancer and social challenges like family
and community support, spiritual directions and accessing to medical support and
emotional challenges like stress/depression, feeling isolation and coping with financial
burden were discussed according to the prior literature in this chapter.

26
 Chapter 03

Methodology
3.1 Introduction
This chapter proposes the methodological approach relevant to the topic under the study-
“Living with Breast Cancer; Sri Lankan Rural Women’s Reflexive Responses to Social
and Emotional challenges”. After reviewing the prior literature and identiying the research
gap from the previous chapter, this chapter directs the methodology to solve the research
problems. it has begun with reserch paradigm and the research approach used. As the
study aimed to discuss sensitive issues regarding individuals’ perceptions, issues and
responses the choice of appropriate research methodologies was essential in creating the
right environment and to gain the information required. This chapter will first discuss the
methodological philosophy adopted for this study, followed by the research design, which
covers the boundaries of the study and the processes for data collection and analysis. The
trustworthiness and methodological limitations of this study as well as ethics involved
will be addressed in the final part of this chapter.

3.2 Rationale for the methodology

Qualitative data analysis has few principles (Denscombe, 2010) and by following them will
probably result in more efficient outcomes. The first principle is to compact extensive and
diverse raw data in to a succinct structure. It could achieve by organizing oral and write
the data into charts and tables. The second principle is to make the relationship between
the research objectives and the summery. This is mostly related when the objectives of any
qualitative study considered the clear drives responsible for its research and analytical
methodologies. The third principle is that one should conclude by developing a model and
improving the conceptual basis of the research (Denscombe, 2010).

While there are various techniques available when developing a research plan, many of
these choices are tied to different philosophical position adapted by the researcher. Choice
of research philosophy therefore was the first decision to be made.

In general, there are two main theoretical approaches to educational research, each with a
different epistemological basis (Cohen et all, 2011). One is positivist methodology which
27
is starting that certain knowledge is based on natural phenomena and their properties and
relations. Thus, information derived from sensory experience, interpreted through reason
and logic, forms the exclusive source of all certain knowledge. The other methodology is
an interpretive perspective which is including symbolic interactionism, labeling,
ethnomethodology, phenomenological sociology and social construction of reality. This
theory is more accepting of free will and sees human behavior as the outcome of the
subjective interpretation of the environment.

Hitchcock and Hughes (1989) and Huysament (1997) point out that the key difference
between these two approaches lie in their epistemological assumptions, what researchers
believe the nature of social reality to be and how to establish their basis of knowledge. The
aim of positivist approach is to understand social institutions by relying on known and
obstacle facts. While this led to a more formal understanding of how societies function,
little credence was given to the study of social mechanisms that could not be observed or
proven through the collection of facts. This prefers quantitative methods such as social
surveys, structured questionnaires and official statistics because these have good reliability
and representativeness. The positivist approach takes a position that the world is rational
and there is a reality out there which exists whether it is observed or not, irrespective of
who observed it.

In contrast, interpretive researchers argue that the social world is complex, consisting of
people who have different perceptions of reality and who constantly construct and
reconstruct the realities of their own lives (Bassey, 1999). The goal of interpretive study is
to understand the meaning behind the action in a social context through a consideration of
a subject’s unique point of view. As a result, the perceived facts that are inherent to the
positivist observational method can take on an entirely new meaning from the perspective
of different individuals. This approach would be much more qualitative, using methods
such as unstructured interviews or participant observation. According to this method
individuals are intricate and complex and different people experience and understand the
same objective reality in very different ways and have their own, often very different,
reasons for acting in the world, thus scientific methods are not appropriate. By adapting
this approach, the research goal is to interpret the complexities embedded in human

28
experiences and seek an understanding of their meanings and significance (Berry, 1998).
Given that these human experiences are shaped and grounded by individual contextual
backgrounds (Ebbs, 1996), it is critical to seek understanding of the meaning of human
experiences in the place where they are found. While the size of sample would normally
raise a concern about generalizability, this qualitative approach generates rich and detailed
data that yield greater understanding of human behavior in relation to the phenomena under
investigation. In deed generalizability ceases to be the main objective of such research.

The purpose of this study is to understand the responses of Sri Lankan Rural women who
are living with breast cancer for their social and emotional challenges. As the social
phenomena stands within the interpretations of individuals and meanings and ideas assign
for them, this study was under the constructivist paradigm which researches are done
mostly in qualitative approach. Constructivist or interpretivism is based on a context and
term.

3.3 Research Approach

As there are two approaches referred to as inductive and deductive, the most acceptable
approach for this study was inductive approach. Inductive approach is a theory building
process, starting with the observations of specific instances and seeking to establish
generalization about the phenomenon under investigation (Gupta & Awasthy, 2015). This
approach aims to generate meanings from the data set collected in order to identify patterns
and relationships to build a theory; however, inductive approach does not prevent the
researcher from using existing theory to formulate the research question to be explored.
Then the patterns and similarities in experience are observed in order to reach conclusions
or to generate theory. With an inductive stance, theory is the outcome of research.

3.4 Research Design

A choice of research design shows assessment about the priority being given to a range of
dimensions of the research process (Bryman, 2012). Or In generally “research design”
addresses the questions of how to plan a study (Flick, 2006) Hence, this section covers
relevant aspects of the research design to the study; choice of method, study context and
data collection in detail.

29
3.4.1 Choice of method
Since, this research was under the interpretivism paradigm and the inductive approach, a
qualitative research is conducted. And also, prior scholars have used qualitative research
when studying on humans‟ life, emotions and feelings as those areas are difficult to
measure by using statistics. A study on identity transition in people who are HIV-positive
(Tsarenko & Polonsky, 2011), a study on transformations and consumption practices of
homeless people (Barrios, 2012), and a study on breast cancer survivors‟ coping strategies
(Pavia, 2004) have been done using qualitative approach. This research was also seemed
to same as above researches that are studied on human lives in liminality periods, thus this
was also used qualitative approach. And, there is a greater interest in the interviewee’s
point of view in qualitative interviewing. Hence, this study was under the basic interpretive
qualitative research, as the researcher was interested in understanding how women living
with breast cancer response to social and emotional challenges.

3.4.2 Study context

The researcher needed to get an understanding on how rural women living with breast
cancer response to social and emotional challenges after diagnosing as a breast cancer
patient. Generally business research can be done in the natural environments where events
proceeds normally which is called as non-contrived settings and where events proceeds in
an artificial environment which is called contrived settings (Sekaran & Bougie, 2013).
Hence, this study was done under non- contrived setting in nature. The respondents were
included breast cancer patients and relations of some breast cancer patients. Some of the
patients were fully recovered and some are still taking treatments. All the patients have
lived more than one and half years after diagnosis. They are in the range of 35-60 age.

3.4.3 Data collection

Certain data collection methods have also been identified with qualitative research such as:
observational methods, in-depth interviewing, group discussions, narratives, and the
analysis of documentary evidence. In order to understand the things which cannot be
30
directly measured such as feelings, stress, opinions, attitudes or behaviors of rural breast
cancer patients, the most appropriate data collection method would be semi-structured
interviews as the primary data source.

Many prior studies related to life changing situations are mainly done through in- depth
interviews (Barrios, et al., 2012). But in some cases, interviews went through as narratives
when participants started to tell their stories. (Ritchie & Lewis, 2003) stressed the
significance of talking to people to grab their point of view, and personal accounts are
having vital importance in social research because of the influence of language to enlighten
meaning. However, it is important to note that practitioners of qualitative research vary
considerably in the extent to which they rely on methods of data collection (Ritchie &
Lewis, 2003). Rambling is often encouraged as it gives insight into what the interviewee
sees as relevant and important in quantitative research. Further, sample size, sample
strategy, sample contact methods, interview guide, field notes, voice recordings,
observations, interview procedure used for the study have been discussed in detail in this
data collection section.

3.4.3.1 Sample size

Within the chosen research study, the next decision was the selection of the participants.
Population means to the whole group of people, events or things of interest (Sekaran &
Bougie,2013). Hence the population of this study is the Rural women living with breast
cancer in Sri Lanka.

Qualitative samples are usually small in size. Selected 10 numbers of rural women living
with breast cancer who are living more than one and half years after the diagnosis in the
range of 35-60 age, is the sample of the study.

3.4.3.2 Sampling strategy

There are several different types of sampling strategy in qualitative research; probability,
non-probability, purposive sampling, opportunistic sampling, convenience sampling and
theoretical sampling.

31
For this research purposive sampling strategy was used which means the members of a
sample are chosen with a 'purpose' to represent a location or type in relation to a key
criterion (Ritchie & Lewis, 2003). Further they elaborate that the sample units are selected
as they have certain attributes or characteristics which enable detailed examination and
understanding of the essential themes and dilemma which the researcher wishes to study.
Those attributes are socio-demographic characteristics, specific experiences, challenges,
behaviors, etc.

3.4.3.3 Unit of analysis

Unit of analysis simply refer to the population that the research is conducted. Which means
the level of aggregation of data collected during subsequent data analysis stages (Sekaran
& Bougie, 2013). Research questions determines the unit of analysis; groups, individuals,
organizations, and nations. In this study – how rural women living with breast cancer
response to social and emotional challenges- unit of analysis was women in different rural
areas in Sri Lanka, who are breast cancer patients or cancer survivors.

3.4.3.4 Sample profile

The sample profile included respondents’ age, district, occupation, marital status number
of children and current status of cancer. Researcher employed those data for the processes
of data analysis, findings and discussions. (Table includes in chapter four)

3.4.3.5 Interview guide

An interview guide stands for list of topics or issues that are to be covered during the
interviews or is can refers to as a brief list of memory. Before conducting the in-depth
interviews, an interview guide was built covering the main research problem areas like
social and emotional challenges. The guide was employed during the in-depth interviews
and when new areas emerged interview guide was reshaped for next interviews (Bryman,
2016)

32
3.4.3.6 Field notes
Field notes are the detailed summaries of events and behavior and the researcher’s initial
reflections on interviews and respondents. The notes need to specify key dimensions of
whatever is observed or heard (Bryman, 2016). During the data collection process,
researcher has done brief notes what was seen, heard and felt. And also, at the end of the
day a summary was written including details about time, location, environment and
disturbances occurred.

3.4.3.7 Voice recordings

All in-depth interviews were recorded using a voice recorder after getting permission from
the respondents. It supported for data preparation and analysis as all the insights cannot be
recorded using field notes.

3.4.3.8 Observations
Respondents facial expressions, eye contacts, background of the house hold, family
members reactions and disturbances were identified and observed during the interviews.
Those observations were recorded as field notes and used for data preparation and analysis
procedures.

3.4.3.9 Interview procedure

This study has been undertaken over two months and had engaged with a range of breast
cancer patients who are living more than one and half years after the diagnosis. Basic
information about the study was communicated to ten self-selected cancer patients in
different areas of Sri Lanka and their confirmation for the interviews were granted before
conducting them. Prior to the interviews, an interview guide was prepared which included
the needed research areas to be covered.

