International Journal of Emergency Mental Health and Human Resilience
Open Access

BACKGROUND OF STUDY: Cancer is a chronic and life- changing disease as cancer patients experience a number of psychosocial adverse effects, including anxiety, depression, cognition changes, fatigue, pain, financial worries, and sleep disturbance among others. Although these symptoms may occur in isolation, and they often co-occur. These symptoms affect not only the patients but also their family members, colleagues, and social interactions with friends. Cancer treatments could be considered successful only if the treatment side effects and symptoms associated with a cancer diagnosis are addressed and managed, in addition to control of the disease itself.

Cancer has been defined by different authors and researchers, but according to World Health Organization (WHO), cancer is view as a group of diseases that involve abnormal cellular growth which is capable of metastasis (Can Treat International, 2010). Similarly, cancer is view as unrestrained escalation and spread of pathological cells (Cancer Fact and Figures, 2017). Furthermore, the two definitions emphasize the fact that cancer can grow beyond their usual boundaries then invade adjoining parts of the body and/ or spread to other organs, and other familiar connation are neoplasm and malignant tumours.

Cancer is capable of affecting nearly several region of the body and has numerous anatomic and molecular subtypes that each requires definite care. Moreover, not all cancer has the ability to metastasis to other parts in human body via lymph or blood, but it could take different forms ranging from cervical, ovarian, breast, lung, cancer of the blood, to prostate cancers and many others. Prostrate, Lung, stomach, liver and colorectal cancer is the mainly frequent types of cancer in men, while, lung, cervix, colorectal, stomach and breast cancer are widespread among women (www.who.int/ cancer/ng).

Cancer knows no borders, and it is the second leading causes of death in developed countries and it is among the three leading causes of death among adults in developing countries which Nigeria is one of them. 12.5% of all deaths are caused by cancer, and that is more than the percentage of deaths caused by HIV/AIDS, tuberculosis, and malaria put together, and it is a public health problem worldwide. Furthermore, cancer is the second leading causes of death globally and accounted for 8.8 million deaths in 2015 (www. who.int/cancer/ng/). The global cancer burden is rising and in 2012, there were 14.1 million newly diagnosed cancer cases (excluding non-melanoma skin cancer) worldwide with 8.2 million cancer-related deaths (GLOBACAN, 2005). By 2035, it is predicted that the incidence of newly diagnosed cancer cases will reach 24 million cases annually (GLOBACAN, 2012). The biggest rates of increase are in developing and newly industrialized countries, and there is need in research to tame this scourge. In contrast, the relative increase is smallest in some western countries where populations are rejecting tobacco and adopting healthier lifestyles. A gradually ever-increasing percentage of old people globally will have roughly 50% raise in fresh cancer cases in the next 20 years, though, if current smoking levels and the adoption of unhealthy lifestyles persist, the increase could be even greater.

Literatures have shown that cancer is one of the leading causes of deaths among Nigerians, it is very sad that quite a good number of people out there are suffering from clinical features of the disease, and have no idea that, it is the disease that is gradually destroying their lives, and the occurrence and damaging effects of cancer in Nigeria cannot be overemphasized. The incidences of cancer in Nigeria are unknown; primarily because of deficiency in data or under- reporting. This is not limited to Nigeria but major parts of Africa. In a study of cancer registry literature update from all over the world, only 1% of the literature emanated from Africa compared to 34% and 42% from Europe and Asia respectively (Abdulkareem, 2009). This is partly due to inaccurate population statistics which makes age specific incidence rates impossible, or if available inaccurate. Large percentage of the people still never looks for orthodox medical care and so is not documented. However, there are 11 cancer registries in Nigeria; located in various tertiary hospitals in various parts of the country. Most of the registries are poorly funded and except probably The Ibadan Cancer Registry (ICR), they all produce hospital-based data (Abdulkareem, 2009).

Moreover, the early study from Nigeria on cancer was from the Ibadan Cancer Registry 1960-1969 (ICR), which reported higher rate of cancer in females with age standardized rates of 105.1 per 100,000 females and 78 per 100,000 male, and in 1978, 74.5 and 65.9 per 100,000 female and males was reported respectively (Abdulkareem, 2009). Similarly, 2001-2005, data from Ibadan registry shows that there is an increasing incidence of cancer at 81.6 and 115.1 per100, 000 male and female with 65.9% and 34.1% in females and males respectively.

According to recent facts, between 30% and 50% of cancer death might be prevented by modifying or avoiding main risk factors, including reducing alcohol consumption, avoiding tobacco products, maintaining a healthy body weight, exercising regularly and addressing infection- related risk factors through genetic counselling (www. who.int/cancer/en/). Further to reduce the significant disability, suffering and deaths caused by cancer worldwide, effective and affordable programs in early diagnosis, screening, treatment, and palliative cares are needed. Palliative care, which focuses on improving the quality of life of patients and their families, is an essential component of cancer care which is an avenue this study wants to leverage on to address cancer risk perceptions and attitude to genetic counselling among relatives of persons living with cancers.

