Abstract
Background: Despite therapeutic advances, cancer remains a disease with a huge impact worldwide. Exercise and increased physical activity (PA) not only prevent cancer but also mitigate the effects of the disease and treatment-related complications. No research is currently available regarding the knowledge, attitudes and practices (KAP) of individuals dealing with prostate, breast and colorectal cancer regarding exercise and/or PA in the Free State.
Objectives: To describe the KAP of individuals dealing with prostate, breast and colorectal cancer regarding exercise and PA.
Method: An observational, descriptive, cross-sectional study, using a self-developed KAP survey for prostate, breast and colorectal cancer patients, was conducted. The research was performed at the Universitas Annex Oncology ward and clinic, and 70 individuals dealing with cancer consented to participate during the data collection period.
Results: Most participants knew that heartbeat (79.7%) and breathing (74.3%) increased with exercise. Many participants reported that, on average, they performed exercise two (30.0%) or three times (30.0%) a week at home, with the duration, on average, of 10–20 min per session (43.6%) and less than 10 min (20.5%). Most participants (91.9%) indicated the importance of PA for their health and/or life, while 90.8% liked doing PA regularly.
Conclusion: Although individuals dealing with cancer engaged in exercise and/or PA, they did not meet the suggested minimum requirements. Psychological barriers to exercise and/or PA are treatable factors, highlighting the importance of a multidisciplinary approach.
Clinical implications: Cancer care should include advice on exercise and/or PA, while the feasibility of exercises and collaborative goal setting should be considered.
Keywords: cancer; KAP study; exercise; physical activity; physiotherapy; advice.
Introduction
Significant advances in treatment shape the global cancer landscape. Yet, cancer remains a debilitating disease and a major health problem around the world (Bray et al. 2021). Each year, millions of people, irrespective of age, gender and race, are diagnosed with cancer, and a large proportion eventually succumb to the disease or its complications (GBD 2017). Cancer incidence rates in sub-Saharan Africa are projected to increase by more than 92% by 2040 (International Agency for Research on Cancer 2020).
Although incidence rates remain higher in high-income countries (HICs) than in resource-constrained low- and middle-income countries (LMICs), survival rates are notably lower in the latter (Ferlay et al. 2013; Roser & Ritchie 2019; Soerjomataram et al. 2023), with some reasons cited as limited healthcare infrastructure and shortages of oncology specialists (Knaul et al. 2018). In Africa, the 3-year survival rate of women with breast cancer was estimated to be 80% in South Africa and 61.7% in Zimbabwe (Soerjomataram et al. 2023). This is less than the 3-year survival rate in Central and South America, where the survival rates range between 80% and 90% (Soerjomataram et al. 2023).
Several behavioural (lifestyle) cancer risk factors, such as smoking, physical inactivity and obesity, are increasingly prevalent in LMICs. This trend is primarily attributed to rapid urbanisation, mechanisation of labour and transport, shifts in dietary patterns and changing gender roles associated with economic transition (Bray et al. 2018; Popkin, Adair & Ng 2012; Torre et al. 2016). These factors contribute significantly to the rising burden of non-communicable diseases, including cancer, in these settings.
Undoubtedly, the burden of cancer, both personal and societal, is enormous, given cancer-related and treatment-associated physical and psycho-emotional adverse effects (American Psychiatric Association 2013; Bower 2014). These effects may persist after completion of the cancer treatment (Bower 2014; Reinertsen et al. 2017) and lead to long-term decreased function and physical activity (PA) levels (Behrens & Leitzmann 2013; Gogou et al. 2015). These long-term effects may become challenging and cause a decrease in health-related quality of life (HRQoL) (Fleischer & Howell 2017; Okamoto, Wright & Foster 2012; Stuhlfauth, Melby & Hellesø 2018).
Physical activity and exercise
Exercise and/or PA is a cost-effective strategy for the amelioration of symptoms in chronic disease and has increasingly been advocated in cancer management in addition to primary treatment strategies such as surgery, chemotherapy and radiation (Bottomley et al. 2019; Sosnowski et al. 2017; Stout et al. 2021). Physical activity is defined as:
[A]ny body movement generated by the contraction of skeletal muscles that raises energy expenditure above resting metabolic rate, and is characterised by its modality, frequency, intensity, duration, and context of practice. (Caspersen, Powell & Christenson 1985)
Exercise is defined as ‘a subset of PA that is planned, structured, repetitive and has a final or an intermediate objective of improvement or maintenance of physical fitness’ (Caspersen et al. 1985). These two definitions are often used interchangeably in literature, and according to Smith et al. (2017), structured exercise programmes facilitate PA in individuals dealing with cancer. Increases in energy expenditure resulting from increased PA have consistently been associated with a reduced risk of developing certain types of cancer and decreased overall and cancer-specific mortality rates (Brown et al. 2012; Kim et al. 2021; McTiernan et al. 2019). This effect is particularly notable in individuals dealing with prostate, breast or colorectal cancer (McTiernan et al. 2019).