Each interview started with the respondents telling their disease history, thus allowing each
participant to discuss experiences in their own words. Participants were asked for their
agreement for having audio recordings and notes before starting the interviews. Then the

33
researcher reshaped respondents’ direction to some specific areas to be cover such as social
and emotional challenges and their responses and experiences regarding them in order to
address the main research problem. At some points interviews flew like a dialogical
exchange between interviewer and interviewee using semi structured questions to obtain
depth understanding on lived experiences with an illness like breast cancer. Interviews
were in places based on each respondent’s preference such as in their home, living room,
garden, etc. In some cases, disturbances like engaging other family members with the
interview, external people entering and pets’ disturbances, and natural disturbances (like
windy and rainy climate) occurred.

3.4.3.10 Duration of interviews

In this study interviews went for considerable amount of time period. Some interviews
went about twenty minutes thirty minutes. The data from the respondents is collected only
one time during a period of two month.

3.4.3.11 Language of interviews

The style of conducting the research was usually informal. The phrasing and sequencing
of questions were varied from interview to interview (Bryman, 2016) .Making Researches
reachable to the individuals involved requires consideration of the suitable language to use
in approaching them, expectation of the possible barriers to participation, and provision to
help to overcome them. If interviewers are not fluent in the chosen spoken language of
participants - it is difficult to carry out effective in-depth fieldwork without matching on
language

Thus, it is required to use a language that is understandable and relevant to the people that
are interviewing (Bryman, 2016).Interviews were done in Sinhala language and words such
as medical terms were emerged.

34
3.4.4 Data preparation and management
In qualitative approach, the most common raw data is coming from transcription of
interviews or discussions (Ritchie & Lewis, 2003) in order to bring the data to an advanced
level that is suitable for data analysis. After conducting the interviews, all audio recordings
were transcribed in to papers but the procedure was very time-consuming and yielded vast
amounts of papers.

Transcription helped to correct the natural limitations of memories and allows more
detailed examination of what respondents said. Further it gave benefits such as permits
repeated examinations of the interviewees’ answers, allows the data to be reused for
emerging new ideas and strategies. It helped to correct the natural limitations of memories,
bought the researcher closer to the data, and encouraged start to identify key themes, and
to become responsive of similarities and differences between different respondents
(Bryman, 2016)

3.4.5 Data analysis

One of the main difficulties associated with qualitative research is rapidly generate a large
database because of interview transcripts, filed notes, recordings etc. Thus, there are few
well-established and widely accepted rules for the analysis of qualitative data (Bryman,
2016). Even though all qualitative studies are inductive, different strategies have been
developed for data analysis such as grounded theory, analytic induction, narrative analysis,
conversation analysis, interpretive phenomenological analysis and thematic analysis. After
reading and searching on such theories, thematic analysis was seemed as the most
appropriate approach for data analysis of this study as it offers an accessible and flexible
approach. And also, it is widely used and is a foundational method for qualitative
researches (Braun & Clarke, 2008). Thematic analysis is a method for identifying,
analyzing and reporting patterns (themes) within data” (Braun & Clarke, 2008, p. 79). This
approach is consisting of six flexible steps namely; Familiarizing with data, generating
initial codes, searching for themes, reviewing themes, defining and naming themes and
producing the report.

35
Ten numbers of in-depth interviews with cancer patients became the source of analysis.
Given that the researcher’s focus was how rural women living with breast cancer response
to social and emotional challenges was initially analyzed using thematic approach. Thus,
the collected data from in-depth interviews with breast cancer patients and their relations
were processed through this thematic analysis. During this process, researcher tried to
identify the range of aspects expressed in the interviews that are seemed to have similar
characteristics and patterns.

3.4.5.1 Thematic Analysis

The popularity of qualitative methods in social science research is a well-noted and most
welcomed fact. Thematic analysis, the often-used methods of qualitative research, provides
concise description and interpretation in terms of themes and patterns from a data set
(Majumdar, 2016). Thematic analysis is considered the most appropriate for any study that
seeking to discover using interpretation and provides systematic elements to data analysis.
It allows associating an analysis of the frequency of a theme with whole context. This will
confer accuracy and intricacy and enhance the research’s whole meaning. Qualitative
research requires understanding and collecting diverse aspects and data. Thematic analysis
gives an opportunity to understand the potential of any issue more widely (Yadley, 2004).

Thematic analysis allows the researcher to determine precisely the relationships between
concepts and compare them with the replicated data. By using, thematic analysis there is
the possibility to link the various concepts and opinions of the learners and compare these
with the data that has been gathered in different situation at different times during the
project. All possibilities for interpretations are possible.

3.4.5.2 Codes
The researcher carefully read through the transcribed data, line by line, and divided the
data into meaningful analytical units by assigning broad categories (Punch, 1998) to the
information and concepts related to the research questions. These preliminary codes were
developed based on both the researcher’s knowledge of the literature and an analysis of the
data.
36
Table 3.1: Themes and codes

Themes First level codes

Changes in feelings when being diagnosed as a

Stress & Depression
breast cancer patient
Way of coping with stress and depression

Family and Community support Support from the family members

Support through social relations

Accessing to medical support Difficulties in accessing health services

and information Availability of accessing to information

Income level of the patient and the family

Coping with financial burden
Financial support by outside parties
Changes in social interactions
Feeling isolation
Felling helplessness
Extent of engage in religious activities
Spiritual directions
Impact for psychological relief

3.5 Rigor of the study

Any research requires ways to evaluate several techniques and methods used to conduct
the research to assess its trustworthiness covering; data collection, formation of
interpretation and presenting those interpretations to readers (Wallendorf & Belk, 1989).
In this part, research procedures and techniques that were used to establish the
trustworthiness of the study is presented through credibility, transferability, dependability,
confirmability and integrity (Lincoln & Guba, 1985; (Wallendorf & Belk, 1989)Those
techniques are researcher flexibility, collaboration, peer debriefing, triangulation, thick and
rich description, reflective journals, independent audit and prolonged engagement which
enable researcher as well as reader to evaluate the trustworthiness of the study (Wallendorf
& Belk, 1989)

37
3.5.1 Credibility
Credibility directs on believability and adequate of the interpretation of data. In this study,
credibility was assessed by having triangulation of sources such as justifying one outcome
from another outcome and debriefing by peers. At the data collection procedure insights
came from one breast cancer patient were evidenced by several other breast cancer patients.
Periodically, briefing about the interview sessions were done with colleagues who did not
have an interested with this study area.

3.5.2 Transferability
Transferability stands for ability for employing the findings in other contexts based on
similarity between contexts (Wallendorf & Belk, 1989). Even though generalizability is
not required for qualitative researches, the findings were employed in circumstances like
stressed and uncertain life changing events for certain extend as the topic under the study
was on changing consumption practices of cancer patients. To support for transferability
of the research, data was collected by using several rural breast cancer patients such as
different age groups and occupations.

3.5.3 Dependability
Dependability stands for repeatable of the findings in similar context with similar
respondents (Wallendorf & Belk, 1989). However, because of the limitation of resources,
researcher did not observe the respondents over the time and explanations of changes or
conducting a dependability audit, dependability of the study is not fulfilled.

3.5.4 Confirmability
Confirmability is about reaching the findings directly through the data rather than interests,
motivations and biases of the inquirer (Tobin & Begley, 2004). In this study confirmability
was enhanced by using reflective journals, field notes and audio tapes that supported to
detect the influence of researcher’s personal biases and tentative interpretations.

38
3.5.5 Integrity
Integrity means avoiding the possibility of conflicts between researcher and respondents
or the informants such as misinformation and lies (Wallendorf & Belk, 1989). In order to
maintain the integrity, respondents’ fear to the researcher was avoided before starting
interviews and good interview techniques like listening, giving enough time to respond and
talk were followed. And also, researcher always had a self-analysis before and after doing
interviews.

3.6 Methodological Limitations

This single case may be seen to have limitations in terms of traditional concerns about
generalizability. As discussed in the preceding section, the transferability is judged by the
reader’s perspective of the relevance of a given study to another context (Morrow, 2005;
Patton, 1990).

In qualitative inquiry, the researcher serves as the primary research instrument. As pointed
out by Jansen and Peshkin (1992) “qualitative researchers, whether interviewing or in
participant observation, are so palpably, inescapably present that they cannot delude
themselves that who they are will not make a difference in the outcomes of the study. Given
this, it is important to note that the researcher’s view could potentially impact the study.
While the researcher has acknowledged this concern and taken several preventive steps, as
discussed in the preceding section, the risk of having another researcher with different
skills and experiences using the same methodology to arrive at different conclusion cannot
be eliminated.

3.7 Ethics

Committing to ethical responsibility is a primary concern of this research. In conducting

the study, the following three key ethnical principles, as set out by the Economic and Social
Research Council (ESRC, 2006), have been followed:

• Participation in the survey should be on a voluntary basis;

• The participant will be informed fully about the purpose, methods, and intended
possible use of the research findings; and

39
 • The confidentiality of information supplied by participants and the anonymity of
respondents must be respected.

The targeted sample was accessed through voluntary sign up to participate in the survey.
An overview of the research study was included in the invitation. During the interviewing
sessions, all participants are informed again on the purpose of the study and assure that the
researcher would keep the information in strict confidence and will only use the collected
data or information for degree examination purposes.

The research topic involves sensitive issues such as emotional experiences of the patients.
The anonymity of research participants and research data was protected, and confidentiality
was ensured in this study (Cohen & Manion, 1994). To achieve anonymity, the researcher
disguised the names of participants as well as all other personal means of identification
when reporting the findings. Special coding was also used for data collection to ensure that
the identity of participants could not be revealed from any working papers.

(Appendix 2: Ethical Considerations)

3.8 Summary
This chapter revealed the methodological approach used for the research problem to be
answered on how rural women with breast cancer response to social and emotional
challenges after diagnosing them as breast cancer patients. First, the chapter identified the
rational for the methodology and approach used for the study. Second it focused on
research design in detail along with research design elements. Then it further expanded for
choice of method, study context and data collection used for the study. In data collection
section sample size, sample strategy, unit of analysis, interview guide was discussed. Data
were collected from seven number of cancer patients using in-depth interviews as primary
data source. Then the chapter discussed on data preparation process that is transcription
and data analysis method used. Next rigor of the study was discussed along with peer
debriefing, triangulation and reflective journals in order to enhance the credibility,
transferability, dependability, confirmability and integrity. Finally, methodological
limitations and ethic concerned have been discussed. The findings presented in Chapter 4
are the results from the application of this methodology.

40
 Chapter 04

Findings
4.1 Introduction

This chapter proposes the findings relevant to the topic under the study – Living with breast
cancer; Sri Lankan rural women’s reflexive responses to social and emotional challenges.
After collection and analyzing of the data, this chapter reveals the findings of the study. It
begins with an account of the study context which covers the nature of the participants and
the interview backgrounds. Secondly this depicts how rural women with breast cancer
response to social and emotional challenges.

The purpose of this study is to identify how rural women with breast cancer response to
emotional social challenges. So, the analysis of information focus on following research
themes.

