Psychosocial needs and their determinants among patients with cancer
1Department of Family and Community Medicine, Davao Regional Medical Center, Apokon, Tagum City;
2Department of Family and Community Medicine, Southern Philippines Medical Center, JP Laurel Ave, Davao City
Correspondence Kristine Israel, email@example.com
Received 26 January 2016
Accepted 13 April 2016
Cite as Israel KC, Baruiz CP, Solis SH. Psychosocial needs and their determinants among patients with cancer. SPMC J Health Care Serv. 2016;2(1):1. http://n2t.net/ark:/76951/jhcs79xnr8
The global burden of cancer is increasing. In 2012, a total of 14 million new cases and 8 million deaths of cancer were recorded. If the trend continues, it has been predicted that deaths from cancer worldwide would reach as high as 13.1 million in the year 2030.1
In the Philippines, the third leading cause of morbidity and mortality is cancer.2
In 2005, cancer ranked number 5 in mortality in Davao Region and number 3 in Davao City alone.3
Despite the current advancements in early detection and treatment of different cancer types, patients with cancer face many consequences including physical impairment, disability, and incapacity to perform daily activities. This places them at risk for developing psychosocial problems unique to patients living with cancer.4
Patients with cancer must cope with the stress induced by the physically demanding and sometimes life threatening diagnostic and therapeutic approaches to the illness. This causes emotional and mental health problems, which can lead to a significant amount of psychosocial needs. The stress brought about by health care management of cancer is intensified by the existence of any pre-existing or underlying psycho-social stressors. These stressors are often closely linked, resulting from and contributing to each other.5 6
In the viewpoint of the patients and their caregivers, these psychosocial needs must be met lest we imperil prolonging life without sufficiently addressing the quality of that life.5
A study done in the United Kingdom was able to identify the psychosocial needs and significant unmet needs of patients with cancer and their carers.5
The most important needs identified in the study included finding quality health care, acquiring information about the course of the disease and its management, gaining social support, and maintaining independence. Most of the unmet needs were within the practical, self-identity, and emotional domains. Patients who were younger, having long-standing illnesses or disabilities, socio-economically disadvantaged, not having a faith, having difficulty in talking freely to a carer about the cancer, having social activities disrupted by the cancer, and having financial difficulties were at greater risk for having unmet needs.5
The prevalence and attributes of psychosocial needs can vary in different cultural contexts. The associations between patient characteristics and their psychosocial needs are also worth pursuing. A greater understanding of the issues in a particular cultural and social setting will help shape targeted services for clients in health care.
In this study, we wanted to determine the information, support, emotional, and practical needs of patients with cancer with the use of a structured psychosocial needs questionnaire. We also wanted to identify the sociodemographic and clinical determinants of unmet psychosocial needs among patients with cancer.
Study design and setting
We conducted a cross-sectional study among patients with cancer admitted or seen at the outpatient department in the Davao Regional Medical Center (DRMC) in Tagum City. DRMC is a 600 inpatient bed capacity tertiary hospital with an Outpatient Cancer Center that caters an average of 50 patients per day, mostly coming from different provinces in Mindanao.
Male and female patients who were at least 18 years old, admitted or seen at the outpatient department in DRMC, with established and disclosed diagnosis of cancer at any stage, and gave written consent were eligible to participate in the study. We excluded patients who were unable to answer the questionnaires or too weak to participate in the study. We calculated the ideal sample size to compute for odds ratio (95% CI) of having an unmet psychosocial need (outcome) for selected exposures, based on the assumptions that: (1) the ratio of unexposed to exposed is 1; (2) the outcome occurs in 50% of the participants in the unexposed group; (3) the outcome occurs in 75% of the participants in the exposed group; and (4) the odds ratio to be detected as significant is 3. In a computation of odds ratio carried out at a 95% confidence level, a sample size of 116 will have 80% power of rejecting the null hypothesis (no significant increase or significant decrease in the odds ratio of having the outcome) if the alternative holds. We were able to recruit a total of 116 eligible participants into the study.