In a ground breaking study by Spiegel et al., (1981), reported women with breast cancer who attended a weekly support group and benefited from sharing their experience with patients who had similar experiences. Particularly, persons in the support group show reduction in mood disturbance rating and had less maladaptive coping strategy than those who did not attend. Sharing experiences also reduces stigma associated with the diagnosis of cancer and helps to overcome social isolation (Weis, 2003). Psycho-social treatment usually centres on precise clinical problems of cancer patients such as anxiety, depression, fatigue, health- related quality of life and pain. These programs usually strive to deliver specific psychosocial interventions that are relatively brief, goal-oriented, and directed at specific clinical outcomes. A meta-analysis of controlled outcome studies revealed that psychosocial interventions can have beneficial effects on cancer patients (Rehse and Purkrop, 2003). Other studies have found that psychosocial programs that incorporate a cognitive-behavioural therapy (CBT) approach are effective in reducing depressive and anxiety symptoms and improving quality of life in cancer patients (Edmonds, Lockwood, & Cunningham, 1999; Kissane et al., 2003; Larson et al, 2000; Lev et al, 2001). These programs were conducted either in group settings or individually, although the specific format of the interventions did not emerge as a relevant factor for the effectiveness of the programs (Rehse and Pukrop, 2003).

The focus of this study is on relatives of persons living with cancer and how best they can benefit from psycho- education interventions in changing their attitude to genetic counselling, which are design to increase understanding and knowledge about cancer and associated issues as opposed to learning techniques to reduce anxiety and cope with stress or pain, which is the primary focus of most psychosocial interventions. There is a popular saying that “prevention is better than cure”, and this is also applicable to cases of cancer, as most diagnosable cancers can be prevented through knowledge of genetic counselling, but few studies have been carried out on relatives of cancer patients toward genetic counselling in the world, and Nigeria in particular. Although that could be as result of the fact that the field of genetic counselling is an emerging discipline compare to medicine, nursing among others. It is worrisome as most relatives of cancer patients lack or unaware of the knowledge of genetic counselling in cancers reduction, prevention and early diagnosis. Even the few educated ones that are aware of it, rarely go for genetic cancer screening or testing, not to talk of genetic counselling, this could be attributed to a lot factors such as psychological feelings accompanying it, inadequate screening or diagnostic centres in the country is another reason and the few centres available just pop up in recent years and the cost of genetic testing and treatment is another factor that made cancer patients vulnerable to death.

Genetic counselling construe by National Society of Genetic Counsellors as the means of assisting people to know and adjust to the medical, psychological, and familial implications of hereditary contributions to disease (McKinnon et al, 1997). Furthermore, genetic counselling is defined by the American Society of Human Genetics as a communication process which deals with the human problems associated with the occurrence or risk of occurrence of a genetic disorder in a family (American Society of Clinical Oncology, 2003).

Against this background, attitude to genetic counselling in this study has been construe as a set of beliefs, emotions, and behaviours toward genetic screening and counselling, especially in respect to relatives of persons living with cancers. Attitudes are often the result of experience or upbringing, and they can have a powerful influence over behaviour, while attitudes are enduring, they can also change. People are considered to be candidates for cancer risk assessment if they have a personal and/or family history (maternal lineage) with features suggestive of hereditary cancers (Olopade, and Pichert, 2001), Such candidates for genetic testing receive genetic education and counselling before testing to facilitate informed decision-making and adaptation to the risk or condition. in contrast, genetic testing is suggested or offered when a risk appraisal suggests the incidence of an hereditary cancer condition for which particular genes have been recognized (Nelson et al, 2014). Pertinent conditions for offering the test include: (i) an individual has a personal or family history suggestive of a genetic cancer susceptibility syndrome, (ii) the result of the test can be interpreted, and (iii) testing will influence medical management. In general, genetic testing is performed when there is evidence of an inherited susceptibility that had neither been tested nor had identifiable mutation and also in families with a documented deleterious (Oluwasola, & Odukogbe, 2017).

Cancers risk perceptions refer to people’s beliefs about their vulnerability to cancer and their judgments about the probability of benefit from interventions (BUPA, UK foundation fund cancer prevention Initiative, 2015). Risk perceptions of cancer are therefore an essential component of health behaviour change for cancer perception. Understanding the behaviours that will reduce your cancer risk is the first step towards informed decision-making and behaviour change, yet awareness of some cancer risk factors (e.g smoking) is high, while for others (e.g alcohol) knowledge is poor (BUPA, 2015).