Furthermore, PA has been shown to alleviate physical symptoms – including pain, fatigue, poor sleep quality and stress – as well as psycho-emotional factors such as depression and anxiety in individuals diagnosed with cancer (Carayol et al. 2013; Galvão et al. 2021).
Hence, the value of exercise and/or PA as an integral component of cancer management cannot be overemphasised. However, individuals living with cancer are often not provided with essential lifestyle information, particularly regarding the importance of engaging in regular PA (Elshahat, Treanor & Donnely 2021; Smaradottir et al. 2017). As a result, many are not referred to physiotherapy for appropriate management.
Literature on knowledge and attitudes towards PA among individuals dealing with cancer is sparse (Smith et al. 2017). To the researchers’ best knowledge, data on knowledge and attitudes towards exercise and PA among individuals dealing with cancer are not available in the context of LMICs.
Therefore, our study aimed to describe the knowledge, attitudes and practices (KAP) of individuals dealing with prostate, breast and colorectal cancer regarding exercise and PA.
Research methods and design
An observational, descriptive, cross-sectional study, using a self-developed KAP survey for individuals dealing with prostate, breast and colorectal cancer, was conducted at the oncology ward and clinic at Universitas Annex in Bloemfontein, Free State. This oncology department provides all services to the catchment area for patients from rural and urban communities in the public sector from the Free State, Northern Cape and Lesotho. A non-randomised convenience sampling method was used in that all patients with prostate, breast and colorectal cancer at the hospital during data collection days were approached for possible inclusion in our study. Data collection took place from 01 April 2024 until 31 June 2024. A required sample size of 146 cancer patients was calculated using the Raosoft calculator (available at www.raosoft.com/samplesize.html), with a confidence level of 90%, a margin of error of 5% and a response distribution of 50%. An estimated 45 new cancer cases (20 prostate, 20 breast, 5 colorectal) and 60 follow-up cases (20 prostate, 30 breast, 10 colorectal) are seen at the clinic monthly. This results in a total of 315 cancer patient cases in 3 months.
Patients 18 years and older who provided informed consent were included. Patients who could not read, write and/or understand and communicate in English, Afrikaans or Sesotho were excluded. Patients presenting with severe cognitive or psychiatric problems and those having difficulty with speech or hearing were also excluded.
No existing questionnaire was available to use; therefore, a KAP questionnaire consisting of 44 multiple-choice items (15 knowledge-, 9 attitude-, 14 practice-related questions and 6 questions on demographic information) was developed by the researchers based on available literature (Hardcastle et al. 2018; Ribeiro & Milanez 2011; Tsiouris et al. 2018). Levels of knowledge were categorised according to a percentage scale, used in our study by Boakye et al. (2018), on the KAP of physiotherapists towards health promotion in Ghana. Scores were categorised as 80% – 100% (very good), 60% – 79% (good), 50% – 59% (fair) and 0% – 49% (unsatisfactory). The questionnaire, compiled in English, was translated into Afrikaans and Sesotho by professional translators utilising forward–backward translation once ethical clearance was obtained from the Health Sciences Research Ethics Committee (HSREC) of the University of the Free State.
The International Physical Activity Questionnaire-Short Form (IPAQ-SF) measured participants’ PA levels. Based on individuals’ responses, the IPAQ classifies PA into three categories: low, moderate or high (International Physical Activity Questionnaire Research Committee 2005). The IPAQ has demonstrated moderate to high reliability in adult populations, with Spearman’s correlation (rho) ρ ≈ 0.8 (Craig et al. 2003). It has also been proven to be a valid and reliable tool for estimating PA across various domains, including leisure, domestic, occupation and transport activities (Hagströmer, Oja & Sjöström 2006). However, its reliability can be influenced by factors such as the version used (short or long), the method of administration (e.g. telephone or self-report) and the characteristics of the target population (Craig et al. 2003). However, the IPAQ tends to overestimate PA levels because of self-reporting bias and shows poor concurrent validity compared with accelerometer data, especially in measuring sedentary behaviour and moderate-to-vigorous PA among older adults (Ryan et al. 2018). Nevertheless, the IPAQ-SF is often preferred in time-constrained surveys because of its brevity and user-friendliness (Craig et al. 2003).