A psychosocial needs inventory (PNI) questionnaire was used to gather data. The questionnaire was based on the 48-item Psychosocial Needs Inventory questionnaire from a previous study done in Lancaster University, United Kingdom.5
The authors of the Lancaster study gave us permission to utilize, modify, and translate the original PNI questionnaire.
A panel, which consisted of three eligible patients with cancer, two resident physicians in Family and Community Medicine, and a fellow in Hospice and Palliative Medicine in Southern Philippines Medical Center, reviewed and validated the contents of the questionnaire. We modified the questionnaire based on the comments and suggestions made by the panel. We translated the questionnaire to Cebuano and Tagalog versions. A licensed educator then back-translated the non-English versions to English. We pilot tested the questionnaires among 10 patients not included in the main sample. Revisions on the translations were based on the patients' comments on the pilot test versions of the questionnaires. Final versions of the PNI questionnaire in English, Cebuano, and Tagalog were produced following iterations.
Each language version of the final study questionnaire was composed of three sections. The first section contained questions on the sociodemographic profile of the patient, including age, sex, educational attainment, employment status and family monthly income. Questions in the second section were about the patient's current illness, duration of illness, and the treatments received. The last section was the psychosocial needs inventory, composed of 22 need items grouped into four psychosocial domains—namely, information needs (4 items), support needs (3 items), emotional needs (9 items) and practical needs (6 items). The information domain consisted of items that may be necessary for the individual to make decisions towards contributing to one's treatment. The support domain contained items that can potentially strengthen the psychosocial resources of the individual. Items in the emotional domain pertained to affective aspects in the individual's experiences that can move life forward in a positive direction. The practical domain contained items that can help the individual think and work productively, and carry out the basic activities of daily living. In answering the last section of the questionnaire, the patient would first rate the importance of each need item on a scale of 1 to 5, with 1 being "not at all important," and 5 being "very important." Subsequently, the patient would rate his or her level of satisfaction in relation to each need item on a similar scale of 1 to 5, with 1 being "not at all satisfied," and 5 being "very satisfied." The importance rating of the needs in each psychosocial domain was determined by getting the average rating of the items within the domain. We considered a need item as unmet if the satisfaction rating was ≤3. We considered the entire domain as unmet when at least one need item in the domain was unmet.
After explaining the study to eligible patients and obtaining their informed consent, we provided them with the study questionnaire in the version of their choice. We gave ample time for the patients to answer the questionnaires. While the participants were answering the questionnaires, we were readily available to answer their queries.
We summarized continuous data, including the importance ratings of psychosocial needs, as means ± standard deviations. We summarized categorical data, including number of patients with unmet needs, as frequencies and percentages. We used Pearson’s correlation to measure the degree of association between importance ratings and continuous data, and we used Spearman correlation to measure the association between importance ratings and ordinal data. We used logistic regression to determine the odds ratio (95% confidence interval) of having an unmet psychosocial domain need for the following pre-specified patient characteristics: being 50 years old or older, being male, having lower household income (lower than 30,000 PHP, the median household income), being unemployed, being in late stage family life (launching family or family in later life stage of the family life cycle), having stage IV cancer, and having cancer for less than 1 year (the median duration of illness). We considered two-sided p-values of <0.05 as statistically significant.
We were able to recruit a total of 116 patients with cancer into the study. The sociodemographic profile and clinical characteristics of the participants are shown in Table 1. The mean age of the participants was 50.28 ± 10.28 years. There were 34 (29.31%) males and 82 (70.69%) females. Most of the patients (73/116, 62.93%) were unemployed and 51 (43.97%) belong to a family in the launching stage. The mean monthly household income was 26,284.48 ± 15,776.59 PHP. The mean duration of the patient’s illness was 19.10 ± 18.33 months. Most of the patients had either stage IV (38.79%) or stage III (36.21%) cancer.
Sociodemographic and clinical characteristics of participants
|Mean age ± SD, years
||50.28 ± 10.28
|Sex distribution, frequency (%)
|Employment status, frequency (%)
|Mean household income ± SD, PHP*
||26284.48 ± 15776.59
|Stages of family life cycle, frequency (%)
| With young children
| With adolescents
| Later life
|Mean duration of illness ± SD, months
||19.10 ± 18.33
|Cancer stage, frequency %
| Stage II
| Stage III
| Stage IV
|* PHP = Philippine pesos.