Research attention has focused more on cancer itself as disease, and its effects on those directly affected, while less attention has been devoted to explaining the causes and how to prevent cancers in the view of advancement in technology to identify genes and familial risks in developing cancers among relatives of persons living with cancer.

The focus of this study is to determine the role of SMS- based psycho-education on attitude to genetic counselling among the relatives of cancer patients. The aim of the study is to educate relatives of persons living with cancers on the need to seek genetic counselling to know the level of cancer risk within the family. However, psycho-education is an evidence-based therapeutic intervention for patients and their loved ones that provide information and support to better understand and cope with illness. In this study, the intervention will be through short message service (SMS), unlike the face to face therapeutic sessions. It will consists of two modules, module one will centre on health information about cancer such as meaning, causes, types, prevention and available treatment options, while the second module will be based on Albert Ellis Rational Emotive Behavioural Therapy (REBT) techniques.

1. Attitude towards genetic counselling and cancer risk perception will be highest after treatment than before treatment among the relatives of persons living cancer patients in Ibadan.

2. Participants who receive SMS-based psycho-education will score significantly higher compare to those who do not receive SMS-based psycho-education among the relatives of persons living cancer patients in Ibadan.

3. Female relatives of cancer patients with tertiary educational qualification will significantly report more favourable attitude to genetic counselling and higher cancer risk perception.

4. Married relatives of cancer patients will significantly report higher cancer risk perception and favourable attitude towards genetic counselling than single, divorced or separated relatives of cancer patients.

5. Older relative’ cancer patients will significantly report higher cancer risk perception and favourable attitude towards genetic counselling than younger relatives cancer patients.

6. Relatives of cancer patients with high number of visits to the hospital will significantly report higher cancer risk perception and attitude towards genetic counselling than those with low number of visits to the hospital.

DESIGN AND PARTICIPANTS: This study adopted pre-test and post-test control group research design. A total of one hundred and one persons were purposively selected and participated in the first phase of the study, while only forty-four persons qualified using inclusion criteria for the post-test representing 22males and 22females participated and were randomly selected into experimental and control groups. The Participants were relatives of persons living with cancer within the age range of 18-76years (M=37.05; SD=11.57) drawn from the radiation oncology department, University College Hospital (UCH), Ibadan, Nigeria.

SETTING: This study took place in Ibadan, Oyo State, known as largest city in West Africa. Data obtained from Radiation Oncology Department, University College Hospital (UCH), Ibadan North LGA, Oyo State. The study was conducted in UCH which is adjudged advantageous for two reasons, UCH was the first teaching hospital in Nigeria and has the most reliable cancer register in Nigeria even in recent time, it is still viewed to have high level of patronage and expertise for a tertiary hospital in Nigeria.

MEASURES AND INSTRUMENTS: Attitude to genetic counselling (AGC) developed by Adejumo & Olaoye. (2018), was used to measure participants attitude to genetic counselling. It contained 8 items with sample items including. ‘’No matter the obstacles, I support genetic counselling’’. Responses were scaled in a 4-point Likert form with ‘strongly Disagree’ as 1 and ‘Strongly Agree’ as 4. Negative items were reversed in scoring. An individual could score between 8 and 36 on the scale. Higher scores mean a more positive attitude towards genetic counselling. The developer reported internal consistency of Chronbach’s alpha of α = 0.59, with mean score of ×=12.46 ±4.14. In this present study, A Chronbach’s alpha of α = 0.77 was obtained, with mean score of × =17.11 ±3.18.

Perceived vulnerability to disease scale (PVDS) developed by Lesley A., D., Mark S., & Justin H. P (2009), was used to measure cancer risk perception. The scale consists of 15 items in which six were reverse items (3, 5, 11, 12, 13, &14). The developer reported an acceptable level of internal consistency (after reverse-scoring of items indicated above): Cronbach’s alpha = .82. The respondents expressed their degree of agreement on a 5-point Likert scale type ranged from 5 strongly agreed and 1 strongly disagreed. In this present study, A Chronbach’s alpha of α = 0.82 was obtained, with mean score of × =36.42 ±7.19.

Ethical approval was sought from the hospital institute for advanced medical research and training (IAMRAT) with approval number UI/EU/18/0141, before I was given permission to access patients and their relatives at the department of radiation oncology, University College Hospital Ibadan. The questionnaire was administered to the participants after informed consent form was signed. A total number of 120 questionnaires were administered and 101 questionnaires were returned and analysed in this study.

1. VOLUNTARINESS & INFORMED CONSENT: Participation in this study was voluntary and participants were free to withdraw from the study at any point in time without any penalty. Informed consent was obtained at the pre-test and post-test phases of the study from the participants and only those who are willing were enrolled for the study.

2. CONFIDENTIALITY AND PRIVACY: The participants were duly informed that all responses obtained would be used for research purpose only and would remain highly confidential. No names were obtained from participants on the questionnaire and all completed questionnaire were stored securely with access to data only given to the research team.

