A cross-sectional study of coping strategies among a sample of women with breast cancer in South-South, Nigeria.

Background
Breast cancer is the most commonly diagnosed malignancy among women worldwide, and a leading cause of cancer-related mortality, with low- and middle-income countries (LMICs) bearing a disproportionate burden [1, 2]. Nigeria has one of the highest breast cancer incidence rates globally, with a 5-year prevalence as high as 70 per 100,000 people and a mortality rate of up to 20.5% [3–6]. Poor outcomes are driven by late-stage presentation, limited healthcare access, prohibitive cost of care, poor health insurance coverage and sociocultural barriers [4, 7–9]. In Nigeria, breast cancer is commonly managed using a combination of chemotherapy, surgery, and radiotherapy to improve survival and treatment outcomes. However, delayed presentation, often with advanced-stage disease, complicates management and is associated with poorer outcomes and negative survivorship experience [7–9]. In addition, access to comprehensive cancer care remains limited, as specialized treatment services are predominantly concentrated in urban government-owned regional centers and private facilities, posing significant challenges for many patients [7, 9, 10].
The diagnosis and treatment of breast cancer are associated with substantial disruptions to daily life and physical well-being, alongside diverse psychosocial responses that impose considerable stress and burden on patients and their families [7, 9–12]. Coping strategies (defined as thoughts and actions people use to manage stressful situations, challenges, or painful emotions, aiming to reduce distress and maintain well-being) have been shown to play a central role in shaping the psychosocial burden associated with breast cancer diagnosis and treatments [11, 13–17] In their research, Lazarus & Folkman [11] posited the cognitive-relational theory of emotion and coping as a theoretical underpinning of coping strategies and their relationship with wellbeing in cancer patients [11, 15–18]. Coping strategies, such as active problem-solving and seeking social support, have been associated with reduced psychological distress, improved treatment adherence, and better quality of life for patients with breast cancer [16–18]. In contrast, disengament coping strategies—such as avoidance, denial, or disengagement—are correlated with adverse psychological outcomes, including higher levels of anxiety, depression, social withdrawal, and reduced quality of life [15, 17, 18]. A comprehensive understanding of the coping strategies employed by patients with breast cancer provides valuable insight into their personal resources, resilience, adaptation, and overall survivorship experience. However, research in this area remains limited, particularly in resource-constrained settings [14–18]. In Nigeria, the psychosocial and clinical burden of breast cancer is further compounded by the use of maladaptive coping strategies and widespread misconceptions about the disease and its treatment [15, 17, 19, 20]. Myths surrounding surgery, chemotherapy, and radiotherapy, as well as fears related to mastectomy, contribute to heightened distress and may impede patients’ ability to adopt effective and healthy coping strategies [17, 19, 20] Additionally, unhealthy coping strategies may hinder adherence to recommended treatments—including mastectomy, neoadjuvant chemotherapy, adjuvant chemotherapy, and radiotherapy—further exacerbating treatment-related challenges [17, 21–24].
While considerable research has explored coping strategies among breast cancer survivors in high-income countries, less is known about how women actively engaged with treatment in LMICs, cope with the diagnosis, manage treatment-related challenges and experience survivorship. Gaining insight into the coping strategies adopted by breast cancer patients after diagnosis and during treatment is essential for identifying barriers to adherence and addressing the psychosocial factors that influence patient outcomes and survivorship experience. Key sociodemographic and clinical factors, including education level, employment status, and cancer stage, are likely to influence these coping mechanisms [13, 17, 25]. This study aims to address these knowledge gaps by examining the prevalence and patterns of coping strategies among breast cancer patients in South-South Nigeria. It also seeks to explore the associations between coping strategies and key sociodemographic and clinical factors. We hypothesized that coping strategies among participants with breast cancer would differ based on identifiable personal and clinical characteristics. Findings from this study are potentially useful to guide the development of culturally-tailored and patient-centric psychosocial interventions to bolster healthy coping, improve treatment adherence, and support the psychological well-being of patients with breast cancer.