Table 2 presents the results of the psychosocial needs inventory among the participants, and Box 1 summarizes the top five psychosocial needs ranked in terms of importance and in terms of frequency of unmet needs. Needs in the information domain had the highest importance rating among all the needs per psychosocial domain (mean need rating = 4.44/5 ± 0.39), followed those in the support domain (4.39/5 ± 0.32), the emotional domain (4.32/5 ± 0.35), and the practical domain (4.08/5 ± 0.28). While the overall importance ratings of need items in all domains were relatively high, ratings of "help in considering my sexual needs" (emotional domain) and "help with child care" (practical domain) were lower compared with those of the other need items, with mean scores of 3.34/5 ± 1.05 and 3.28/5 ± 0.87, respectively. Needs in the practical domain had the highest frequency of being unmet (107/116, 92.24%), followed by those in the emotional domain (103/116, 88.79%), information domain (63/116, 54.31%) and support domain (49/116, 42.24%).
Psychosocial needs inventory, with need items per domain arranged in terms of importance rating
Mean ± SD
| Advice on what other services and help are available
||4.56 ± 0.73
| Opportunities to participate in choices around treatment
||4.54 ± 0.62
| Information about treatment plans, medications and side effects
||4.34 ± 0.54
| Easy and quick access to health professionals who have time to discuss issues with me and honest information
||4.32 ± 0.60
| Domain summary†
||4.44 ± 0.39
| Support from family
||4.46 ± 0.53
| Support from health care professionals
||4.44 ± 0.64
| Support from friends
||4.27 ± 0.52
| Domain summary†
||4.39 ± 0.32
| Spiritual support
||4.78 ± 0.50
| Help with anger
||4.47 ± 0.65
| Help with my fears
||4.47 ± 0.62
| Help with finding a sense of purpose and meaning
||4.40 ± 0.62
| Support in dealing with changes in my body of the way I look and in the sense of who I am
||4.38 ± 0.67
| Help in maintaining a sense of control in my life
||4.35 ± 0.58
| Hope for the future outcomes
||4.35 ± 0.55
| Help in considering my sexual needs
||3.34 ± 1.05
| Opportunities for meeting others who are in similar situation
||4.34 ± 0.68
| Domain summary†
||4.32 ± 0.35
| Help with transport
||4.40 ± 0.59
| Help with housework and daily activities
||4.31 ± 0.65
| Advice about food and diet
||4.18 ± 0.60
| Help with financial matters
||4.17 ± 0.61
| Help with any distressing symptoms
||4.12 ± 0.53
| Help with child care
||3.28 ± 0.87
| Domain summary†
||4.08 ± 0.28
|* 1=least important; 5=most important.
** Rating given to the item was 1 ("not at all satisfied"), 2 ("not very satisfied"), or 3 ("neither satisfied nor unsatisfied").
† The domain summary value for importance was taken from the mean importance scoring for all the need items within the domain. The entire need domain was considered unmet if at least one need item within the domain was unmet.
Top 5 psychosocial needs ranked in terms of importance and frequency of unmet needs
|1. Spiritual support
2. Advice on what other services and help are available
3. Opportunities to participate in choices around treatment
4. Help with anger
5. Help with my fears
|1. Help with financial matters
2. Help with my fears
3. Help in considering my sexual needs
4. Spiritual support
5. Help with anger
Correlations between characteristics of patients and the mean importance ratings of the needs within the psychosocial domains are shown in Table 3. Age and duration of illness were inversely proportional to the mean importance ratings of information needs and emotional needs (r=-0.364, p<0.001 and r=-0.25, p=0.006, respectively). Household income (r=0.233, p=0.0118) was directly proportional, while stage of family life cycle (r=-0.463, p<0.001) and stage of the cancer (r=-0.289, p=0.002) were inversely correlated with mean importance ratings of emotional needs.