Following ethical approval, a pilot study followed the same procedure as the main study. All participants were informed that their participation in our study was voluntary and would not affect their scheduled appointment in any way. If privacy could not be ensured, the participants were taken to a private area in the clinic to complete the questionnaire. The researchers were available to clarify any questions. The researchers imported data on the completed hard copy questionnaires into Research Electronic Data Capture (REDCap) software. The second researcher checked and cleaned the data during the importing process. Data analyses were performed by the Department of Biostatistics, UFS. Descriptive statistics were calculated for both numerical and categorical data.
Ethical considerations
Ethical clearance was obtained from the Health Sciences Research Ethics Committee, University of the Free State (HSREC) (HSD2022/1267/2911-0002) and other relevant stakeholders. Each participant received a detailed information document explaining the aim and procedure of our study. Participants were informed in the document that they could withdraw at any stage, that there were no risks involved in taking part in our study and that they would not receive any remuneration for participation. It was made clear that our study’s findings would be presented in group format and not participant-specific if published. Participants provided written informed consent before taking part in our study. Our study data were managed per the Protection of Personal Information Act 4 of 2013 (POPIA).
Results
The total number of participants was 77, with a mean age of 57-years-old (standard deviation [s.d.] 13). A summary of the sociodemographic information of participants can be viewed in Table 1.
| TABLE 1: Summary of sociodemographic information (N = 77). |
A question was posed to participants to determine their knowledge regarding the effects of exercise on the body while dealing with cancer. Most participants knew that exercise increased heartbeat (79.7%) and breathing (74.3%).
A summary of participants’ answers related to whether you may exercise while dealing with cancer can be viewed in Table 2.
| TABLE 2: Summary of knowledge questions (N = 77). |
Four questions were posed to participants to explore their attitudes towards exercise or PA while dealing with cancer. Most participants (91.9%) indicated that they considered PA important for their health or life, while 90.8% indicated that they liked doing PA regularly. Physical activities were classified as sweeping, walking to and from a shop or market in the neighbourhood, washing their car and gardening. Participants indicated that they liked doing PA as it ‘generally made them feel good and stronger’ (59.4%), ‘makes them feel and sleep well’ (50.7%) and ‘gives them confidence that they are strong and do not need assistance from others’ (47.8%).
Only 29% of participants described themselves as sitting all day or most of the time, and 59.1% indicated that they are worried about this. Many participants, 56 (74.7%), indicated that they liked doing exercise. Exercise was explained as being an activity in which you move the whole or part of your body – for example, walking fast or jumping – continuously for approximately 20–30 min that increases your heartbeat and breathing to promote better health and fitness. The main reasons for doing exercise given by participants were ‘that it generally made them feel good and stronger’ (64.3%), ‘it makes them sleep better’ (57.1%) and ‘it makes them worry less about cancer’ (50.0%). Overall, most of the participants felt that they got sufficient exercise (64.0%).
A summary of the answers related to participants’ practices regarding exercise while dealing with cancer can be viewed in Table 3, Table 4, Table 5 and Table 6.
| TABLE 3: Participants receiving information regarding exercise (N = 77). |
| TABLE 4: Participants’ practices regarding doing exercise (N = 77). |
| TABLE 5: Types of physical activity or exercises done (N = 77). |
| TABLE 6: Reasons why participants did not engage in regular physical activity or exercise (N = 77). |
Participants were asked from whom or where did they get information regarding the importance of doing regular exercise or PA, with 59.9% indicating that they received the information from their doctor. When asked whom they wanted information from about exercise or PA, the participants once again indicated that they would like to receive this information from their doctor (59.7%).
Most of the participants indicated that on average, they engaged in exercise at home twice (30.0%) or three times (30.0%) a week, with the duration on average per session 10–20 min (43.6%) and less than 10 min (20.5%). The option chosen by 56.1% of participants regarding the intensity at which they were exercising was that their heart beats faster, but not to a point they must breathe hard, which indicated low-intensity exercise, while 29.3% indicated that they were working during the exercise session but not working so hard that they did not want to go on during the next few minutes. They also breathed harder, but did not gasp for breath or air, which indicated moderate-intensity exercise.