Methods

Study population
This cross-sectional study was conducted at the University of Calabar Teaching Hospital (UCTH) surgical outpatient clinic located in Calabar, Cross River State, in the South‒South region of Nigeria. This hospital provides services in all areas of primary and secondary health care to patients residing in the Cross-River state, and serves as a referral centre for patients from across the state’s public and private hospitals as well as adjacent states. Cancer services including surgery (lumpectomy and mastectomy) and chemotherapy are delivered by a team of healthcare professionals, including surgical oncologists, patho-oncologists, residents’ doctors, nursing staff, and other allied health professionals.
The present study included consecutive female attendees of the outpatient clinic with a histological diagnosis of breast cancer. The inclusion criteria were women aged 18 years or older, with a confirmed diagnosis of breast cancer, receiving treatment (surgery and/or chemotherapy) for at least four weeks, and providing informed consent. The exclusion criteria included participants with a history of other chronic or life limiting medical conditions (e.g., thyroid disease, diabetes mellitus, chronic kidney diseases etc.) to limit their cofounding effects and women who were physically unstable or unable to respond to the questionnaire.

Study procedure and instruments
Ethical permission (UCTH/HREC/33/353) was obtained from the Health Research Ethics Committee, UCTH before study enrolment started. All participants provided informed consent and were administered the study instruments described below. A total of 240 participants were enrolled into the study, with a power analysis conducted to detect a small to medium effect size changes between variables in a multiple regression model. The analysis assumed an alpha level of 0.05 and a medium effect size (f² = 0.30), consistent with conventional effect size guidelines for behavioral and social science research [26]. With a total sample size of N = 240, the analysis yielded a good statistical power of 96% indicating that the study was adequately powered and reduced the likelihood of committing a Type II error [27]. Data were collected from all participants through face-to-face interviews conducted during clinic attendance, using the study instruments described below.

Socio-demographic and Clinical Questionnaire (SDCQ)
The SDCQ was designed by the researchers and comprises two sections (See Appendix A). Section A collected participants’ sociodemographic data, while Section B included questions on clinical and illness-related variables. The sociodemographic variables included age, marital status, number of children, family type, level of education, religion, ethnicity, employment status, and monthly income in Naira (₦) and United States Dollar (USD). The clinical or illness-related variables included duration of illness, affected breast, current treatment, and treatment adherence. Good treatment adherence was defined as individuals who had completed the required six courses of chemotherapy and surgery (mastectomy/lumpectomy). Data for section B was extracted from case notes.

Coping Strategy Inventory (CSI-32)
The CSI-32, adapted from the Folkman and Lazarus Ways of Coping Questionnaire, is a 32-item self-report tool designed by Tobin et al. developed to assess individuals’ coping strategies in response to stressors [28]. Coping strategies represent innate or acquired methods that individuals use to respond to internal and/or external changes in order to adapt, especially in the face of stress [11, 17, 28]. It includes eight primary subscales, each with four items: problem-solving, cognitive restructuring, emotional expression, social support, problem avoidance, wishful thinking, self-criticism, and social withdrawal. The responses are rated on a 5-point Likert scale (1 = “not at all” to 5 = “very much”). These primary subscales combine into four secondary (problem-focused engagement, emotion-focused engagement, problem-focused disengagement, and emotion-focused disengagement) and two tertiary subscales (engagement and disengagement). The tertiary subscale with the higher score (engagement versus disengagement coping) was considered the predominant coping strategy practiced by an individual patient.This aligns with the hierarchical structure and user manual for the CSI-32, where higher domain scores indicate more frequent use of that domain of coping [28–32]. The scale has been previously validated and well-used in Nigerian studies, and the reliability coefficient (Cronbach’s alpha [α] of 0.81) in the present study is consistent with the range (0.74 to 0.84) reported in previous studies in Nigeria [17, 29–32].