3. RISK/BENEFIT RATIO: The first phase of study causes little or no harms to the respondents as it only survey. The second phase of the study provides SMS- based psycho-education intervention aimed at changing attitude to genetic counselling and cancer risk perception of the participants. The participants benefit from the psycho- education intervention of the study which assists them to make informed decision about genetic counselling and reduce their cancer risk perception in their families.

4. TRANSLATION OF PROTOCOL TO THE LOCAL LANGUAGE: The research instruments were translated to local language, because of those who cannot read or understand English language.

5. DEBRIEFING OF PARTICIPANTS: Following the completion of experiment, participants were debriefed on the aim of the study, hypotheses being tested and the methods used by the researcher.

Hypotheses were analysed with the use of appropriate statistical tools. One-samples T-test and Independent T-test were used to analysed hypotheses one and two, hypothesis three and four were analysed with Multivariate Analysis of Variance (MANOVA), and One-Way Analysis of variance (ANOVA), while hypotheses five and six were analysed with T-test Independent and One-Way Analysis of Variance (ANOVA).

Table 1 presents the descriptive results of socio-demographic information of respondents. As regards age distribution, more of the respondents 34 (33.7%) were between 30 and 39 years old, 25 (24.8%) were between 40and 49 years old, 21 (20.8%) were between 20 and 29 years old, 15 (14.9%) were 50 years and above, while the other 6 (5.9%) indicated to be less than 20 years old. Also, sex distribution revealed that more of the participants 53 (52.5%) were females, while the other 48 (47.5%) were males. Further, marital status distribution revealed that more of the relatives of cancer patients 62 (61.4%) indicated to be married, 27 (26.7%) were single, 7 (6.9%) were divorced, while the other 5 (5%) were widowed.

Table 1. Descriptive statistics of respondent’s socio-demographic information.

From Table 1 as well, more of the respondents 52 (51.5%) indicated to be HND/ University degree holders, 22 (21.8%) were NCE/OND holders, 18 (17.8%) were postgraduate certificate holders, while the other 9 (8.9%) were SSCE holders. Finally, frequency of visitation revealed that more of the respondents 37 (36.6%) visits the hospital between 5 and 9 times, 27 (26.7%) visits the hospital between 10 and 14 times, 17 (16.8%) visits the hospital less than 5 times, 12 (11.9%) visits the hospital more than 20 times, while the other 8 (7.9%) visits the hospital between 15 and 19 times.

INTER-CORRELATION BETWEEN VARIABLES OF THE STUDY:

Table 2 presents results on the relationship between variables of the study. It is shown on Table 2 that attitude towards genetic counselling had no significant relationship with cancer risk perception (r = -.06; P>.05), educational qualification (r = -.01; P>.05), number of visit (r = -.16; P>.05) and age (r = -.16; P>.05). Also, cancer risk perception had no significant relationship with educational qualification (r = -.04; P>.05), number of visits (r = -.04; P>.05) and age (r = -.01; P>.05). However, educational qualification had significant positive relationship with number of visits (r = .33; P<.01) and age (r = .42; P<.01). Finally, there exists significant positive relationship between number of visits to hospital and age (r = .49; P<.01).

Table 2. Zero-order correlation matrix table showing the relationship between attitude to genetic counseling, cancer risk perception, and demographic factors.

HYPOTHESES TESTING:

Hypothesis one stated that attitude towards genetic counselling and cancer risk perception will be highest after treatment than before treatment among relatives of persons living with cancer in Ibadan. This was tested using one- sample t-test and the result is presented on Table 3.

Table 3. One sample T-test showing results difference between pre-test and post-test of psycho-education in attitude towards genetic counseling and cancer risk perception

The result in Table 3 above shows that exposure to psycho- education boosted the level of attitude towards genetic counselling favourably (t (43) = 47.84; p<.001). Attitude to genetic counselling increased significantly after exposure to psycho-education (Mean = 17.57; S.D = 3.14) than before exposure to psycho-education (Mean = 15.00, S.D = 2.08).

As regards cancer risk perception, it is shown that psycho- education boosted the level of cancer risk perception (t (43) = 63.98,p<.001). Cancer risk perception increased significantly after exposure to psycho-education (Mean = 35.71; S.D= 3.70) than before exposure to psycho-education (Mean = 3.93; S.D = 3.93). This confirms the stated hypothesis, hence was retained in this study.

Hypothesis two stated that participants who receive SMS- based psycho-education will score significantly higher compare to those who do not receive SMS-based psycho- education. This was tested using t-test for independent samples and the result is presented on Table 4.

Table 4. Summary of T-test for Independent Samples Showing Difference in Exposure to Psycho-Education in Genetic Counseling and Cancer Risk Perception.