Correlations between characteristics of patients and mean importance ratings of needs within the psychosocial domains
||Correlation coefficient (p-value)
|Stage in family life cycle‡
|Stage of cancer‡
|Duration of illness†
|* Statistically significant.
† Using Pearson r.
‡ Using Spearman rho.
Table 4 shows the comparison of mean importance ratings of the needs per psychosocial domain between males and females, and between employed and unemployed patients. Employed patients gave higher importance rating to the needs in the emotional domain compared to unemployed patients (4.45 ± 0.25 versus 4.24 ± 0.38, p=0.0017). Importance ratings in the rest of the needs per domain did not significantly differ between males and females, and between employed and unemployed patients.
Mean importance ratings of needs per psychosocial domain, according to sex and employment status
|Means ± SD
||Means ± SD
||Means ± SD
||Means ± SD
||4.40 ± 0.38
||4.46 ± 0.26
||4.29 ± 0.29
||4.14 ± 0.27
||4.45 ± 0.39
||4.36 ± 0.33
||4.33 ± 0.37
||4.05 ± 0.28
||4.48 ± 0.34
||4.34 ± 0.35
||4.45 ± 0.25
||4.02 ± 0.29
||4.42 ± 0.41
||4.42 ± 0.30
||4.24 ± 0.38
||4.11 ± 0.27
|* Statistically significant.
The univariate cross-sectional odds ratios of having unmet needs per domain for selected sociodemographic characteristics are presented in Table 5. Odds ratios of having unmet information needs were significantly high among patients ≥50 years old (OR=3.08, 95% CI 1.43 to 6.66; p=0.0042), without employment (OR=3.37, 95% CI 5.25 to 34.03; p<0.0001), in late-stage family life (OR=34.21, 95% CI 4.44 to 263.64; p=0.0007), and with stage IV cancer (OR=3.18, 95% CI 1.43 to 7.05; p=0.0045). Similarly, the odds ratios of having unmet support needs were significantly high among patients ≥50 years (OR= 2.39, 95% CI 1.12 to 5.08; p=0.0237), with lower household income (OR=3.23, 95% CI 1.50 to 6.96; p=0.0028), who were unemployed (OR=2.25 , 95% CI 1.01 to 4.98; p=0.0465), and in late-stage family life cycle (OR=3.42, 95% CI 1.37 to 8.56; p= 0.0085). Finally, the odds ratio of having unmet emotional needs was significantly high among patients with lower household income (OR=5.19, 95% CI 1.10 to 24.55; p=0.0379).
Univariate cross-sectional odds ratios of having unmet needs per domain for selected sociodemographic characteristics
|Odds ratios (95% CI)
||Odds ratios (95% CI)
||Odds ratios (95% CI)
||Odds ratios (95% CI)
|Age 50 years or older
||3.08 (1.43 to 6.66)
||2.39 (1.12 to 5.08)
||0.66 (0.21 to 2.12)
||1.69 (0.40 to 7.11)
||2.20 (0.95 to 5.08)
||1.32 (0.59 to 2.95)
||5.66 (0.71 to 45.35)
||1.49 (0.29 to 7.58)
|Lower household income†
||3.23 (1.50 to 6.96)
||5.19 (1.10 to 24.55)
||13.37 (5.25 to 34.03)
||2.25 (1.01 to 4.98)
||0.47 (0.12 to 1.82)
||0.46 (0.09 to 2.32)
|Late stage family‡
||34.21 (4.44 to 263.64)
||3.42 (1.37 to 8.56)
|Stage IV cancer
||3.18 (1.43 to 7.05)
||1.81 (0.85 to 3.86)
|Less than 1 year illness§
||0.86 (0.41 to 1.80)
||1.49 (0.70 to 3.14)
||0.57 (0.18 to 1.81)
||0.87 (0.22 to 3.44)
|* Statistically significant.
** Undefined odds ratio.
† Lower than 30,000 PHP, the median monthly household income.
‡ Launching family or family in later life stage of the family life cycle.
§ Less than 12 months, the median duration of illness.