Data analysis
The data were analyzed using the Statistical Package for Social Sciences software version 22 (SPSS 22). Percentages and frequency distributions were used to summarize categorical data, and means with standard deviations were used to present continuous data. Patients were dichotomized into using either engagement versus disengagement coping by comparing their scores on the two CSI-32 tertiary scales [28–32]. We conducted a paired sample t-test and a repeated-measures analysis of variance (ANOVA) to compare the mean scores of participants across all the CSI-32 subscales. Relationships between categorical variables (engagement versus disengagement coping by clinico-sociodemographic variables) were assessed via chi-square tests. Given that disengagement was most prevalent in the sample, we conducted multiple regression analyses to identify factors that are independently associated with disengagement coping (dependent variable) by including clinic-demographic variables that were significant from bivariate analysis as independent variables in the model. Statistical significance was set at p ≤.05.

Results

Sociodemographic and clinical characteristics of the participants
Tables 1 and 2 summarize the sociodemographic and clinical characteristics of the 240 study participants. The participants had a mean age of 46.8 years (SD = 13.4), with 26.7% belonging to the 31–40 years age group. Most participants were married (62.1%), in monogamous relationships (95.8%), and had children (74.6%), with 42.5% reporting having between four and six children. Christianity was the predominant religion (99.6%), and the participants represented various ethnic groups, including Efik (20.0%), Ibibio (18.7%), Igbo (13.8%), and others (47.5%). Over three-quarters (76.2%) had attained secondary school education or less. Most participants were employed (89.2%), working primarily as traders or farmers (54.6%) or civil servants (30.8%). The majority (60.8%) reported a monthly income between ₦18,000 (91 USD) and ₦36,000 (182 USD).

The clinical profile revealed that 60.4% of the participants had undergone both chemotherapy and surgery. Breast cancer was predominantly unilateral, with only 7.5% of patients having bilateral breast cancer. Most participants had been diagnosed within the past 12 months (91.2%) and presented with advanced disease (74.6%). Treatment adherence was poor, with 77.1% of participants completing fewer than six courses of treatment. Relatives were the primary source of care for all participants.

Distribution of participants across multiple dimensions of coping strategies
Table 3 summarizes the distribution of participants based on findings in the primary, secondary, and tertiary coping strategies. Among the primary coping subscales, the most frequently used strategy was wishful thinking (M = 14.92, SD = 3.58), followed by social withdrawal (M = 13.96, SD = 3.58). In contrast, self-criticism was the least common primary coping strategy (M = 5.49, SD = 3.58). A repeated-measures ANOVA for the primary coping strategies revealed significant differences in mean scores across the eight strategies, F (5.016, 1198.85) = 785.96, p <.001, η² = 0.77. For the secondary coping strategies, problem-focused disengagement was the most utilized (M = 22.32, SD = 3.58), whereas problem-focused engagement was the least utilized (M = 19.17, SD = 5.40). A repeated-measures ANOVA for secondary subscales also revealed significant differences, F (2.317, 553.863) = 69.96, p <.001, η² = 0.27. At the tertiary level, disengagement coping had a higher mean score (M = 41.78, SD = 3.58) compared to engagement coping (M = 39.68, SD = 5.40), indicating that participants were generally more likely to disengage from problems as a coping strategy. Approximately 61.25% (n = 147) of the participants used disengagement coping (e.g., wishful thinking and social withdrawal) predominantly compared to 38.75% (n = 93) that reported engagement coping as their predominant coping strategy. A paired samples t test comparing these two broad strategies revealed a significant mean difference, t (239) = −5.69, p <.001, with a small to moderate effect size (Cohen’s d = −0.367) [26].