The result in Table 4 above shows that result on the efficacy of psycho-education in genetic counselling and cancer risk perception. As regards attitude towards genetic counselling, it is shown that there exists significant difference between experimental and control group in genetic counselling (t (42) = 12.46; p<.001). Attitude towards genetic counselling is more favourable among relatives of cancer patients who received psycho-education (Mean = 20.32; SD = 1.21) than those who did not receive psycho-education (Mean = 14.82; SD = 1.68).

As regards cancer risk perception, it is shown that there exists significant difference between experimental and control group in cancer risk perception (t (42) = 5.39; p<.001). Relatives of cancer patients who received psycho-education reported increased perception of cancer risk (Mean = 38.05; SD = 2.92) than those who did not receive psycho-education (Mean = 33.36; SD = 2.84). This confirms the stated hypothesis, hence was retained in this study.

Hypothesis three stated that female relatives of cancer patients with tertiary educational qualification will significantly report more favourable attitude to genetic counselling and higher cancer risk perception. This was tested using 2x4Multivariate Analysis of Variance (MANOVA) and the result is presented on Table 5.

Table 5. 2x4 MANOVA showing the effect of sex and educational qualification on attitude towards genetic counseling and cancer risk perception

Table 5 above presents results on the main and interactive effect of sex and educational qualification on attitude towards genetic counselling and cancer risk perception. It is shown that sex had no significant main effect on attitude to genetic counselling [F (1, 15) = 5.76; P>.05] and cancer risk perception [F (1, 15) = .96; P>.05]. Also, educational qualification had no significant main effect on attitude to genetic counselling [F (1, 15) = 2.77; P>.05] and cancer risk perception [F (3, 15) = 1.69; P>.05]. In addition, sex and educational qualification was found to have no significant interactive effect on cancer risk perception [F (3, 15) = 16.40; P>.05]. However, sex and educational qualification was found to have significant interactive effect on attitude towards genetic counselling [F (2, 15) = 4.71; P>.05]. Descriptive analysis of the interactive effect of sex and educational qualification on attitude towards genetic counselling is presented on Table 6.

Table 6. Descriptive result of the interactive effect of sex and educational qualification on genetic counselling.

From Table 6, it is shown that attitude towards genetic counselling is highest among male relatives of cancer patients with postgraduate educational qualification (Mean = 16.00; SD = 1.01) and female relatives of cancer patients with NCE/ND educational qualification (Mean = 16.00; SD = 1.01). However, attitude towards genetic counselling is less favourable among female relatives of cancer patients with postgraduate educational qualification (Mean = 11.50; SD = 1.01).

Hypothesis four which stated that married relative of cancer patients will significantly report higher cancer risk perception and favourable attitude towards genetic counselling than single, divorced or separated cancer patients. This was tested using One-Way Analysis of Variance (ANOVA) and the result is presented on Table 7.

Table 7. One-way ANOVA summary table showing the effect of marital status on attitude to genetic counseling and cancer risk perception.

Table 7 presents results on the effect of marital status on attitude towards genetic counselling and cancer risk perception. It is shown that marital status had no significant effect on attitude towards genetic counselling [F (3, 40) = 1.766; P>.05] and cancer risk perception [F (3, 40) = .261; P>.05]. This negates the stated hypothesis, hence was rejected in this study.

Hypothesis five which stated that older relative’ cancer patients will significantly report higher cancer risk perception and favourable attitude towards genetic counselling than younger relatives cancer patients. This was tested using t-test for independent samples and the result is presented on Table 8.

Table 8. Summary of T-test for independent samples showing difference in age in attitude to genetic counseling and cancer risk perception.

The result in Table 8 above shows that result on the influence of age on genetic counselling and cancer risk perception. It is shown that there exists no significant difference of age in attitude towards genetic counselling (t (42) = 1.07; p>.05) and cancer risk perception (t (42)= 1.25; p>.05). This negates the stated hypothesis.

Hypothesis six stated that relatives of cancer patients with high number of visits to the hospital will significantly report higher cancer risk perception and attitude towards genetic counselling than those with low number of visits to the hospital. This was tested using One-Way Analysis of Variance (ANOVA) and the result is presented on Table 9.

Table 9. One-way ANOVA summary table showing the effect of number of visits to the hospital on attitude to genetic counselling and cancer risk perception.

Table 9 presents results on the effect of number of visits to the hospital on attitude towards genetic counselling and cancer risk perception. It is shown that number of visits to the hospital had no significant effect on attitude towards genetic counselling [F (3, 40) = 1.653 P>.05] and cancer risk perception [F (3, 40) = 1.174; P>.05]. This negates the stated hypothesis, hence was rejected in this study.