▪ Stress and Depression

▪ Family and Community support
▪ Accessing to medical support and information
▪ Coping with financial burden
▪ Feeling isolation
▪ Spiritual directions

4.2 Study context

To investigate the underlying research questions on how Sri Lankan rural women living
with breast cancer response to social and emotional challenges, the researchers’ focus was
on discovering personal stories, experiences, and social and psychological changes during
and after the diagnosis and how they respond to those.

This research has been undertaken over four weeks and engaged with rural breast cancer
patients who are fully recovered while some are still taking treatments. The data collection
followed the method of in depth interviewing and the process resulted in 10 interviews
with self-selected breast cancer patients. The Interviews were in various locations, based

41
on respondents’ preferences. Some interviews were done with the relatives of the patients.
8 individuals had got breast cancer from 5 years to 15 years ago. However, two had been
diagnosed with the breast cancer relatively recently (less than 2 years). Majority of the
respondents were housewives. Two were teachers and one is working in a private bank.
Respondents were from different districts of the country including Puttlam, Kurunegala,
Nuwaraeliya, Kandy, Kaluthara, Galle, Anuradhapura and Matara.

The participants as self-narrators use their life stories to with the breast cancer and to high
light the events that they perceived as significant. Each interview started with respondents
telling their story of symptoms and diagnosis in their own words. Then involved dialogical
exchange between interviewer and interviewee based on using semi-structured questions
to get further understanding what it meant to live with the breast cancer and how responded
to the challenges. But in few cases participants narrated their stories outside the guide too.
Participants discussed different aspects of their experiences in hospitals, clinics, work
places, and family members and friends and the initial reaction to this event regarding both
social and emotional issues.

Participants have been had a tough time period during their treatments and immediately
after the treatment period along with both physical and mental challenges and during this
time, they seemed themselves as vulnerable in consumption and other aspects. They had
concerns about their body changes such as hair, skin and shape that occur because of the
tough treatments they had to go with. High family involvements and help during the illness
seemed as a significant support for the breast cancer patients. Some respondents were able
to manage their social and emotional challenges, while some were stressed at the very first
beginning of the diagnosis and still disappointed about facing to the future.

During all interviews, participants spoke about the stress, support from the family and
society, feelings towards children, access to health services and information, feeling
isolation, coping with financial burden, religious or spiritual directions and the karma.
Some interviewees believed that it as a turning point in their lives after being recovered as
they have got much psychological and spiritual freedom to see the life from a new corner
based on their religious believes.

42
Hence to achieve the objectives of the study, the way how rural women with breast cancer
response to social and emotional challenges were presented in this type of a context along
with immediately after the diagnosis and in the long term.

4.3 Participant Coding system

The study involved 10 participants including 6 rural women who were/are living with
breast cancer and 4 were relatives of the rural women with breast cancer. When reporting
their responses, they have clustered in to 2 groups to reflect their response and perspectives
clearly. First group named as Direct Patients and the second group named as Relatives of
the patients. Each participant was assigned a two-part code, which starts with two letters
followed by a digit. The two letters represent the group in which the participant belonged,
and the digit is the individual participant’s identification code. Below is the set of codes:

Table 4.1: Participants' coding system

Group Code Participants codes

Direct Patients DP-6 DP-1, DP-2, DP-3, DP-4, DP-5, DP6
Relatives of the Patients RP-4 RP-1, RP-2, RP-3, RP-4

4.4 Sample Profile

The sample profile included respondents’ age, district, occupation, marital status number
of children and current status of cancer. Researcher employed those data for the processes
of data analysis, findings and discussions.

43
Table 4.2: Sample profile

Patient Age District Occupation Marital No.of Current

Code status children status of
No. cancer

DP-1 53 Puttlam Housewife Married 4 Recovered

DP-2 55 Kurunegala Retired Married 2 Recovered

Teacher

DP-3 37 Kaluthara Housewife Married 2 Taking

treatments

DP-4 52 Kalutara Housewife Married No Recovered

DP-5 40 Galle Housewife Married 2 Taking

Treatments

DP-6 39 Kurunegala Housewife Married 2 Taking

Treatment

RP-1 45 Nuwaraeliya Housewife Married 5 Taking

treatments

RP-2 35 Kandy Bank officer Married 1 Taking

treatments

RP-3 56 Anuradhapura Retired Married 2 Recovered

Teacher

RP-4 48 Kurunegala Housewife Married 2 Partial

Recovery

44
4.5 Stress and Depression
Normally most symptoms of stress and depression can be recognized in breast cancer
women in western literature. It is the same in Asian countries too. According to the
experiences and the responses of this research respondent’s majority of them were highly
stressed at the very first beginning of the breast cancer diagnosis. But significantly no one
was identified suffering with depression.

4.5.1 Changes in feelings when being diagnosed as a breast cancer patient

Under this, purpose of the interviewer is to identify and get an understanding about
emotional changes of rural breast cancer women when they are being diagnosed as a breast
cancer patient at the very first. 9 of 10 respondents said they were feared and stressed when
they diagnosed it. DP-4 who is a housewife with no children cited that she didn’t feel
anything bad especially due to this. She just said, “[I] didn’t feel anything such”. Except
her all others had scared and sad responses towards that.

DP-1 is a mother with 4 children. Two children are married now. she was working as a
laborer for living and her husband works as a servant in a rich house in Colombo. She
shared her immediate reactions towards the diagnosis, and it shows her helplessness when
confronting with the sudden disclose of breast cancer. “[I] feel feared, my god feel feared
lot. [I] can’t say how it felt, couldn’t even eat, drink. [I] was staying crying. I was afraid
when hearing that breasts will cut off and removed”. DP-2 was a school teacher and she is
retired now. She is a mother of two young children, shared the same feeling of fear at the
diagnosis of breast cancer. “I diagnosed it in 2005. Fear is the thing I felt when I got to
know I have a breast cancer. Later, I worried much about my hair, because I had a very
long hair close to knees. When hair falls regularly my mother got heart attack and died
after a year from my cancer diagnosis. So, really it sad”. DP-3 is a young housewife and a
mother of two kids. Her husband works in the Army. She was highly feared and stressed
about her future life and her kids when she diagnosed the breast cancer. “Actually, I was
scared so much. I felt feared about my future and uncertainty about the life when I heard
about the word breast cancer. And also, I couldn’t believe with my age that I have a cancer.
But however, I had to accept that”. DP-5 is a housewife having two children also shared

45
the same idea. “Actually, I was sacred so much, because I was in a mentality of weather I
will get cured or not”.

Some patients and their relatives didn’t want to allow the patient to remind their sad
situations and experiences again and again. So that, to avoid the inconvenience occurs
within some women with breast cancer, their closest relatives talked with the interviewer
to give data regarding the responses of the patient with the consent of the patient.

So, RP-1 talked about her aunty (Younger sister of the father) who is having 5 children.
“She is one my aunts, living next to my house. She was firstly diagnosed with a cancer in
womb and the later again diagnosed the breast cancer three years ago. Actually, she is
feared about the uncertainty about her life, she has five children and three of them are in
schooling age. So, she always worried about the future of the children if she would loss her
life”. RP-2 talked about her elder sister who is, having an infant and working in a private
bank. She is the youngest patient in the unit of analysis. She was stressed highly since she
couldn’t believe such hard situation in her young age. “At the very first level of cancer she
could diagnosed it through an annual medical checkup in the workplace. Normally,
everyone can understand how hard that feeling for a woman to be diagnosed with a cancer.
she cried lot, scared lot, her kid is just 3 years old, kid is a girl. Still she is very young, so
she is worrying about her family life and scared about whether any problems will arise
from the family of her husband. So, she got pressured and was sad very much since all
these things came to her mind”. RP-3 presented data about his mother. She is having two
children, now she is a retired teacher. According to her sons’ responses, she had suffered
lot internally. “My mother was a teacher, her both breasts were removed, and she went
school again regularly. Two years after that again cancer cells had spread. So, she was
suffered lot inside, but she tried her best not to show her suffering to us”. RP- 4 shared his
ideas about his wife. She is a housewife, having two children. according the views of her
husband she also has suffered psychologically. He cited that “actually as such thing was
diagnosed newly, she fell lot in every side mentally and physically. [she] scared so much
when thinking of our children”.

So, except one (DP-4), all others were feared and stressed about many things in their lives
when they were diagnosed as breast cancer patients.

46
4.5.2 Way of coping with stress and depression
Majority of the patients suffered with stress but significantly no one wasn’t being suffered
with depression situations. They had good ways to cope with psychological stress. So that
their sufferings haven’t not let them to develop as depressed situations. Any one didn’t
want special or separate medical support to cope with stress. All of their coping
mechanisms were support given by closest members of the family and the religious prayers
and guides.

DP-1 cited that “This has happened to me due to the sin I have done in previous life. So, I
have made my mind to be okay with whatever comes to my life in future, even death. I’m
taking a relief through religious activities.”. DP-2 hadn’t been suffered with lot of stress
or depressed situations. She told that due to the support from lot of people she didn’t fall
mentally, it was a huge strength for her to cope with the breast cancer. “I think due to the
goodness of mine, fortunately I had a huge support from everyone. I was the first woman
who had this type of cancer in this area, even my two children were small then, So, I
received sympathy from everyone. Always whoever come to me and make my mind, I read
religious books and specially [I] practiced many meditation methods, meditation method
was my best way to cope with pressure in mind. Because of those things I never had such
psychological issues during that period”. DP-3 had a big stress but never it had gone for a
depression situation. “Actually, I had a stress, [I] had a huge stress of how I face to this
disease with my kids. I had heard about this cancer and its suffering earlier. Kids also don’t
have an understanding about what their mother is suffering. They are asking many things
and I cannot answer them sometimes. So, I’m being so sensitive at that times and get
stressed. But I didn’t need a special medical treatment to overcome that. My mother, family
members and surrounding people are making my mind, doctors too advise not to fear when
going to take treatments. So, any depressed situation didn’t occur”. DP-4 is again different
from others’ responses, because she hadn’t not any fear, stress or depression due this breast
cancer. Sometimes as she doesn’t play a big role in the family as a mother and just a
housewife, this might feel her as a normal disease like an illness. She cited that “[I] didn’t
feel such special feelings like fear and stress”. DP-5 also cited about her stress level and
how she copes with that. “There was no such depressed level, but there is a worry always
in mind, a big worry actually. [I] was always thinking and felt like helpless, and still feeling

47
like that. But now I have an understanding about my situation and I’m getting a
psychological relief through religious activities and from the support of others. So, I didn’t
need separate medical support to overcome the stress”.