In this study, we found out that psychosocial needs in the information domain are the most important needs for patients with cancer. Odds ratios of having unmet information needs were significantly high among patients who were older, unemployed, in the late-stage family life, and with stage IV cancer. Odds ratios of having unmet support needs were also significantly high among those with lower household income, unemployed and in late-stage family life. Odds ratios of having unmet emotional needs was significantly high among patients with lower household income.
Strengths and limitations
Through this study, we are able to glean patients’ perceptions of the importance of the psychosocial aspects of their lives in relation to their illness, as well as data on whether the needs attached to those psychosocial aspects have been addressed. We were also able to determine some demographic and clinical characteristics that can reasonably alert clinicians about the likelihood of certain needs to be unmet. This is different from mainstream psycho-oncology studies, which focus more on the psychological morbidities as a consequence of cancer.5
Furthermore this study has a more comprehensive approach to psychosocial needs and their determinants performed in a local setting, compared to previous studies which only dealt with particular dimensions of needs, and were done in certain tumor-specific populations.7 8 9
A limitation to this study is that it is more quantitative than qualitative. We adapted a tool with fixed questions, and although the process of modifying it was qualitative in nature, the final questionnaire that we administered to the study participants was quantitative. Quantitative studies may fall short in capturing the nuances of psychosocial needs, especially when cultural contexts of the needs will have to be accounted for. Because the questionnaire we used had fixed questions, our results are likely to miss unquantifiable needs or attributes of those needs.
Overall, the needs in the information domain were rated to be the most important psychosocial needs, followed by those in the support, emotional and practical domains. This is similar to the results of the Lancaster study where information and support domains had higher mean scores compared to emotional/spiritual and practical categories.5
The factors for gaining information services are complex. Patients' preferences for information have been attributed to their coping strategies or attitudes towards managing their own illness.10
In a previous study, three attitudes that limited a patient’s desire for more information have been identified: faith in their doctor's medical expertise, hope for a normal life, and charity to fellow patients.10
In our study, age and duration of illness had significant inverse relationships with the importance of information needs. Older patients may have been used to a doctor-centered practice, wherein information is gained solely from the physician, whereas younger patients today find greater use of alternative independent information services (i.e. the Internet).
Among the individual items explored in our PNI, the most important rated need was "spiritual support," which was different from the study done in Lancaster where "confidence in the health professional I meet" was the most important. Nonetheless, our finding was consistent with that of a previous study done in the Philippine General Hospital, which reported spiritual support as the most pressing need of terminally-ill geriatric cancer patients.9
The need for spiritual support is attributed to the Filipinos' deep sense of religiousness and belief that a supreme power can alleviate their suffering. Child care was ranked the least important psychosocial need. This was because most of the patients in this study belong to families in the launching and later life family cycle stage.
The domain with the highest frequency of unmet needs was the practical domain. The item in the practical domain with the highest frequency of unmet need was "help with financial needs." This was expected, as most of the patients in this study were unemployed and had relatively lower household income. In the Philippines, where medical expenses for accessing health care for late-stage cancer are usually from out-of-pocket spending, many patients with cancer experience economic hardships (i. e., 56% suffering financial catastrophe a year after being diagnosed).11
Health expenditure for cancer has been reported to be higher than the annual family income, and patients would ask financial assistance from family and/or friends, use savings, take out loans, sell assets, and seek financial assistance from charitable institutions.11
The domain with the least frequency of unmet psychosocial needs was the support domain. This can be attributed to the fact that Filipinos are known to have closely knit families and communities who are usually ready to help the patient in difficult times. The lowest unmet need item was information about treatment plans, medications and side effects. The high satisfaction rate for information need is expected since all patients included in this study have sought the services of a tertiary hospital with cancer care.
In this study, importance of information and emotional need domains were identified to be significantly correlated with certain sociodemographic characteristics. Importance of the information needs is inversely correlated with age and the duration of illness. This means that younger patients and those recently diagnosed with cancer are more hopeful towards the outcome10
and more proactive in the decision making process about treatment approaches. This can also mean that, among older patients, the task of acquiring information about the illness, the financial burden, and the decision making in relation to the illness are delegated to younger family members.