Hypothesis 1 which stated that attitude towards genetic counselling and cancer risk perception will be highest after treatment than before treatment among relatives of persons living with cancer in Ibadan was confirmed in the result in Table 3. This result was supported by Andersen (1992) in a study of the effects of psycho-educational interventions on cancer patients at different stages (initial learning about the diagnosis, early treatment, and post treatment). The result revealed that these interventions are effective because they increase patients’ knowledge, teach them how to confront stressors with positive cognitive states, and teach active behavioural strategies. An educational component combined with specific strategies to intimate relatives of cancer patients on the need for genetic counselling, especially those with high cancer-risk perception and those that family history alluded to be vulnerable to cancers. This finding was further corroborated by Mahendran et al (2017) who conducted evaluation of a brief pilot psycho-educational support group intervention for family caregivers of cancer patients: a quasi- experimental mixed-methods study. Family caregivers of cancer patients often experience an impaired quality of life (QOL) and emotional distress as a result of their care giving duties, which may potentially influence the quality of care of their care recipients. The findings show that quantitative analysis imply that while QOL is consistent in control group, intervention group participants QOL improved, both in generally QOL and in the specific area of burden. There were no significant differences in anxiety and depression in both groups. Qualitative interpretation revealed that this might have been the consequence of the intervention not only teaching participants the important coping skills, but also providing a platform for emotional expression and situational re-evaluation. This finding was further substantiated by the result of Dieng et al (2018) in a study that investigated the role of psycho-educational intervention for people at high risk of developing another melanoma: a pilot randomized controlled trial. 24 participants with mean age: 58 years, SD=12.2 at risk of developing a subsequent primary melanoma were recruited and randomly assigned 1:1 to the intervention (a psycho-educational booklet, a Cancer Council booklet on malignancy and up to five phone-based sessions with a psychologist) or usual care (Cancer Council booklet only). Feasibility, acceptability, apprehension of melanoma reappearance and secondary psychosocial outcomes were assessed at baseline, 1 and 6 months. The findings outcome revealed satisfaction and perceived benefits were rated extremely for all intervention components, particularly the telephone-based psychology sessions. The value of information and support rendered throughout the experiment was rated as ‘high’ by the intervention group, with a mean score of 4.6 out of a possible 5 (SD=0.9) and 4.2 (SD=1.2) for the control group. The intervention was practicable and suitable for improving psychological adjustment. Timely access to effective, evidence-based, psychological care is a recognized need for people with melanoma. The intervention is intended to naturally tackle this need in a way that is practicable in a clinical setting, good enough for patients and health professionals.

Hypothesis 2 which stated that participants who receive SMS-based psycho-education will score significantly higher compare to those who do not receive SMS-based psycho- education was confirmed in the result in Table 4. This result was supported by the findings of Wargny et al., (2018) who investigated the role of SMS-based intervention in type 2diabetes: clinical trial in Senegal. The findings revealed in Senegal, SMS sending was associated with an improved glycemic control in people with type 2 diabetes. As SMS has a high broadcasting in low-middle-income countries where medical investment are scarce, medical interventions using mobile phone should be developed to ease interactions among people with diabetes and health teams; this might decrease diabetes-related complications. The HbA1c change from M0 to M3 in center S was better than in center P, with a median difference of −0.4%, quartiles (−1.0; 0.3) versus 0.2% (-0.5; 0.8), respectively (p=0.0038). HbA1c reduced in the space of 3 months following stopped of SMS in center S and was established in center P. This result was further substantiated by the findings of Aguilera and Munoz (2011) on text messaging as an adjunct to CBT in low- income populations: a usability and feasibility pilot study. The findings asserted that after using text messaging for 2 months, 10 of the 12 patients gave feedback on the use of the text-messaging adjunct. 9 of 10 patients indicated that the text messaging made them feel closer to the group and their therapists by responding that they agreed or strongly agreed with that statement. Most patients (80%;n=8) also agreed or strongly agreed that receiving text messages increased their attendance to sessions, with 2 patients (20%) responding “neutral” to that statement. Regarding the amount of messages received, 40% (n=4) of the patients reported wanting to receive more messages, 60% (n6) stated that they received the right amount, and no one reported that fewer messages were desired. Furthermore, the study as part of the usability–feasibility testing, we assessed response rate as well as qualitative feedback from patients on their experiences with receiving messages as part of their mental health treatment. Over a period of 2–4 months (individuals started at different times), the response rate was 64.88% (SD 24.85%), with a range of 27%–99%. In making suggestions for improvement, patients most often reported that receiving messages at inopportune times was the biggest downside, and 1 person requested medication reminders and more messages with specific tips. Among all patients approached, higher age was related to lower rates of SMS use before the study (r = -59, p<.01) but was not related to eventual use of SMS as part of the study (r<-.09, p=.70) because some patients were taught to use it. Among patients who participated and completed follow-up, higher ratings of group closeness were related to ratings that SMS increased likelihood of attendance (r=.82, p<.01). Patients were overwhelmingly positive and supported our expectations about the benefits of SMS in a psychotherapy setting. Patients commented that receiving text messages improved self-awareness. One patient stated that the messages “help me check in with myself,” and another also stated, “It makes me check in with myself, it’s the best thing I’ve done, besides group.” We also received feedback that being prompted about mood helped make an individual aware of things that improve mood: “I noticed that when I got rung by the study that my mood was high when I was playing music or speaking with a woman I was interested in.” We also received feedback suggesting that using SMS as a part of psychotherapy may help improve self-efficacy, with 1 patient remarking, “We do have control over our mood.” Spanish-speaking patients often mentioned that receiving messages made them feel as if someone cared for them. Although the focus was on usability, we did assess for depression symptoms at baseline and 1–2 months later. Using the PHQ-9, we saw average ratings go from 10.1 at baseline to 8.5 at follow-up (scores of 5 represent mild depression and scores of 10 represent moderate depression; Kroenke et al., 2001. The difference between the two ratings was not significant (p=.15). Overall, patients generally liked the text messaging component of therapy and commented frequently during therapy sessions about times that they were prompted for their mood during the previous week. At one point, a message was sent giving participants the option of not receiving messages if they chose by replying with the word REMOVE. No one requested removal; instead, participants requested that they should not be removed, stating, for example, “Please don’t remove me.” Many patients also responded to certain messages, such as reminders, with “OK” and “Thank you,” even after receiving those messages repeatedly. This result negated the findings of Patrick et al (2009) who investigated the role of a text message based intervention for weight loss: randomized controlled trial find out that there were no differences in sample characteristics (i.e. sex, age, weight, & race) between the intervention and comparison groups, except for mean age where the intervention group was 5 years older.