To determine the IPAQ PA categories, only complete data sets were included in the analysis. Participants with incomplete responses or those who answered ‘Don’t know or Not sure’ were excluded from the analysis. In the past seven days, only 10 participants reported engaging in vigorous activities, 15 in moderate activities and 21 in walking. Most participants did not complete this section of the questionnaire (see Table 7). The number of hours participants reported doing vigorous activities varied between participants, ranging from one to eight hours per day. Three of the ten participants who reported engaging in vigorous activity stated that they did so for 2 h per day. Almost half (47.6%) of the participants who reported walking stated that they walk every day of the week. The duration of walking varied from 1 min to 10 h, with 1 h being the most reported.
| TABLE 7: Results of the international physical activity questionnaire. |
Because of the large number of missing frequencies regarding the number of days they performed activities and the duration of these sessions, it was difficult to calculate the number of PA minutes per week. Hence, data analysis was restricted to comparing the number of participants who reported doing vigorous, moderate PA or walking.
Discussion
According to the American Cancer Society (ACS), the recommended dosage of exercise for the prevention and treatment of cancer is 150–300 min of moderate-intensity aerobic exercise or 75–150 min of vigorous aerobic exercise weekly, as well as progressive resistance exercises for the major muscle groups at least twice a week (ACS 2025). It is estimated that the adherence of individuals dealing with cancer to PA guidelines is between 17% and 58% (Troeschel et al. 2018). It was interesting to note that the participants in our study reported that they exercised at home and felt that they got enough exercise. However, they indicated that they exercised 2–3 times a week for 10–20 min, which is insufficient according to the recommended ACS guidelines. A 2018 study involving breast cancer patients in Ekurhuleni, South Africa, found that most participants were physically active. The study utilised the Global Physical Activity Questionnaire without including specific questions about exercise, which makes comparison with our study difficult (Wilkinson & Smith 2023).
A systematic review conducted by Cesnik et al. (2023) included 33 studies that met their inclusion criteria regarding PA levels in people with cancer undergoing chemotherapy. Only nine studies used self-reported PA levels that could be compared against the WHO guidelines. Seven of the nine studies reported that most participants did not meet the WHO aerobic guidelines (Cesnik et al. 2023).
Although it seems there is a global tendency for cancer patients not to be sufficiently active, comparing our study’s exercise findings to the above-mentioned studies is challenging. Our study specifically investigated the number of minutes exercised. All the other studies use the words exercise and/or PA interchangeably without specifying the minutes exercised.
Numerous reasons were provided by participants in our study for not engaging in regular exercise and/or PA. The reasons included back pain, joint pain, no specific reason and not feeling that they could exercise, to mention a few. The barriers reported by the participants in our study were similar to the findings of other studies. An international study conducted on patients diagnosed with prostate, breast and colorectal cancer found that 30% – 60% of these patients experienced a lack of guidance from the doctor, no access to exercise facilities, poor educational levels and comorbidities as barriers to perform PA. These factors were associated with decreased PA levels following their cancer diagnoses (Depenbusch et al. 2022). A systematic scoping review by Elshahat et al. (2021) reported similar findings to the results of our study, indicating that cancer-related side-effects, such as pain and inability to exercise, prevented participants from engaging in regular PA. Frikkel et al. (2020) highlight that fatigue and depression were major factors predicting low motivation for PA among cancer patients. These psychological factors often co-occur with physical symptoms such as pain, further decreasing motivation for engaging in exercise and/or PA (Frikkel et al. 2020).
According to Balcetis, Cole and Bisi (2016), ongoing poor health might originate from how individuals perceive and interpret exercising. Some people may see exercise as more difficult than others. In their research, Balcetis et al. (2016) hypothesise that viewing the content of the environment as harsh or more extreme may impact the exercise experience. If distance is viewed to be longer by unfit individuals, then individuals who perceive that they have poor health may consider exercise relatively harder and less feasible to complete (Balcetis et al. 2016). Perceptual judgement (the way we perceive and interpret the world around us, based on information our senses provide) increases the feasibility of exercising. It even improves the quality of the exercises objectively. Changing how individuals subjectively see their surroundings and circumstances may change their beliefs about their ability to do a task, which may ultimately encourage them to do more exercises. Feasibility is a motivational mechanism that can be used as a strategy for action; however, this did not affect consideration of desirability (Balcetis et al. 2016).