Relationship of engagement versus disengagement coping (tertiary subscale on CSI-32) with clinico-sociodemographic variables
Table 4 summarizes the relationship of participants’ tertiary coping strategies (engagement versus disengagement coping) with clinic-sociodemographic characteristics. A significant relationship was observed between the number of children and tertiary coping strategies, χ2(1, N = 240) = 4.93, p =.03, with women who had four or fewer children being more likely to use disengagement coping than those with more than four children. Education level was also significantly associated with the tertiary coping strategy, χ2(1, N = 240) = 5.71, p =.01. Participants with post-primary education levels were more likely to disengage than those with a primary school education or less. Similarly, employment status was significantly related to tertiary coping, χ² (1, N = 240) = 6.38, p =.01, with employed participants being more likely to use disengagement strategies than their unemployed counterparts. In the context of clinical characteristics, both early-stage cancer (stage 1 or 2), χ2(1, N = 240) = 2.94, p =.03, and poor treatment adherence, χ2(1, N = 240) = 3.22, p =.03, were significantly associated with participants being more likely to utilize disengagement strategies. No statistically significant differences in tertiary coping strategies based on age, marital status, or duration of illness.

Regression analysis of factors associated with disengagement coping
Regression analysis was conducted to determine which clinico-sociodemographic characteristics were significantly associated and explained variance in disengagement coping. As shown in Table 5, being employed was significantly associated with the use of disengagement coping (β = 0.974, p =.028), as did post-primary school education (β = 0.777, p =.012), and poor treatment adherence (β = 0.672, p =.040).

Discussion
The increasing incidence and persistently high mortality rates of breast cancer in lower- and middle- income countries (LMICs) are major public health concerns [1–5, 33]. Nigeria has one of the highest standardized incidence and mortality rates globally [6, 33]. While substantial research has focused on the experiences of breast cancer patients, there is a notable gap in the literature addressing the coping strategies of patients currently receiving breast cancer treatment Nigeria, especially in the in South-South region [7–10, 12–20, 34–36]. To address this gap, this cross-sectional study assessed coping strategies and the associated factors of disengagement coping among breast cancer patients in the South‒South region of Nigeria. Several important findings are highlighted, offering insights into the challenges faced by patients with breast cancer.

Overview of clinico-sociodemographic characteristics of participants
Consistent with previous studies, most participants were in their fourth decade of life, were married, and had moderate levels of education, including attainment of secondary or post-secondary school education [17, 34, 36]. The employment rates were also notably high, with 89.2% of the participants engaged in work, primarily civil servants or farmers. However, this contrasts with studies conducted in the southwestern and northwestern regions of Nigeria, which reported lower employment rates of 59.5% and 25%, respectively [34, 35]. These differences may reflect a combination of regional economic disparities and temporal trends [35–37]. Reproductive history also has a well-established role in breast cancer risk. While the literature demonstrates long-term protective effects with higher parity, [38] most participants in this study had children, with over two-fifths reporting four to six children. It is possible that the transient increase in breast cancer risk observed in the years following pregnancy may contribute to the prevalence of multiparous women included in this study [39, 40]. Additional factors, such as higher average parity in the region and nuances among different subtypes of breast cancer, may also provide further context to the findings of this study [41, 42].
From a clinical perspective, most participants presented with advanced-stage unilateral breast cancer and demonstrated poor treatment adherence. Advanced disease presentation has previously been attributed to various factors, including low rates of mammography and ultrasound use in Nigeria, lack of disease-specific education, and sociodemographic factors such as younger age, recent pregnancy, low education and unskilled employment [4, 8, 43, 44]. Despite treatment guidelines recommending radiation therapy alongside surgery and chemotherapy, no participants received radiation therapy in this study because of limited availability of this treatment resource in the study hospital. As of 2021, only eight government-funded radiotherapy machines were available in Nigeria, with just two capable of delivering modern radiotherapy treatment for breast cancer [10, 45]. Treatment adherence was poor in this cohort, with over three-quarters of participants completing fewer than six courses of chemotherapy. Similar findings were reported in a 2011 study by Anyanwu et al., which identified persistently low adherence rates across mastectomy, neoadjuvant chemotherapy, adjuvant chemotherapy, and radiotherapy treatments [24]. The high cost of treatment is a significant barrier: in 2022, the mean cost of care in Nigeria was ₦2,159,309 ($5192.77 USD), whereas the mean annual capacity-to-pay for the cohort was ₦1,192,155 ($2866.93 USD) [36]. Additional barriers included limited knowledge about breast cancer and a high reliance on complementary and alternative medicine [46].