Respondents of the RP group shared their ideas about the stress and depression related to
their patients very well. They had seen how they cope with this challenge. RP-1 cited that,
“she has a pressure mentally, normally as she is in the age of 45 it means she has more time
to live. Duties towards the husband and 5 children and their economic level is a pressure
for her certainly. But she bared those things however, mostly through the engagement in
religious activities and support from others. There was no a situation like depression. So,
she didn’t want medical support to cure from psychological issues”. RP-2 also shared the
same idea regarding her sister. “At the beginning she got angry lot, cried, tried to separate
from others and like those things could be seen with her. But with the interference of us
and specially with advices from the Monk of the village temple, she could handle the stress
situation without going to a situation like depression”. Both RP-3 and RP-4 also told that
they gave their fullest support not to get stress for the patient. “According my view, mother
didn’t show her stress and pressure because she thought we also get upset if she is in stress.
And we also didn’t show big sadness unless she thinks about them also. Father also worked
very patiently; he didn’t even shout in any problem happened in the family. So, we all
didn’t allow anything mother to get stress” (RP-3). “Actually, at the beginning she had a
mental stress, but never had/ has suicidal thoughts. Normally cancer patients save their
lives rarely. So, I would thank to the doctors because they always make her mind not to
fear and can get recovered when going for treatments. I too gave my fullest support, and
through religious activities also she has a mental relief” (RP-4)

4.6 Family and Community support

It could identify that a huge family and community support has been given to these rural
women with breast cancer. Some of them has been helpless sometimes. It has differed one
to another with the extent of they engage with others; family members, relatives and the
society.

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4.6.1 Support from the family
One woman said that she hadn’t a much support from the family members to manage her
works. It might specially because of her husband is not at home, two daughters are married
and living far away from the home, and two sons haven’t a capability of good
understanding.

“So, many problems were there in the home, I was staying at elder daughter’s home
also when taking treatments. So many things I did alone, there was no great support
from the family, even two sons didn’t look after me well. They don’t have an
understanding, no one came to see me while I was in the hospital” (DP-1)

All others mentioned that they had a greater support from their husband, parents, siblings,
children and other closest members in the family to manage day today household activities
and all other thing related to medical treatments and also psychologically as well.

“I received a huge support from my family members and the society too, it was difficult
for me to do the house works. So, my mother and husband helped me lot. One of my elder
brother (cousin) said me, Nangi (younger sister) don’t stay like this and bought me a wig
as soon as he saw me without my hair” (DP-1). DP-3 cited again the same idea. “I receive
a big help from the family, my husband works in the Army. So, he is not at home. Only
comes in holydays. I was much worried about managing the works of my kids. I had a
greater support from my mother and husband’s mother to manage them and household
works”. “Husband and the relatives supported to manage day today activities at the home”
(DP-4) “when I go for treatments, I couldn’t manage the household works and the works
of the children too. At those times all members in the family support me” (DP-5).

Respondents in RP group (relatives of the patient) shared their view regarding the family
support they are giving to these rural women with breast cancer.

“All most all the members of family support her to remove the fear and to look after her
five children. most of the times her elder daughter manages the household works” (RP-1).
“a big support was given by the family; we are always with her in every situation. specially
her husband always with her. she couldn’t manage her day today works alone, so specially
our mother supports her lot” (RP-2). “Most of the time our father did everything in the

49
home, I and my elder sister support him. We always tried to give a rest to mother without
making her tired. Our father cooked for us also” (RP-3). “When wife goes to take
treatments, our children are alone at home. Then specially her sister comes and looks after
our children and manage their school works. All our relatives are living around our house.
So, they always help my wife” (RP-4).

4.6.2 Support through social relations

These women had/has a considerable support from the society also. No one mentioned that
they had rejections from the society. So, luckily the Sri Lankan people are showing their
kindness when some difficulties occurred to any other known to them.

People in the society have shown their kindness towards the emotions of these rural women
living with breast cancer. DP-1 cited that “They always say don’t fear, [you] will get
recovered. These are common things happen to every one of us, if we born, we have to die
one day, and they say don’t worry”. “Actually no one was insulting me, everyone talked
with me to make my mind” (DP-3). DP-2 shared her ideas like this.

“I received a huge support from my family members and the society too, actually
the people living around my house came and support me even to boil water and
bath, to wash and iron clothes. So, their support was a huge strength for me. Leaves
were also given me from school to have treatments. People in the society had more
sympathy towards me. I had huge love and kindness from others”

As the same way other woman also have/had received a good support from the society.
They quoted as follows.

“Nearby people helped me when I needed” (DP-4). “Ladies in the village come to see me
and support me lot” (DP -5). “Her relations and surrounding people in the village helps her
in many ways like financial and non-financial support” (RP-1). “She has a big support
from her workplace also, still she not fired from her job. They support her financially also
specially to pay medical bills. So, everyone helps her even by a word” (RP-2). “Since she
is a school teacher, she interacts with the society highly. So, everyone known supports her
as they can” (RP-3). “Actually, teachers of our children’s school and parents supports us
and my friend who with me also support us” (RP-4).

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4.7 Accessing to medical support and information
There are no developed health services in rural areas compared to urban areas in Sri Lanka,
specially knowledge about the breast cancer also very less of these women before the
diagnosis. So, almost all they have faced difficulties in accessing to medical support and
information.

4.7.1 Difficulties in accessing health services

Two women in Puttlam District had gone for Treatments and operations to District Genaral
Hopital- Chilaw and Puttlam Base Hospital at the beginning. Later they also had to come
to Apeksha Hospital, Maharagama. One lady in Kandy is doing all treatments in Kandy
national hospital. She hasn’t any need of going to Apeksha Hospital, Maharagama. So, nine
out of ten women had/ must come to Apeksha Hospital, Maharagama for treatments. It is
a long journey for them to come from their villages and costly. When they are admitted
any other also needed to come with them to look after. They shared their difficulties in
accessing to medical services as follows.

“To a greater extent I did everything myself alone. No one is there, I went to hospital alone
by bus. Most of the times I was alone in the hospital” (DP-1). DP- 4 cited that “I went to
cancer hospital by bus, when I admit in the hospital someone stayed with me in the
hospital”. DP-5 also shared same idea. “In case of travelling, firstly I went by bus, later I
had to travel by separate vehicles also. My mother and sister looked after me when I’m in
the hospital” (DP-5).

DP-2, DP-3, RP-1, RP-3 and RP-4 expressed their views regarding accessing to health
services and its’ difficulties in explanatory way.

“Firstly, I went to District Genaral Hopital- Chilaw, always my husband came with
me. My mother looked after me when I was in the hospital, and also other relatives
came to see me and stayed with me. Later, doctor asked me to go to Apeksha
Hospital, Maharagama for clinic monthly. I went by bus with my husband or some
other relative. Then it was somewhat tired for me as it is a long journey”. (DP-2)

“Firstly, I travelled by bus with my mother to take treatments, but later when I
become physically weak, I had to hire a three-wheel or any other vehicle to go to

51
 hospital. Financially it was a challenge. When I’m admitting in hospital my mother
or husbands’ mother stays with me, then sometimes it is difficult to let child alone
without both mother and father” (DP-3).

“There was no any known health facilities or medical centers in her area to take
treatment for cancer. So, normally about 5-6 hours takes to travel to Maharagama
from Nuwaraeliya. It is so hard for her. When her body becomes weaker, she
couldn’t travel by bus, then family members had to hire vehicles. It is so costly”
(RP-1)

“Initially this breast cancer was diagnosed, and treatments were done in
Anuradhapura Hospital. Later a doctor advised us to admit mother to Maharagama
Cancer hospital for further treatments. So, coming to Maharagama from
Anuradhapura is a hard journey. My father takes mother mostly through public
transport, because coming by a separate vehicle is much costly. So. Time to time
I’m, father and my sister came with mother” (RP-3).

“Breast cancer diagnosis was done in Kurnegala Hospital and got treatments for a
certain period there. After that doctor transfer wife to Apeksha Hospital,
Maharagama for further treatments, then it was difficult for us to travel every week.
We went by bus” (RP-3).

RP-2 who is in Kandy district hasn’t a need of coming to the Apeksha Hospital,
Maharagama. She tells that they are satisfied with the treatments and the facilities received
from the Kandy national hospital for breast cancer. So, RP-2 cited “All the treatments were
done in Kandy hospital, facilities in the Kandy hospital is now in a satisfied level. There
was no need of going to Apeksha Hospital, Maharagama”.

4.7.2 Availability of accessing to information

These rural women hadn’t a considerable knowledge regarding breast cancer before they
diagnose it. And also, they highlighted that all the information regarding breast cancer and
about its’ treatment was got to know after going to the hospitals.

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“At the first one of my arms got pain, I went to take medicine. Then doctor said to do a
check-up related to breast cancer. Before that I didn’t thought of this type of cancer. After
going to the Apeksha Hospital, Maharagama, doctors gave many information” (DP-4). DP-
5 also mentioned the same idea. “I hadn’t any knowledge about this cancer, everything I
got to know after meeting the doctors”. “There was no any chance to get information about
this cancer before. Everything got to know after she came to the Cancer hospital” (RP-1)

“No one has diagnosed with breast cancer in our village before my mother. It was
a new thing for everyone because at the time we diagnosed it in 2014 my mother
hadn’t much knowledge regarding that. There was no any way to know about it
before going to the hospital” (RP-3)

“Actually, my wife never had a check-up of breast cancer earlier. So, she hasn’t not
much knowledge about it. After going to Kurunegala hospital doctors gave all
information”. (RP-4).

Three of them have obtained information by contacting with other women who were
suffered with breast cancer and got recovered.

“It was seeming like the breast has embedded inward and then few ladies told me
to go to a doctor. Then I first went to District General Hospital - Chilaw and then
doctors told the details and gave every information regarding treatments. And also,
I met other women with breast cancer and shared their experiences also” (DP-1).

“Doctors gave me many advices and there were leaflets in the hospitals related to
this cancer, I read them. In addition, I contact with a lady in Horana area who
recovered from this type of cancer, when I got changes physically, I asked from her
and again went and talked to the doctor, sometimes went to private doctors too. Her
information was a big strength for me” (DP-2).

“I firstly knew about this when I went to take medicine to a private place. That
doctor gave me some details and advised to do a check-up. Then after going to
Apeksha Hospital, Maharagama, I got more information from doctors. And also, I

53
 talked to a recovered breast cancer lady, she shared her experienced with me” (DP-
3).

RP-2 who represented from Kandy district gave a little different idea since her sister an
educated lady. She had a bit knowledge about the cancer before the diagnosis. “my sister
is an educated lady. She has a little bit of knowledge about this Cancer. And also, while
taking treatments, doctors also gave all the details regarding breast cancer and its’
treatments”.

4.8 Coping with financial burden

Cancer is a burden issue that arises big financial problems to rural women with breast
cancer. So, their financial difficulties and income level of the patient and the family has
described under this and the financial support received by outside parties as well.

4.8.1 Financial difficulties and Income level of the patient and the family
Except high level income families, it is difficult for low -income level and middle- income
level families to face financial issues that arise when someone diagnosed with a chronic
disease in the family. So, almost all the rural women in the sample profile are in middle-
income level or low-income level families. Patients’ and the family’s income level and
their financial difficulties are quoted below.

DP-1 is working as a laborer and her husband works as a servant in a rich house Colombo.
“[I] couldn’t go to work and husband gave a little money. Since the operation was done in
Putlam government hospital its’ cost hasn’t to bared by me. But other expenses were not
easy to manage”. DP-2 was a teacher and her husband was doing farming at the time that
she prevails the cancer. I was a school teacher and my husband is a farmer. Only I had the
permanent income method. So financial problems arose. I even cut and sold the trees in
our home and sold them to earned money”. RP-2 explained the income level of her sister
and the family. They are in middle-income level. “Though we are in a rural area, we are in
a middle-income level because both my sister and her husband having job in private sector.
But it doesn’t mean that she is not having financial problems. I and my parents also gave
money when they needed”.