Current literature reports that individuals dealing with cancer prefer to receive information regarding exercise and/or PA from their oncologist and indicates that patient-doctor discussions can help encourage individuals to perform PA (Fisher et al. 2015; Ligibel et al. 2019; Pinto, Papandonatos & Goldstein 2013), which was also the case in our study. Most oncologists in a study by Ligibel et al. (2019) support providing exercise to individuals dealing with cancer. However, in a study on medical practitioners, barriers to delivering exercise information to patients such as insufficient knowledge and lack of time were clearly identified (Nadler et al. 2017). Knowledge, attitudes and practices regarding exercise and PA interventions among doctors working in oncology at Universitas Academic Hospital Complex, Bloemfontein, are being explored during a follow-up study, which has been approved. Our study will provide insights into healthcare professionals’ take on exercise for individuals dealing with prostate, breast and colorectal cancer.
The results indicated that the IPAQ did not perform effectively in our study. Despite participants meeting the inclusion criterion of literacy, many failed to respond appropriately to the questionnaire items. Potential factors contributing to these challenges included participants’ inability to quantify the time spent on activities and their limited familiarity with completing surveys. Similar challenges have been reported in Colombia and Brazil, where researchers observed inaccurate responses. Although the IPAQ has been tested in LMICs and HICs and has shown acceptable psychometric performance, urban samples showed better reliability than rural samples (Craig et al. 2003). According to Craig et al. (2003), this might have been because of educational differences and the fact that the rural sample was research-naïve in completing surveys. This could also be attributed to a greater variability in daily activities carried out in rural populations. It was interesting that although there were differences noted in the interpretation of questions because of cultural differences, this did not seem to influence the measurement properties of the IPAQ (Craig et al. 2003). Hallal et al. (2010) suggest that how the IPAQ is structured might confuse participants, as it combines four different PA areas into one assessment. Future studies in rural LMIC settings are strongly recommended to utilise interviewer-administered questionnaires as standard practice to mitigate response bias inherent in utilising self-reported measures, especially in healthcare research (Rosenman, Tennekoon & Hill 2011).
Clinical implications
The findings of the current baseline study clearly indicated that individuals dealing with cancer find it challenging to engage in exercise and/or PA and find it difficult to achieve recommended exercise and/or PA guidelines. Collaborative goal setting is essential in person-centred rehabilitation, but apparently, healthcare professionals are reluctant to adopt this practice (Collado-Mateo et al. 2021; Crawford et al. 2022). Person-centred goal setting is a process that involves the patient in goal identification and agreement, considering the individual’s values and preferences, resulting in meaningful personal outcomes that are measurable (Collado-Mateo et al. 2021; Crawford et al. 2022). Person-centred goal setting assists the healthcare professional and the patient in focusing on their behaviour and ultimately achieving meaningful and feasible outcomes that improve the patient’s quality of life (Crawford et al. 2022).
In addition, when prescribing exercise and/or PA for individuals dealing with cancer, physiotherapists should consider the feasibility of the exercises (Liberman & Förster 2008). Individuals who had committed to a manageable goal that they could accomplish soon, and who believed that they could meet the goal, perceived exercising as being easier (keeping your eye on the prize) (Balcetis et al. 2016). This approach can change subjective expectations despite physical limitations, which may assist individuals dealing with cancer to reach exercise goals that otherwise seem impossible to meet – an important consideration not fully realised by physiotherapists when designing exercise programmes for individuals dealing with cancer. This might mitigate our study’s findings that participants did not meet the required minutes of exercise and/or PA per week.
Psychological barriers to exercise and/or PA in individuals dealing with cancer may include depression, lack of motivation and fear, which may affect cancer patients’ motivation to engage in exercise and PA (Frikkel et al. 2020). These factors are treatable and highlight the importance of following a multidisciplinary oncology approach when managing patients dealing with cancer.
Limitations
Changes in memory, thinking and focus, so-called chemo brain (cancer-related cognitive impairment), may have influenced recall in participants and should be noted as a potential limitation (Haywood et al. 2023). Chemo brain is characterised by memory lapses, difficulty concentrating and mental fatigue (Campbell et al. 2020). This may have decreased the participants’ ability to accurately recall their PA over the past seven days, largely what the IPAQ intends to determine. In addition, participants may have found it challenging to remember which activities they engaged in or inaccurately assessed the activity intensity, as fatigue commonly experienced can influence their perception of physical exertion (Vassbakk-Brovold et al. 2016). Another limitation that should be considered is that although the questionnaires were forward–backward translated into Afrikaans, English and Sesotho, the three most prevalent languages in the Free State, the spoken language still differs vastly from the translated language because of dialects developing – a product of urbanisation. In addition, the KAP survey was self-developed and pilot-tested, but psychometric properties were not established.