Coping strategies among participants and their relationship with sociodemographic and illness-related variables
A greater proportion of participants in this study demonstrated significantly greater reliance on disengagement coping compared to engagement coping. Specifically, wishful thinking and social withdrawal were the two most common primary coping strategies. Among secondary coping strategies, problem-focused disengagement was the most frequently adopted, whereas problem-focused engagement was the least utilized. These findings align with those of previous studies that highlighted recurrent themes of health condition concealment and lower tendencies for active coping and support seeking among breast cancer patients in Nigeria [16]. However, our findings differ from those of a prospective cross-sectional survey of patients with advanced cancer in Nigeria [17] and the United States, [47] which identified more frequent adoption of engagement and healthy coping strategies respectively compared to unhealthy strategies [17, 47]. Similarly, a cross-sectional study of post-mastectomy breast cancer patients in Nigeria reported higher mean scores for engagement coping strategies than disengagement strategies [17, 28, 31]. These discrepancies may be attributable to modifiable factors such as stage of treatment and access to social and financial resources, which warrant further exploration.
The implications of these findings are significant, as previous research has shown that reliance on unhealthy coping strategies negatively impacts patients’ psychological well-being, resulting in increased psychological distress, anxiety, depression, social isolation, and reduced quality of life for breast cancer patients [12–16, 19, 20]. For example, a 2018 longitudinal study by Stanton et al. in the United States revealed that cancer-related avoidance coping was significantly associated with a heightened likelihood of developing depressive symptoms and experiencing a major depressive episode within a year [48].
Interestingly, disengagement coping strategies were significantly associated with specific sociodemographic and clinical factors, including fewer children, higher education levels, employment, early-stage cancer, and poor treatment adherence. This finding contrasts with reports from other local studies and countries, where higher educational attainment and continued employment following a recent breast cancer diagnosis are associated with better quality of life [49, 50]. However, in the present study context, stigma and misconceptions surrounding breast cancer—regardless of educational or employment status—have been linked to adverse effects on treatment-seeking behavior and overall quality of life [7–9, 13–20]. In the same vein, the role of cancer stage in shaping coping strategies has shown variability, with mixed findings across studies [51, 52]. These contrasting patterns underscore the complexity of coping behaviors and their associations with sociocultural, demographic, and clinical factors. Further, findings of this study also highlight the need for individual- and context-tailored psychosocial interventions that consider the unique contexts of diverse populations, addressing resource disparities and cultural influences that shape coping strategies and their outcomes [17].