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According to the view of RP-3, they are also having middle-income level. Both the patient
and her husband were having government jobs. So, they hadn’t arisen big financial
problems. “since both my father and mother did government jobs, economic problems
didn’t arise to a greater extent, but we had to spent big amount of money for medicines,
treatments, injections, travelling and etc.”

Except above four respondents, all other six patients are just house wives, who are not
having any income method. Their husbands are the only breadwinner of the family.
According to their views, they are/were facing to many financial challenges when coping
with the breast cancer and its’ treatments.

DP-3 is a housewife whose husband works in the Army. She quoted like this. “Actually, I
face many difficulties related to money for medicines and travelling. In our home, only my
husband does a job. Many expenses occur for the education of the kids also. We haven’t
saved such a considerable amount of money for an emergency like this”. DP-4 is a
housewife. She has no children and only her husband earns money. “[I] had some money
problems, but however could manage them” (DP-4)). DP-5 is a housewife and her husband
is having a boutique, their only income is that, “our only income is having through the
boutique of my husband, so we had financial problems really. But my husband doesn’t let
me to worry about them. He however tries to find money”. RP-1 mentioned that her aunt
also a housewife and her husband is the breadwinner of the family. “her husbands’ salary
is the main way of income and they have no other way. So, it is enough for them to manage
all the things, because they have five children to feed also”. RP-4 also quoted that only he
is earning money in the family and her wife stays at home while looking after the children.“
since I’m riding three-wheel for hire, we have a daily basis income, so it is not enough
actually to face such situation, we have to feed our children also. We got loans from others
also”.

4.8.2 Financial support by outside parties

All most all the women had a good financial support from the outside parties as well
including relatives, people in the village, colleagues in workplaces and others in the
society. Financial support they received from them is/was greatly impact for their survival
through the breast cancer. So, they all quoted their ideas regarding that as follow.

55
DP-1 quoted, “Surrounding people gave me money many times voluntarily”. “My mother
and father gave me money, and my brothers’ salary was totally spent for me. In addition,
some of our nearby people gave money. Around twelve hundred thousand rupees had to
spend” (DP-2). “I have a big problem with money, but I could manage those financial
difficulties to a certain extent through the money received by our relatives and other known
persons in the village” (DP-3). “Other people in the village gave money when in difficult
times” (DP- 4). “friends of my husband gave us money” (DP- 5). “actually, money I
received from others was a big strength to me and my husband, many people voluntarily
gave money as they can. Even I received money from village temple” (DP-6).

Relatives who shared their ideas also significantly mentioned that the financial support
they received from other parties is/was a bid strength to cope with financial burden that
arose within the family. According to the ideas shared by RP-1, her aunt has received
money through a fund where her husband works. “They are given a financial support from
a fund where her husband works, other than that relatives and their friends give money in
their difficult situations”. RP-2 also said that her sister good support from the workplace.
“she has a good financial support from her workplace to pay medical bills and also from
the relatives”. “some people supported us financially, specially the teachers of our
children’s’ school” (RP-4)

Although RP-3 said that their family hadn’t the financial burden to a greater extent,
whenever they needed support, there were good people around them in every time.
“whenever she need financial support there were kind people around her to support without
any hesitation”.

4.9 Feeling isolation

Breast cancer creates psychological pressure for women since it affects to the changes
physically, mentally and socially as well. So, at the very first beginning of the diagnosis of
breast cancer they have felt helplessness and changes happened in social interactions in
different levels. Extent of feeling helplessness and changes of social interactions differ one
to another, some women told that they didn’t feel isolation or helplessness since they have
a good support from others. And also, they mentioned no any changed occurred in the

56
social interactions, but majority of them had felt helplessness and changes in the social
interactions in some occasions.

4.9.1 Felling helplessness

Mostly these rural women living with breast cancer feel helpless due to the challenges they
face even there are supportive people around them.

DP-1 was the most helpless one as the researcher identified. Because all most all the times
she has managed all the difficulties alone though there were people to help. she quoted like
thus.

“To a greater extent I did everything myself alone. No one is there, I went to
hospital alone by bus. Most of the times I was alone in the hospital, once I was in
the Anuradhapura Hospital, people were coming to see other patients no one came
to see me, others were asking why anyone was not coming, So, I’m saying it is
difficult them to come, daughters have small kids and others also have works. I felt
so alone and helpless” (DP-1).

DP-3 is a housewife whose husband works in the army. So, according to her views, she
feels helpless since her husband is not at home. “I] feel big helplessness than an isolation,
because my husband also not at home all the time. I feel scared about the future of my kids
if something happens to my life, they are still small” (DP-3). RP-1 and RP-2 also shared
little similar idea related to thinking of the future of patients’ kids. “she always worries
about her children since all five children are still in schooling age. She took some
considerable time to make her mind” (RP-1). “At the very beginning of breast cancer
diagnosis, she worried so much, she cried and got angry, her daughter is very small, still
she is living with little sadness” (RP-2).

Both DP-5 and DP- 6 had a helpless feeling regarding the question whether their breasts
would have to removed and the fear about it. “actually, I had a feeling of helplessness
because I always had the question whether I could get recovered or not, whether I would
have to remove the breasts. So, I was mentally upset and still there is a fear inside me”
(DP-5). “I’m so scared of removing my breasts because I feel I’m not complete without
them. I felt so helpless” (DP-6). RP-3 also shared similar idea about his mother. “both her

57
breasts have removed now. So, it is a thing to worry for a woman definitely. She even went
to school after removing breasts. But my mother never showed her sadness and
helplessness to others” (RP-3).

In different to above eight responses two women said that they didn’t feel such helplessness
due to the breast cancer. “Actually, I hadn’t a chance to feel isolation, whoever come to
me and make my mind always, my family and friends supported me” (DP-2). “I didn’t feel
such things like helpless or isolation” (DP-4)

4.9.2 Changes in social interactions

Breasts are significant body part for women. So, having cancer of them is a big problem
for such ladies. Sometimes they are unwilling to go to the society because of the curiosity
arise regarding the perception of others towards them. Then they might fear to interact with
others. So, under this heading, responses related to their changes in social interactions are
described.

Different level of changes and no changes could be identified by the researcher related to
the sample selected.

According to the responses of DP-1, DP-2, DP-4 and RP-3, there are/ were no a change in
social interactions of those rural women living with breast cancer. Their quotes as follows.
“There was no a big change of social interactions, I went out as usual and talk with people
without any doubt” (DP-1). “since I received lot of love, kindness and sympathy from
everyone, I had not much difficulty in interacting with the society” (DP-2). “No big
changes happened when engage with other people” (DP-4). “She is a lady who engaged in
social works very well. Even after removing the two breasts also she went to school and
worked. So, the interaction with the society didn’t change much” (RP-3)

Few others had/have a dislike of talking to others at the beginning. But later, they have
used it.

“Actually, at the beginning I had a little fear to face the society because I don’t
know how they will see and interpret me. So, I have a little dislike of going out
because when they are always asking about my conditions, it is a pressure for me,

58
 my sadness and stress renew again and again, but since it has gone more than one
year, I’m used to it now” (DP-3).

“I’m so sensitive, sometimes it was difficult me to answer the all questions when
others asking about my conditions. So, I didn’t like to talk to others. But now I’m
somewhat okay with that because I’m used to it now” (DP-6)

“at the beginning she had a dislike of talking others and tried to stay alone, but with
the advises of elders and monk of our temple, now she has good understanding”
(RP- 2).

“I was little dislike of talking to others and going out at the very first beginning.
Sometimes still it is” (DP- 5).

One respondent mentioned that, at the beginning patient had usual interaction with others,
but now she doesn’t like to participate in functions where lot of people are gathering due
to knowing her limits of life span.

“She is a very social woman, [she] treats others very well. As usual she talks with
others and interact with others, but now she has reduced going to functions like earlier.
Because she knows that there is a limit for her life time now” (RP-1).

4.10 Spiritual directions

Except one woman all others a greater extent of engage in religious activities in order to
have blesses and psychological relief through that. These spiritual directions/ religious
prayers had been a big strength for them to minimize their fear and cope with stress
successfully. So, the findings related to the extent of engage in religious activities and the
psychological relief they had through it are mentioned under this.

4.10.1 Extent of engage in religious activities

Normally Sri Lankan people used to engage in more religious activities when they are in
unhealthy situations in order to relax their mind. So, these rural women living with breast
cancer are also have a greater extent of engagement of their religious activities.

59
One woman said that she didn’t tend to engage more in religious activities after the
diagnosis of breast cancer, she has continued the regular religious observances as earlier.
“[I] didn’t tend to do more religious activities than before, I engage with them as usual”
(DP-4).

Except DP-4 all others has/had a greater extent of engagement. They quoted their responses
as below.

“Really when I couldn’t do works, I always chanted Pirith, did Bodhi Pooja,
worshiped lord buddha and participated in almsgiving for monks also. [I] read
religious books and did mediation to a greater extent” (DP-2).

“Really I tend to religious activities more when I diagnosed a such dangerous

disease and tried to have a mental relief through that” (DP-3).

“Actually, I engage in religious activities to have blesses and mental relax than
before. Husband takes me to temple. We did Bodhi Pooja and a Pirith chanting even
at home” (DP-5)

“Normally she is a lady who lived a peace life, but I saw significantly she engages
in more religious activities rather than before, read religious books also” (RP-1).

“She is a Buddhist; we believe sin and merit. We did so many religious activities
to bless her. She also practices meditation. Monk of our village temple also always
advises her. And we are going to the Temple of Secret Tooth Relic also. We pray
to the gods also” (RP-2).

“I take her to the temple. [we] did Bodhi Poojas and participated to many religious
observances” (RP-4).

RP-3 highlighted that except to religious observances, his mother and the family believed
in myths also in some occasions. Myths like there are persons who can cure the patients
through his spiritually developed mind. But he said it was useless, but they went after such
people due to the patients’ and their helplessness.

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 “Really she knows about the limit of her life span. We take her to the Sri Maha
Bodhi also. [she] is engaging in regular religious activities. She even chants Pirith
while she is in the hospital by her own mouth. Sometimes we believed in myths
and went after them also to have a relief even through them, because not only
mother, we are also helpless in a kind of this disease” (RP- 3).

And DP-1 said that she had a little influence from people in another religion to take her for
prayers. But however, she has rejected them and understood only prayers cannot cure from
this disease.

“[I] made my mind, there were religious activities in the hospital also. A monk was
coming regularly to sermonize, some of Christian people also told me; Let’s us go
to church and pray. But I knew there is no any use of praying without doing medical
treatments. So, I engaged in activities of my religion to understand the uncertainty
of the life” (DP-1).

4.10.2 Impact for Psychological Relief

A big psychological impact for these rural women living with breast cancer could identified
by the researcher through the engagement of religious activities.

“Now I’m always ready to face anything what would happen in the future. It is no
matter for me, always monks are saying to collect merits for both this life and next
life. So, now I understand the life is uncertain and death is certain” (DP-1).