Hypothesis 3 which stated that female relatives of cancer patients with tertiary educational qualification will significantly report more favourable attitude to genetic counselling and higher cancer risk perception in Ibadan was partially confirmed in the result in Table 5. It was mixed result, sex and education qualifications had no significant main effects on attitude to genetic counselling and cancer risk perception among relatives of persons living with cancer in Ibadan. Sex and education qualifications had no significant interactive effects on attitude to cancer risk perception, while sex and educational qualification had significant interactive effects on attitude to genetic counselling. This finding was substantiated by Olwi et al., (2016) in a study that examined knowledge of genetics and attitudes toward genetic testing among college students in Saudi Arabia. Cross-sectional research conducted with multistage stratified sample of 920 senior university students participated at King Abdulaziz University, Saudi Arabia. Information regarding knowledge of genetics, attitudes toward genetic testing, and socio- demographic data were collected using a self-administered questionnaire. Findings revealed that in general, students had a good knowledge of genetics but lacked some fundamentals of genetics. The majority of students showed positive attitude toward certain aspects of genetic testing such as resorting to abortion in the case of an untreatable major genetic defect in an unborn foetus. The major important predictors of knowledge were faculty, sex, academic year, and various previous knowledge of genetic testing. Furthermore, Olwi, et al (2016) suggested genetic educational programs that target youths may improve knowledge of genetic and create a public perception that further supports genetic testing and counselling. The knowledge of genetics counselling among college students was higher than has been reported in other studies and the attitudes toward genetic testing and counselling were fairly positive. This finding was further supported by Su YeonKye et al (2015) in a study that investigated perceptions of cancer risk and cause of risk in Korean Adults. The study reported that overall, 59.5% of the respondents thought they had chances of developing cancer. Significant bivariate differences in perceived cancer were observed for sex, age, education, monthly income, job, and family history of cancer.

Hypothesis four married relatives of cancer patients will significantly report higher cancer risk perception and favourable attitude towards genetic counselling than single, divorced or separated relatives of cancer patients was not confirmed in the result in Table 7. This finding was substantiated by the findings of Ravi and Subhalakshmi (2015) on the impact of gender and marital status on the online shopping attitude of cosmetic products. The study shows that the demographic factors gender ad marital status have a minimum effect on attitude factors towards online shopping of cosmetic products. The study has depicted the impact of gender and marital status towards different factors of online shopping attitude rather than focusing on attitude as a single dimension. Comparatively, gender has a higher influence than marital status but, overall the impact of both the factors gender and marital status are less. This finding negated the study by Duke et al., (2015) on influence of marital status on attitude of midwives towards objective structured clinical examination (OSCE) and their performance in the examination in Akwa Ibom and Cross River states, Nigeria. The result shows that marital status and attitude are significant joint predictors of midwives’ performance in OSCE (f=6.74 p<.001). Hence, inter correlation among variables was significant on performance with r2=0.051. This means that 5.1% of variability of midwives’ performance in OSCE is jointly accounted for by the predictor variables of attitude and marital status. The regression model also shows a contribution of each of the variables in the prediction of midwives performance in OSCE. As regards the marital status, the negative direction means that marital status has no significant influence on midwives performance in OSCE. The findings also revealed that marital status does not have any influence on midwives’ attitude towards OSCE and their performance in OSCE. These findings of this present study are in line with the findings of Cuttance (1980) which revealed non-significant correlation between attitude and their academic performance.