Factors independently associated with disengagement coping
Employment and post-primary education were identified as sociodemographic factors significantly associated with disengagement coping. These findings challenge much of the literature on breast cancer patients, which has largely suggested that lower socioeconomic status and lower educational attainment are associated with greater use of avoidance coping strategies [53, 54]. This contrast may reflect variability in the study populations, differences in methodological approaches, or unaddressed cofounders, such as the type of employment, occupational stress, or perceived support within the workplace. It is also possible that certain groups of employed individuals experience unique psychosocial stressors, including role conflict and financial strain, which may contribute to disengagement coping behaviors in specific contexts. Furthermore, the model is not exhaustive; therefore, the roles of several moderating factors identified in previous studies—such as prognostic index, stigma, illness perceptions, and psychological distress among others—could not be examined [17, 20]. Further research is warranted to explore these nuanced relationships within the Nigerian setting and to identify subgroup characteristics that may help explain these divergent findings.
Among the clinical factors, poor treatment adherence was identified as a significant associated factor with disengagement coping, which is consistent with previous findings. Avoidant coping strategies, including behavioral disengagement, have been shown to negatively affect medication adherence in individuals with cancer and other chronic conditions [55]. A study conducted in Ghana similarly reported that behavioral disengagement was among the most frequently utilized avoidant coping strategies in breast cancer patients, potentially undermining their ability to comply with demanding treatment regimens [56]. Additionally, findings from a 2024 multi-centre study suggest that low to moderate levels of hopelessness can moderate the relationship between treatment information and psychological distress [57]. These findings may help explain the low adherence rates for treatments such as mastectomy, chemotherapy, and radiotherapy among breast cancer patients in Nigeria, emphasizing the critical role of addressing psychosocial barriers to care. This highlights the need for further research into the complex interplay between psychosocial factors and treatment adherence, as well as the integration of tailored psychosocial support into cancer care in LMICs.
The importance of addressing psychosocial challenges and promotion of healthy coping in breast cancer is underscored by recommendations from major organizations, including the National Comprehensive Cancer Network (NCCN), [58] the American Society of Clinical Oncology (ASCO), [59] and the International Psycho-Oncology Society (IPOS) [60]. Evidence suggests that interventions that promote adaptive responses in place of maladaptive coping strategies can significantly improve breast cancer patients’ quality of life; however, it is important to consider barriers to implementing such interventions in resource-constrained settings like Nigeria, such as stigma surrounding mental health, resource allocation, inadequate oncology training that integrates psychosocial care, and limited inter-professional models of care [61, 62]. For instance, a cross-sectional study in Nigeria reported that nearly three-quarters of patients did not have access to pre-mastectomy psychosocial support [34, 35]. Moreover, a 2018 study reported that 48.5% of Nigerian breast cancer patients had unmet psychological needs [63]. Efforts to address these gaps should focus on implementing routine screening for psychosocial concerns and distress, addressing the stigma associated with mental health needs, and incorporating the psychosocial dimensions of cancer care into oncology training and services. Such measures are critical for fostering holistic, patient-centred care, and improving treatment adherence and outcomes for breast cancer patients.

Study limitations
The limitations of this study include its cross-sectional design, which precludes causal inference, and the recruitment of participants exclusively from clinical or tertiary hospital settings. The associated factors of coping strategies examined in this paper are by no means exhaustive. For example, prognosis was not operationalized objectively as a distinct variable; however, proxy prognostic indicators such as cancer stage and treatment adherence were captured. Also, information on radiation therapy and molecular tumor typing was not collected in the present study. Notably, radiation therapy is not available at the study site, and molecular tumor typing remains limited or is still evolving in many low- and middle-income countries [10, 64]. Another related limitation is that coping was assessed using a single measurement tool. These limitations should be considered when interpreting and generalizing the study findings to a broader population.
In view of these study’s shortcomings, future research would benefit from the use of multiple validated measures to better capture coping in breast cancer patients as well as employ validated tools-models to assess prognosis and other clinicopathological factors [65]. More broadly, there is a need for validated and culturally sensitive measures and tools in psycho-oncology research. We also advocate for future studies to adopt longitudinal design to better understand the trajectory of coping strategies and psychosocial well-being among patients with breast cancer. Such future studies should also employ larger, more robust sample sizes and encompass broader contexts and populations (e.g., individuals on radiotherapy). It is important to highlight that some of the findings of this study regarding breast cancer services likely reflect the realities and constraints in resource-limited settings, where comprehensive cancer care services are often concentrated in designated regional tertiary hospitals and payment for services is mostly out of pocket [11–13, 17, 64, 66]. Consequently, additional resources and support are needed to expand comprehensive cancer treatment services, strengthen capacity development, and support research efforts [9, 17, 67–71].

Conclusion
This study highlights the high prevalence of disengagement coping among breast cancer patients undergoing treatment in South-South Nigeria. Participants exhibiting disengagement coping were more likely to be employed, have post-primary education, and report poor treatment adherence. Addressing these challenges within Nigeria’s context of limited resources and unique sociocultural dynamics requires culturally tailored interventions that prioritize social support, patient education, and better access to mental health services. Notably, there is a need for the development of scalable, resource-sensitive psychosocial interventions. Future research should investigate the long-term effects of coping strategies on treatment outcomes and survivorship.

Supplementary Information