“I really tend to religious activities to a greater extend, actually I could have a relief
through that. My fear also could release, meditation was my best way to relax my
mind” (DP-2).

“With tending to more religious activities, I could have a mental relief and could
minimize the fear” (DP-3).

“I could control my emotions through those religious activities” (DP-5).

Relatives of the patients also significantly described how those spiritual directions can
strengthen their patents’ endurance and coping abilities.

61
 “Actually, her biggest strength of surviving is these religious blesses” (RP-1).

“She has a big psychological comfort through engage in religious activities, she
tells that with us” (RP-2).

“It was great relief for my wife to understand the truth of the life” (RP-4).

RP-3 mentioned that, spiritually being strong is very important for a lady to cope with a
chronic disease like breast cancer.

“My mother is ready to face anything what happen in the next minute, it is because
of the spiritual directions actually” (RP-3).

4.11 Conclusion
Findings related to the six themes was described in this chapter. Majority of the women
suffered/suffers with stress, but no one could identify with depressed conditions. Except
one woman, all other has/had a good family support and social support they received was
highly valued by them. All most all the women has/had challenges in accessing to medical
support and information. Income level of the patients and their families had differently
impacted for their financial problem. All of them had a good financial support from outside
parties. Finally, all the women had a greater extent of engagement in spiritual direction
after the diagnosis of breast cancer except one respondent. It has greatly impact for them
to have psychological relief and cope with the breast cancer. To what extent the above
findings are consistent with previous research findings and existing theory as discussed in
Chapter Two and what the significant contributions of this study are to the existing body
of knowledge will be discussed in detail in Chapter Five.

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 Chapter 05

Discussion of findings
5.1 Introduction

Chapter Four presents the details of the research findings based on the data obtained
through semi-structured in-depth interviews by face to face and telephone calls. This
chapter focuses on a discussion of the results by comparing the findings of this study with
previous research and existing theory. The discussion addresses the six specific research
questions of this study which cover the themes of how rural women living with breast
cancer response to Stress and Depression, Family and Community Support, accessing to
medical support and information, coping with financial burden and spiritual directions.
This nature of research study couldn’t find in the Sri Lankan context. So, the discussion of
the findings is mainly done with comparing western and other Asian countries’ research
literature. This chapter concludes with a summary of the contributions made by this
research study to the existing theory and body of knowledge based on the comparison of
the results.

5.2 Stress and Depression

According to the responses, majority of the rural women living with breast cancer in Sri
Lanka are suffering with stress in different situations due to various circumstances like
physical changes like hair loss, weakening of the body, social issues, unable of managing
day to day activities and the thinking of the future of the children. Women with breast
cancer experience suffering related to life dimensions: physical pain, spiritual, emotional,
psychological and social forms of suffering (Banning , et al., 2009).

5.2.1 Changes in feelings when being diagnosed as a breast cancer patient

At the stage of diagnosing the breast cancer, most women were sacred and worried about
the life. Nonetheless, a diagnosis of breast cancer is a distressing event that affects physical
and psychological functioning and impacts on lifestyle and relationships with family and
friends (Leung, et al., 2014). According to the findings of a research done by Girgis, et
al.,2000, those stressful symptoms could be identified. For many women, the diagnosis,
treatment and subsequent follow up cause considerable psychological, physical and social

63
dysfunction (Girgis, et al., 2000). Several studies have found that many women with breast
cancer experience elevated levels of distress, anxiety and depression. 4-10 Other studies
have found that many breast cancer patients encounter a range of negative experiences
including fear of the cancer spreading or recurring, debilitating treatment side effects such
as fatigue or nausea, poor self-esteem and body image. (Girgis, et al., 2000). Women were
unequivocal in their response to the onset of cancer, many expressed feelings of distress,
shock, disbelief, emotional upset, worry, fear of the diagnosis and its possible outcome
(Banning , et al., 2009). In this study also nine out of ten women felt fear, worry when
diagnose the breast cancer and after that also sometimes due to physical and social changes.

5.2.2 Way of coping with stress and depression

Luckily these Sri Lankan rural women who are living with breast cancer hasn’t suffered
with depression anytime although they had stressful symptoms. They could cope with
stress mainly by engage in spiritual activities and with the family and community support.
Family members and closest people give a greater support to maintain the emotional
wellbeing. Similar finding has investigated by other researchers. Family members offer
emotional support like esteem, trust, concern, and listening, Instrumental support consists
of aid in kind, money, labor, and time and peers offer appraisal support that enhances the
individual’s self-esteem. (Katapodi, et al., 2002).

The development of cancer was a stimulus to strengthen religious beliefs and a coping
strategy that the women used for comfort, inner strength support during their troubled time
(Banning , et al., 2009). In this research, all the respondents’ biggest coping mechanism of
stress was the religious activity engagements. All the rural women in the unit of analysis
was Buddhists. Most of them has understood uncertainty and the truth of the life through
Buddhism teachings after the diagnosis of breast cancer. It was a great strength for them to
cope with the emotional issues. One woman mentioned that mediation was her best
mechanism of coping with turbulent mind.

So, the main coping strategies of stress were family and community support and engage in
religious activities according the views the respondents of this research.

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5.3 Family and Community Support
Family and community support were significantly described by the respondents of this
research study. It is clear that, rural women have supportive people around them rather than
people in urban areas. So, they are given good support except one respondent (DP-1).
Having a good support from family and community is big strength for these rural women
who are living with breast cancer. Rural women might be able to draw upon a number of
strengths to empower their responses to psychological and social stressors. These strengths
could include a pride in the achievements and traditions of rural living, a culture of self-
reliance, strong family connections, and a strong sense of community. On a positive note,
the women found significant support from within the informal support networks operating
in rural areas (McGrath, et al., 1999). These networks included family, friends and
community, and offered significant practical and emotional support to the woman and her
loved ones through the ordeal of breast cancer (McGrath, et al., 1999). To those women
from family, friends and neighbors in their communities, and felt that this support was very
important to their capacity to overcome their illness. (Leung, et al., 2014).

5.3.1 Family Support

Except DP-1, all other women had/has great support from the family members. Reasons
behind the unsupportive family members for that respondent was her husband is not at
home and he is not supportive, two daughters are married and having infants and two sons
haven’t a capability of understanding her difficulties; they are not completed their primary
education even. so, family support was a challenge for her. But she has received the support
from nearby people in the village to some extent financially and non-financially. Through
some western research studies also, it has revealed about non-supportive partners. Non-
supportive partner behavior can be even more powerful than positive support, leading to
emotional distress and maladaptive coping (Manne & Schnoll, 2001). Community support
was an important aspect of support for these rural women, who were experiencing breast
cancer without a supportive intimate partner (Sawin, 2002). The majority of women in this
study were housewives and therefore the disease had a significant impact on their ability
to undertake their household chores (Banning , et al., 2009). Husbands of some women has
expanded their role within the family due the illness of their wives. They have cooked,
wash the clothes of wife and children and manage the children’s school works also. Parents

65
and siblings also had look after these women significantly. Same findings have been
revealed by Pakistan researchers. For many women, the family support that was offered
both from immediate and extended family members, husbands and siblings was a positive
source of support. (Banning , et al., 2009).

5.3.2 Support through Social relations

All most all the women in the unit of analysis had/have good or considerable support from
the society. But the level of support they received differ from each other. Two women were
school teachers and there is a woman working in a bank who is a graduate. Those three
women had/has greater extent of social support because of the high social interaction.
Others were housewives with only general interaction with the society. So, their
educational level and employability has affected to the degree of social support. This type
of finding has revealed by group of another researchers. They mentioned that their study’s
social support scores differed significantly by educational level. Women who had only
grade school education reported significantly lower social support compared to those with
only high school education or those with graduate school education and women with
college or university education did not report significantly lower levels of social support
than those who attended graduate school (Katapodi, et al., 2002). Those women who had
greater level of social support also had the less difficulty in financial issues rather than
others.

5.4 Accessing to medical support and information

This is a major challenge of rural women who are living with breast cancer due to the lack
of developed health services in their areas. Living in a rural area means living away from
specialist health services, yet for these participants it also means living within a close-knit
community that provides significant emotional support and solace. Only one of ten
respondents mentioned that she had knowledge and information related to breast cancer
and its’ treatments prior to diagnosis. So, not having access to information is also a
challenge for these women who are living with breast cancer I rural areas. It is ironic that,
in the drive to highlight the significant social and economic problems that rural
communities are experiencing, the positive aspects of rural living are dismissed and
replaced with images of decline and hardship (Rogers-Clark, 2002-2003). Inadvertently,

66
this could actually be adding to the declining populations of rural areas and the inability of
rural communities to attract professionals like nurses and medical practitioners to their
areas. In relation to rural women with a history of breast cancer, it is vital that any
interventions seek to build on the strengths of rural communities in relation to lifestyle and
support, rather than assuming that rural communities are defined by their absence of
specialized services (Rogers-Clark, 2002-2003). This study also has determined that the
informal supports available in rural communities are often highly effective in assisting
people due to the lack of proper health services and information.

5.4.1 Accessing to health services

Travelling for medical treatments was/is a major challenge for these rural women. Only
one woman is taking treatment from Kandy national hospital. All others had/have to come
to Apeksha Hospital, Maharagama although diagnosis and basic treatment was done in
hospitals in their districts. Some of them have to travel more than 5-6 hours by bus or by
hiring a vehicle. As a positive sign, money for bus tickets are not taking from cancer
patients who are travelling to Apeksha Hospital, Maharagama by buses under Sri Lanka
Transport Board (SLTB) from long distance areas.This difficulty has been found by other
researchers also related to western country context. As noted by Gray, et al., 2003, many
of the women participating in the focus groups reported having to travel to cancer centers
in order to access treatment. For many this involved extensive distances, by car, plane, train
and/or bus. (Gray, et al., 2003)

Their distance from rural areas led to further hardships such as being separated from family
and friends at a time of heightened vulnerability, having to travel long distances for follow-
up care, and additional financial burdens arising from travel and accommodation costs
(Rogers-Clark, 2002-2003). Rural women travel further for treatment, creating increased
stress and financial burden. They also may encounter disturbances in work due to distance
to treatment and distance between home and place of medical care can also create problems
with social roles, such as caregiving (Sawin, 2002). Another researcher also has shared
similar finding through his research study. All but one of the participants had travelled
significant distances for surgery, radiotherapy and follow up care, and this was disruptive
and financially costly at a time of great personal upheaval (Katapodi, et al., 2002).

67
5.4.2 Accessing to information
In a meta-analysis of literature on women’ s experiences of breast cancer, Smyth et al
(1995) found that the literature consistently revealed inadequacies in the amount and
quality of information and support available to women who had been diagnosed with the
disease. The need to deal with this problem is highlighted by National Breast Cancer Centre
in their publication Clinical Practice Guidelines for the Management of Early Breast
Cancer (National Breast Cancer Centre 1995). Few studies have explored the extent to
which cancer patients’ perceived needs are being met across a range of issues such as
information provision or emotional wellbeing, despite their recognized importance. The
small body of existing needs assessment literature consistently suggests that cancer patients
experience high levels of unmet needs, particularly in relation to health information
(McGrath, et al., 1999). Lack of health information has negatively impact for these women.
All women except one, had got every information after going to a hospital. They even don’t
know what are the symptoms, available treatments, where to go for treatments and etc.