Hypothesis five older relatives of cancer patients will significantly report higher cancer risk perception and favourable attitude towards genetic counselling than younger relatives of cancer patients was not confirmed in the result in table 8. This finding negated the findings of Su YeonKye et al (2015) in a study that investigated perceptions of cancer risk and cause of risk in Korean Adults. The result revealed that younger age and lower income were associated with greater perception of cancer risk (0.68, to o.69 and 0.73) respectively, while family history of cancer was associated with perceived cancer risk (2.80). The study further find out that being male and older were both associated with lower perceived cancer risk , because these two factors have consistently been linked to higher risk communications to address any misinterpretation surrounding age and sex. The inverse relationship between age and perceived risk is consistent with a previous study using a representative female sample in the United Kingdom in which 35% of those aged > 65years reported reduced perception of personal risk of breast cancer in comparison to the general population, which is higher than the average of 17%. This may reflect existing evidence regarding participants’ barriers, including poor knowledge and lack of awareness of age-related breast cancer risk among older women. Only 30% of women knew that advanced age is a risk factor for developing breast cancer and older women were less able to identify risk factors correctly. This finding was further negated by the findings of Adeyemo et al., (2007) on the level of awareness of genetic counselling in Lagos, Nigeria: its advocacy on the inheritance of sickle cell disease. The findings revealed that only 20.4% of young adults within age bracket of (16- 24) have heard about genetic counselling and had favourable attitude towards genetic counselling, 9.9% in this age group (25-35) and none in this age group (36-45) have heard about genetic counselling.

Hypothesis six cancer patients with high number of visits to the hospital will significantly report higher cancer risk perception and attitude towards genetic counselling than those with low number of visits to the hospital was not confirmed in the result in Table 9. This negated the findings of Ogunba and Abiodun (2017) on knowledge and attitude of women and its influence on antenatal care attendance in southwestern Nigeria. The results show that a significant relationship (r=-0.276, p=0.000) existed between the attitude of the respondents towards antenatal care and the attendance of the clinic. However, there existed no significant relationship (r=0.055, p=0.388) between knowledge and the attendance of the antenatal clinic.

Undoubtedly, attitude to genetic counselling and cancer-risk perception is major challenges among relatives of cancer patients in Nigeria, although studies on attitude to genetic counselling and cancer-risk perception are very limited, however, none have simultaneously examined the role of psycho-education on attitude to genetic counselling and cancer-risk perception among relatives of persons living with cancer, indicating a vacuum in literature. The present study attempted to fill the gap by investigated the influence of role of SMS-based psycho-education on attitude to genetic counselling and cancer-risk perception among relatives of persons living with cancer in Ibadan as samples. In support of the studied hypotheses, the findings of this present study showed, SMS-based psycho-education had significant influence on attitude to genetic counselling and cancer-risk perception among relatives of persons living with cancer in Ibadan. More so, oncologist should endeavours to ensure and incorporate in their treatment plan the need for clinical psychologist to give psycho-education to both patients and their relatives in order allay their fears that cancer diagnosis is not a death sentence has most perceived by majority of people.

This finding has practical implications for reviewing and updating clinical practice on the imperative of incorporating psycho-education on patients with family history of cancer and their relatives on the need for genetic testing as well as genetic counselling. In contrast, less attention should be pay to the issue of gender, educational qualification, marital status, and number of visits to hospital in this present study, because all these demographic variables had no significant influence on attitude cancer-risk perception among relatives of cancer patients in Ibadan, except on attitude to genetic counselling. As demonstrated in this present study, SMS- based psycho-education had significant influence on attitude to genetic counselling and cancer-risk perception just as face-to- face psycho-education, however, SMS-based psycho-education is as potent as the other forms of psychological interventions.

I wish to express my profound gratitude and sincere appreciation to my indefatigable supervisor the person of Prof. A.O Adejumo for his meritorious support, guidance and suggestion during this project. I would also want to appreciate Prof. Adenipekun of Radiation Oncology Department of the University College Hospital (UCH), the nurses, the resident doctors; the member of staff of the department most notably is Mr David, and my co-supervisor the person of Prof. Asuzu. I won’t forget my research assistant Mr Ikenna for his support. My appreciation won’t be complete without acknowledging the support I received from the office of the CMAC most notable is Mr Oshadare for his support during my ethical approval uproar. May Almighty God reward you abundantly.