The importance of emotional needs domain was inversely correlated with age, family life cycle stage, cancer stage and duration of illness. On the other hand, income is directly correlated with the emotional needs domain. The affective aspects in the individual's experiences that can move life forward in a positive direction may be more important among younger patients, patients with families in earlier family life cycle, and among patients in the early stage of the disease.
Patients older than 50 years old and patients in the late stages of family life are significantly at risk of having unmet information needs. Although information need was initially found to have lesser importance among older patients in comparison to younger patients, information needs still turned out have high frequency of being unmet among older patients. Another study reported about lower expectations from health services among older persons,12
but our findings may reflect the need to address unmet information needs among older persons despite apparent delegation of acquisition of information to younger family members. Support need was also found to be at risk of being unmet in this subgroup of patients. Support domain has the least frequency of unmet psychosocial need, however our findings suggest that older patients may still lack support from immediate family members especially if these members have families of their own.
Patients with lower household income and unemployment are also at risk for having unmet support and emotional needs. Psychosocial needs may vary across different socioeconomic groups.5
In fact affluence has been previously reported to affect importance of psychosocial needs.5 13 14
More well-off patients have greater demands and expectations from the services of health care providers, information sources, and informal social support groups.13 14
In contrast, patients with lower household income and those who are unemployed would have difficulty in acquiring these needs because more practical and financial issues are usually addressed first.5
Additionally, patients who are unemployed are also at risk for unmet information needs. For this subgroup of patients, access to health care and information may be difficult as previously discussed.
Patients with stage IV cancer are at risk of having unmet information needs. In a previous study, most of the physicians would prefer to disclose information about the illness first to the relatives of terminally-ill patients because they feel that patients do not want disclosure. It is the patient's relatives who would then decide whether to tell the patient with terminal ill cancer.15
Our findings however was more congruent with another study, which reported that patients wanted to be informed of their illness and wanted to be included in the decision making.16
This is also similar to other studies, which reported that the level of need increases as health status declines.5 17
Our findings in this study can be improved by conducting further studies that utilize qualitative methods to explore the contexts of the findings and provide a deeper understanding on the interrelatedness of patients' characteristics and their psychosocial needs.
Although this study was done among patients with cancer, the psychosocial needs identified in this study may also be present in patients with other chronic debilitating illnesses, the same sociodemographic characteristics, similar cultural backgrounds and similar experiences with health care. In general, it is important that these unmet psychosocial needs and their determinants be addressed, as they may also affect the patients' quality of life and their ability to deal with the consequences of their illnesses.
In the light of our findings on the interrelationships of certain patient characteristics and unmet psychosocial needs, we recommend: 1. emphasizing the communication of information about the nature of illness and options on treatment and other services among older patients, those with advanced cancer, those who are unemployed, and those who belong to families in late-stage family life; 2. involving all patients in decision making with regards to their health care; and 3. screening for unmet support and emotional needs with the use of family tools [i.e., Family APGAR (A
ffection, and R
ducational, and M
and FICA (F
aith and belief, I
ommunity, and A
ddress in care)20
] especially among older patients, those in late stage family life cycle, those who are unemployed and with low household income.
Patients with cancer consider information needs to be of highest importance among the psychosocial needs related to the experience of the disease. Being 50 years or older and having stage IV cancer significantly increased the odds ratio of having unmet information needs. Being unemployed and belonging to a family in late-stage family life significantly increased the odds ratio of having unmet information needs and support needs. Having a low household income significantly increased the odds ratio of having unmet support needs and emotional needs.
We would like to extend our heartfelt gratitude to all the people who made this study possible, namely, the consultants and staff of Cancer Center for Mindanao of Davao Regional Medical Center (DRMC), the consultants and staff of Family and Community Medicine of DRMC, Dr Alvin Concha, Dr Ma Elinore Concha, and all the patients who participated in this study.
This study was reviewed and approved by the Department of Health XI Cluster Ethics Review Committee (DOHXI CERC reference P14040101).
Supported by personal funds of the authors
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