5.5 Coping with financial burden

Due to the rurality, these women have a challenge in coping with financial issues. Because
they need money for medicines, injections, treatment, travelling, foods and etc. In other
research studies related to breast cancer also have highlighted financial difficulty face by
rural women. Economic realities of rural life added extra urgency to the concerns voiced
by women in his research study (Gray, et al., 2003). It was very expensive for families, and
often led to financial difficulties with many families using all their savings to pay for
treatment and it was often related to loss to bread winners and income in the family
(Banning , et al., 2009).

5.5.1 Financial difficulties and Income level of the patient and the family
Three participants were in middle-income families while all others are in low-income
families. Most of them are housewives whose husbands are the only breadwinners. Due to
the rurality they are not easy to access health services quickly. As they have to travel long
distant for treatments, they have to incur more money for that. Women in middle-income
families could bear this difficulty to some extent. But not at all. Sometimes some of these

68
women had to get loans from others. One said that she cut and sold trees in the home to
earn money although she has a government job.

5.5.2 Financial support by outside parties.

As a positive point of being rural, these women have good supportive people around them.
So, those surrounding people have supported financially in many times. Women who have
greater interaction with the society has greater financial support rather than others.
Financial support from workplace has received for few respondents.

5.6 Feeling isolation

Isolation continued for some of the women unable to find support locally. Sometimes this
was because of a perceived lack-of-interest from others, while in other situations women
decided to isolate themselves in order to avoid being the topic of gossip. Women’s
experiences with hospital stay and post-treatment follow-up varied across the country.
Many felt they were sent home too soon, given the distance they needed to travel home and
the relative lack of medical/nursing supports available once they arrived home (Gray, et
al., 2003). Most of the times when they become helpless, they tend to be isolated and reduce
the interaction with the society. At the early period of diagnosis, they feel fear and helpless.
This isolation could be mostly identified in younger women rather than older ones. Other
researchers also could identify this finding in their researches. Many of the women who
participated in focus group discussions described having struggled with a sense of isolation,
both in their home setting and in the urban setting where they received treatment (Rogers-
Clark, 2002-2003).

5.6.1 Feeling helplessness

While some women didn’t feel helplessness due to the great family and community
support, some have been helpless due to many circumstances. When their husband not at
home, those women are difficult to cope with illness while managing all other things like
household activities, parenting ant etc. For many women, the inability to work efficiently
due to physical weakness was a constant reminder of the disease (Banning , et al., 2009).
Such women feel helpless rather than others.

69
5.6.2 Changes in social interactions
In interviews with both young and older women the issue of isolation was a common theme
that appeared to manifest itself 4-5 days after receiving chemotherapy. Women emphasized
the need to be alone, preferred not to talk or discuss issues with people and also experienced
a dislike of being surrounded by other people, because of the fear of being a topic for others
to gossiping. Similar finding has revealed by Banning, et al., 2009. Some of the women do
not like to attend to functions Women expressed that they disliked meeting people and
family members and preferred not to attend family functions and weddings (Banning , et
al., 2009). This common problem may be related to the experiences of women in relation
to the issue of torture (family members constantly gossiping about them which was a
constant reminder of their illness) and issues of extreme discomfort felt by women in
relation to relationship with close relatives (Banning , et al., 2009). But some older women
who had social interaction to a greater extent hadn’t much changes, they even went to the
job without any doubt after removing both breasts.

5.7 Spiritual Directions

Spiritual directions can be recognized as a main coping mechanism of stress and fear. All
the respondents were Buddhists. They have engaged in many religious activities with the
advises of elders and monks of the village temple. And also, as a positive note, some
religious activities have been organized in hospitals too in order to give a psychological
relief to the patients. Similar idea has given by other researchers too. Spirituality was a
source of comfort for women, it reduced their fear and uncertainty and gave them the
strength to fight the disease, tolerate the treatment and look to the future (Banning , et al.,
2009). People can draw strength from their faith or relationship with God, which positively
affects their ability to cope with cancer. (Wyk & Carbonatto, 2016).

5.7.1 Extent of engage in religious activities

Except one woman all others had a greater extent of engage in religious activities after the
diagnosis of breast cancer. They have practiced and done meditation, Pirith chanting, Bodhi
Pooja, Arms giving, reading religious books and etc. one respondent said that they believe
in myths also due to the helplessness that the patient and the family felt. But those were
not useful for any positive change of the patient. Other women had some influence from

70
people who in another religion to go through on their religious perspectives, but she has
rejected them and engage in religious activities according to buddhism teachings. Some
have prayed for gods. The same finding could be revealed by Banning, at al., 2009
regarding Muslim women with breast cancer in Pakistan. Although they are belonging to
two religions, they believe that they could have a relief through their religious observances.
For many women, their faith and confidence in Allah held the key to future developments,
life expectancy, living to see their children mature and ultimately being cured of cancer.
(Banning , et al., 2009).

5.7.2 Impact for Psychological Relief

Those women who are living with breast cancer had a greater psychological relief through
the spiritual directions. It was their coping mechanism. Another researcher also had the
same idea. Religious beliefs were viewed as a source of strength which has a positive
impact on their outlook (Taleghani, et al., 2006). They could cope with stress and fear.
Some were able to understand the truth and the uncertainty of the life.

5.8 Conclusion
In this chapter, findings under each research themes and codes has been discussed with
comparing to the current literature so as to answer the research questions of this study. In
the Last chapter, conclusion of the research, implications and recommendations are given
for future research studies.

71
 Chapter 06

Conclusion and Recommendations

6.1 Introduction
The findings of this study were testified in Chapter Four and discussed in detail in Chapter
Five by comparing them with relevant previous studies and theories reported in the
literature. In this concluding chapter, the main contributions of this study will be
summarized. The implications of the findings and recommendations for future health
service development will then be explored. Finally, the chapter concludes with a statement
of the limitations of the study and suggestions for future research.

6.1 Conclusion
This research was preliminary designed with the aims of discovering how Sri Lankan rural
women living with breast cancer responses to Social and Emotional challenges. There were
many prior literatures on Breast cancer and its social and emotional challenges faced by
rural women. But this study discovered specific and unique responses of women living
with breast cancer in Sri Lankan rural context. It couldn’t identify similar researches in Sri
Lankan context. So, the findings and the recommendations of this research will be highly
important for future researchers and to the development of health services related to breast
cancer in Sri Lanka.

The researcher selected the qualitative approach as methodology of this study. Information
needed for this study was collected in-depth, semi-structured interviews with breast cancer
patients and their relatives. The sample included ten number of rural women living with
breast cancer. Participants from Puttlam, Kurunegala, Kalutara, Galle, Kandy, Nuwareliya
and Anuradhapura that covers rural areas in Sri Lanka. Six interviews were done directly
with the patients and four were done with relatives of the patients.

Then the researcher identified six main themes that interprets the social and emotional
challenges of Rural women with breast cancer through prior literature and the existing
knowledge. Those themes were Stress and depression, Family and community support,
accessing to medical support and information, feeling isolation, Coping with financial

72
burden and Spiritual directions. Another twelve first level codes were developed under
above six research themes.

According to the responses made by participants, majority of the rural women living with
breast cancer in Sri Lanka are suffering with stress in different situations due to various
circumstances like physical changes like hair loss, weakening of the body, social issues,
unable of managing day to day activities, financial burden, and the thinking of the future
of the children. Luckily these Sri Lankan rural women who are living with breast cancer
hasn’t suffered with depression anytime although they had stressful symptoms. They could
cope with stress mainly by engage in spiritual activities and with the family and community
support.

Family and community support were significantly described by the respondents of this
research study. It is clear that, rural women have supportive people around them rather than
people in urban areas. So, they are given good family support except one respondent (DP-
1). Having a good support from family and community is big strength for these rural
women who are living with breast cancer. All most all the women in the unit of analysis
had/have good or considerable support from the society. But the level of support they
received differ from each other. Women that had/have greater extent of social support
because of the high social interaction. Their educational level and employability also have
affected to the degree of social support.

Accessing to medical support and information is a major challenge of rural women who
are living with breast cancer due to the lack of developed health services in their areas.
Some of the patients have to travel more than 5-6 hours by bus or by hiring a vehicle. It’s
so costly for them and stressful thing as well. As a positive sign, money for bus tickets are
not taking from cancer patients who are travelling to Apeksha Hospital, Maharagama by
buses under Sri Lanka Transport Board (SLTB). Lack of health information has negatively
impact for these women. All women except one, had got every information after going to
a hospital. They even don’t know what are the symptoms, available treatments, where to
go for treatments and etc. So, communication of breast cancer related information should
be increased within rural areas of Sri Lanka.

73
Three participants were in middle-income families while all others are in low-income
families. Most of them are housewives whose husbands are the only breadwinners. Due to
the rurality they are not easy to access health services quickly. As they have to travel long
distant for treatments, they have to incur more money for that. Women in middle-income
families could bear this difficulty to some extent. But not at all. So, all the participant is
facing to the financial difficulties. Women who have greater interaction with the society
has greater financial support rather than others.

While some women didn’t feel helplessness due to the great family and community
support, some have been helpless due to many circumstances. When their husband not at
home, those women are difficult to cope with illness while managing all other things like
household activities, parenting ant etc. So, they have to cope with isolation. some older
women who had social interaction to a greater extent hadn’t much changes after breast
cancer diagnosis, but women in younger age have a dislike of engage with the society.

Spiritual directions can be recognized as a main coping mechanism of stress and fear. All
the respondents were Buddhists. They have engaged in many religious activities with the
advises of elders and monks of the village temple. And also, as a positive note, some
religious activities have been organized in hospitals too in order to give a psychological
relief to the patients. Except one woman all others had a greater extent of engage in
religious activities after the diagnosis of breast cancer.

6.3 Implications and recommendations

Cancers specially like breast cancer is widening all over the world in recent years. Hence
a massive number of patients are suffering with such illnesses in their rest of life. There
seemed to be no a considerable number of research studies in line with breast cancer and
its challenges and responses in Sri Lankan rural context. So, it is important to identify their
responses to challenges for building up coping strategies in counseling and psychology.

Although the women with breast cancer gets recovered, they must live the rest of the life
with many side effects of socially, psychologically and physically as well. So, their
challenges remain with their life. Hence it is important to know how they react and response
to those challenges for themselves to build and rise again in their lives. From the

74
perspective of women, breast cancer and its treatments can impact to occur changes in their
roles and relationships within the family and in the society as a wife, mother, daughter,
sister or an employee.

Findings of this research can be applied to real world context when dealing with rural
women who are living with breast cancer. Sri Lankan rural women have good strength of
coping with the breast cancer, since any one couldn’t found with any depressed situations
although they have to suffer due to many difficulties and challenges. But the medical
services and information should be developed more. Rural women suffer when accessing
to medical services by travelling long distance. It keeps away them from their family
members and loved once. And also, more communication methods should be developed
within rural areas in share information related to breast cancer, its symptoms, treatments,
available services and etc. It is better if government authorities could take actions to hold
mobile clinics and medical check-ups in rural areas. Although they are available in urban
areas it is difficult those women to access it also it is costly for them.