Although the inclusion criteria for our study specified prostate, breast and colorectal cancers, the specific type of cancer for each participant was not specified. We acknowledge that this was a critical omission as KAP regarding exercise and/or PA are known to vary across cancer types because of differences in treatment modalities and personal experiences. For instance, breast cancer patients may face challenges such as lymphoedema, which could influence their exercise engagement. Results should be interpreted with caution because of the small sample size. Only 77 participants took part in our study, while the calculated sample size required was 146, which substantially limits the statistical power and generalisability of our study. The small sample size is attributed to patients declining to participate and the time frame set for data collection, which was limited because of resource and time constraints. It is acknowledged that selection bias because of single-site convenience sampling occurred, and therefore also limits the generalisability of data.
As mentioned in the results, the data set for the IPAQ was incomplete because of the large number of missing frequencies regarding the number of days and the time that activities were performed. Hence, the IPAQ in our study failed to evaluate the levels of PA of our study population accurately. It should be noted that our study’s findings are not generalisable but serve as exploratory baseline data to inform future large-scale studies.
Recommendations
The self-developed KAP questionnaire utilised in our study should be validated for use in future research. It is also recommended that the IPAQ questionnaire be administered using a personal interview approach to minimise participants not completing all the required questions. The same sentiment has been echoed by Craig et al. (2003), who found similar challenges in South African and Guatemalan populations during their IPAQ 12-country reliability and validity study.
Future research should prioritise including subgroup analyses to better understand the relationships between exercise and/or PA and individuals dealing with cancer across diverse populations. Variables such as gender and level of education may influence engagement in exercise and/or PA. Including sub-group analysis would facilitate understanding of the findings, help identify disparities and tailor interventions more effectively to address the unique needs of individuals affected by breast, prostate and colorectal cancers.
Furthermore, the research study should be repeated utilising multiple sites for recruitment of patients dealing with cancer.
In a systematic review of implementation outcomes of exercise interventions for people diagnosed with cancer, Czosnek et al. (2021) conclude that studies (37 unique exercise programmes) did not evaluate and measure implementation outcomes under real-world conditions. The Czosnek et al. (2021) review supports our recommendation that research be conducted to identify specific strategies within the context of the Free State to facilitate the successful implementation of an exercise and/or PA intervention for individuals with cancer. In addition, understanding the impact of person-centred goal setting in individuals of diverse cultural backgrounds within a group-based exercise intervention should also be explored.
Conclusion
This was a baseline study describing the KAP of individuals dealing with prostate, breast and colorectal cancer regarding exercise and PA in the Free State. The findings of our study indicate that although individuals coping with cancer engage in exercise and/or PA, they do not meet the requirements as stipulated by the ACS. Efforts by healthcare professionals are needed to motivate and encourage individuals dealing with cancer to be more active and engage in regular moderate exercise and/or PA. Healthcare professionals should identify feasible exercises, achieve a manageable goal and suit the interests of the individual. Psychological factors affecting motivation to exercise and/or PA must be acknowledged and treated. The involvement of a multidisciplinary oncology team is therefore essential. Physiotherapists are ideally suited to play an integral role in providing exercise and/or PA interventions, whether in group-based settings or individually, for individuals dealing with cancer.
Acknowledgements
The authors would like to extend their gratitude to the staff and patients of the Oncology ward and clinic at the National District Hospital, Universitas Annex in Bloemfontein, Free State. The authors would further like to acknowledge Dr J Nuhu, who conceptualised the initial idea for the research project.
Mrs Daleen Struwig – Medical writer from the Faculty of Health Sciences, University of the Free State.
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. R.B. serves as an editorial board member of this journal. The peer review process for this submission was handled independently, and R.B. had no involvement in the editorial decision-making process for this manuscript. R.B. has no other competing interests to declare.
Authors’ contributions
R.Y.B. and J.W. conducted the research, were responsible for capturing the data and writing the article. F.C.v.R. was responsible for data analysis and input in the final article. All authors contributed to the article, discussed the results and approved the final version for submission and publication.
Funding information
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data availability
Data are not available because of the data management policies of the institution and HSREC approval.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. They do not necessarily reflect the official policy or position of any affiliated institution, funder, agency or publisher. The authors are responsible for this article’s results, findings and content.
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