Family and community support and spiritual directions should be further promoted so as
to maintain psychological well-being of the rural women living with breast cancer. Because
family and community support and the spiritual directions could be identified as major
mechanism of coping with stress, isolation and fear.

Future researchers can investigate more depth in to this study including women in urban
areas, different races, different religions, Professionals and workers in variety of
occupations also under many other research themes.

6.4. Summary
Sri Lankan rural women with breast cancer have suffered with many challenges in different
levels. This research was done under six themes that align with social and emotional that
they are facing. So, stress and depression, family and community support, accessing to
medical support and information, coping with financial burden, feeling isolation and
spiritual direction were discussed as the six themes coming under this research study. So,
this chapter conclude the whole research study by giving the conclusion, implications and
recommendation.

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Appendix 1: Interview Question Guideline

Living with Breast Cancer; Sri Lankan Rural Women’s Reflexive Responses to Social
and Emotional challenges.
I am HPNI Kumarasinghe who is reading for a Bachelor of Human Resources Management
(Special) Degree in Management Studies and Commerce Faculty of the University of Sri
Jayewardenepura and I hope to conduct my final year research study on “Living with
Breast Cancer; Reflective responses of Sri Lankan Rural women to social and emotional
challenges”.

The purpose of this short interview is to gather information by getting your valuable
feedback and ideas on this research topic. The confidentiality of the information you
provide is highly protected and it only used for academic purposes.

I do not expect any personal information other than the age, marital status, number children
and occupation.

Each patient is expected to interview for about 10-20 minutes, during that time he or she is
free to comment if there is any difficulty in commenting.

Participation in the interview is voluntary and there are no known or anticipated risks to
participate in the study.

If the patient feels uncomfortable to talk, family member or closest can provide feedback
and ideas.

I would greatly appreciate your willingness to participate in this interview and I would like
to express my gratitude for your participation.

Following are the interview questionnaires.

1. How old are you?

2. What district are you living in?

3. Marital status?

XII
4. Have children? If yes, how many children?

5. Are you employed? What is the occupation?

6. How long you have been diagnosed with breast cancer?

7. Are you currently undergoing treatment? Or is it recovering?

8. How did you feel when you heard it?

9. Do you have problems with stress, depression, etc. due to this condition? How did you
meet those challenges? Did you need medical help to overcome this situation? Or were you
able to get them out of your closets?

10. Have you received help from family and community members? Or did they challenge
or insult you? How did you respond?

11. How did you cope with problems that arise during the day-to-day running of your
family and work?

12. What are the facilities and difficulties you have when travelling to get treatments? Did
you have facilities to find out more about breast cancer and its treatment options?

13. What are the economic and financial difficulties faced by this ailment and its treatment?
How do you deal with them?

14. Does this condition make you feel lonely, helpless, alienated, uncomfortable or afraid?

15. Do you tend to be more religious? What is your view on the psychological support that
comes through it?

16. What are the physical, psychological and social changes that have resulted in this
cancer as a whole? How would you respond?

I have read all the above and would like to give information to this study.

Signature of the patient or family member ……………..…. Date…………………

XIII
Appendix 2: Ethical Considerations

පියයුරු පිළිකා සමඟ ජීවත් වීම; සමාජ හා චිත්තවේගීය අභිවයෝගයන්ට ශ්‍රී ලාාංකික
ග්‍රාමීය කාන්තාවන්වේ පරාවර්තක ප්‍රතිචාර.

එච්.පී.එන්.අයි.කුමාරසිංහ වන මා ශ්‍රී ජයවර්ධනපුර විශ්ව විද්‍යාලයේ, කළමනාකරණ අධයයන හා

වාණිජ විද්‍යා පීඨයේ විද්‍යායේදී මානව සම්පත් කළමනාකරණ (වියශ්ෂ ) උපාධිය හද්‍ාරමින් සටින
අතර මායේ අවසන් වසර යේවල පර්යේෂණය “පියයුරු පිළිකා සමඟ ජීවත් වීම; සමාජ හා
චිත්තයේගීය අභියයෝගයන්ට ශ්‍රී ලාිංකික ග්‍රාමීය කාන්තාවන්යේ පරාවර්තක ප්‍රතිචාර.”යන
පර්යේෂණ මාතෘකාව යටයත් අධයනයේ කිරීමට බලයපායරාත්ු යවමි.

මා යමම සුළු සම්ුඛ පරීේෂණයයන් අරුණු කරනු ලබන්යන් ඉහත සඳහන් පර්යේෂණ
මාතෘකාවට අද්‍ාළව ඔබයේ වටින ප්‍රතිචාර හා අද්‍හස් ලබගැනීම මඟින් යතාරුරු එේ රැස්
කරගැනීමයි.ඔබ විසන් ලබායද්‍න යතාරුරු වල රහසයභාවය ඉතා ඉහළින් ආරේෂා කරගනු ලබන
අතර අධයයන කටයුු සඳහා පමණේ භාවිතා කරනු ලැයේ.

යරාගියායේ වයස, විවාහක අවිවාහක බව, දරුවන් සංඛ්‍යාව සහ රැකියාව හැරුණුයකාට යවනත්
කිසම යපෞද්ගලික යතාරුරේ අයපේෂා යනාකරමි.

එේ යරෝගියයේ සඳහා විනාඩි 10-20ක පමණ කාලයේ සම්ුඛ පරීේෂණය කිරීමට

බලයපායරාත්ු වන අතර ඒ කාලය ුළ අද්‍හස් ද්‍ැේවීමට කිනම් යහෝ අපහසුතාවයේ
ඇතිවුවයහාත් ඉන් ඉදිරියට අද්‍හස් ද්‍ැේවීයමන් ඉවත් වීමට සම්පුර්ණ නිද්‍හස ඇත.

සම්ුඛ පරීේෂණයට සහභාගී වීම ුළුමනින්ම ස්යේච්ඡායවන් සදු වන අතර අධයයනයට සහභාගී
වීමට ද්‍න්නා යහෝ අයේේිත අවද්‍ානම් යනාමැත.

යරෝගියාට යමම සම්ුඛ පරීේෂණය සඳහා අද්‍හස් ද්‍ැේවීමට අපහසුතාවයේ ද්‍ැයනන්යන්නම්

ඇයයේ කැමත්ත පරිදි පවුයේ සමීපතම අයයකුට අද්‍හස් ද්‍ැේවීමට හැකියාව ඇත.

යමම සම්ුඛ පරීේෂණයට සහභාගි වීම සඳහා ඔබයේ කැමත්ත මා ඉහළින් අගය කරන අතර
ඔබයේ යහෝ ඔබයේ සමීපතමයයකුයේ සහභාගීත්වය සඳහා මායේ කෘතඥතාවය පළකර සටිමි.

සම්ුඛ පරීේෂණයට අද්‍ාළ ප්‍රශ්නාවලිය පහතින් ද්‍ැේයේ.

XIV
 1. ඔබයේ වයස කීයද්‍?
2. ඔබ ජීවත්වන දිස්ීේකය කුමේද්‍?
3. විවාහක අවිවාහක බව?
4. ද්‍රුවන් සටීද්‍? සටී නම් ද්‍රුවන් ගණන?
5. ඔබ රැකියාවක නියුේතව සටිනවාද්‍? රැකියාව කුමේද්‍?
6. පියයුරු පිළිකාවේ තියයන බව ද්‍ැනයගන යකාපමණ කාලයේ යවනවද්‍?
7. ද්‍ැනට ප්‍රතිකාර ලබමින් සටිනවාද්‍? නැතිනම් සුවය ලබා සටීද්‍?
8. එය ද්‍ැනගත් විට ඔබට යමාන වයේ හැඟීමේද්‍ ද්‍ැනුයන්?
9. යමම යරෝග තත්ත්වය නිසා ආතතිය, විශාද්‍ය වැනි ගැටලු ඔබට ඇති උනාද්‍? ඒ අභියයෝග
වලට ුහුණ දුන්යන් යකයස්ද්‍? යමම තත්ත්වයයගන් මිදීමට වවද්‍ය ප්‍රතිකාර වල සහය
අවශය වූවාද්‍? නැතිනම් සමීපතයන්යේ සහයයෝයයගන් ඒවා මග ඇර ගැනීමට හැකි වූවාද්‍?
10. පවුයේ අයයගන් සහ සමාජයේ පුද්ගලයන්යගන් ඔබට උද්‍ේ උපකාර යහාඳින් ලැබුණද්‍?
එයස් නැතිනම් ඔවුන්යගන් ඔබට අභියයෝග, අපහාස එේල උනාද්‍? ඒවාට ඔබ ප්‍රතිචාර
ද්‍ැේවුයේ යකායහාමද්‍?
11. පවුයේ එදියනද්‍ා වැඩ කටයුු කර යගන යායම්දී සහ රැකියා කටයුු කරයගන යායම්දී මු
වුන ගැටලු සඳහා ඔබ ුහුණ දුන්යන් යකයස්ද්‍?
12. ප්‍රතිකාර සඳහා යාමට ඒමට තිබුන පහසුකම් හා අපහසුකම් යමානවාද්‍? පියයුරු පිළිකාව
සහ එහි ප්‍රතිකාර ක්‍රම පිළිබඳ යතාරුරු ද්‍ැනගැනීමට පහසුකම් තිබුණද්‍?
13. යමම යරාගී තත්ත්වය නිසා සහ එහි ප්‍රතිකාර යවනුයවන් ුහුණ දුන් ආර්ික සහ තවමත්
ුහුණයද්‍න ආර්ික අපහසුතාවයන් යමානවාද්‍? ඒවාට ඔබ ුහුණ යද්‍න්යන් යකයස්ද්‍?
14. යමම යරෝග තත්ත්වය නිසා තනිකමේ, අසරණකමේ, අන් අයයගන් ඈත්ව සටියම්
උවමනාවේ, සමාජයට ුහුණ දීමට අපහසුවේ යහෝ බයේ ආදිය තියයනවද්‍/ තිබුණද්‍?
15. ඔබ ආගමික කටයුු සඳහා වැඩි වශයයන් නැඹුරු උනාද්‍? ඒ ුළින් ලැබුන මානසක
සහනය පිළිබඳ ඔබයේ අද්‍හස කුමේද්‍?
16. සමස්ථයේ යලස යමම පිළිකා තත්ත්වය යහ්ුයවන් ඔබ ුළ ඇතිවූ කායික, මානසක හා
සමාජීය යවනස්කම් යමානවාද්‍? එවාට ඔබ ප්‍රතිචාර ද්‍ේවන්යන් යකයස්ද්‍?

ඉහත සඳහන් සියලු විස්තර කියවූ අතර වමම අධ්‍යනය සඳහා අදහස් ලබාදීමට මාවේ කැමත්ත පල
කර සිටිමි.

යරෝගියායේ යහෝ පවුයේ අයයකුයේ අත්සන............................... දිනය ………………

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