INFORMATION NEEDS OF BREAST CANCER PATIENTS AT CANCER DISEASES HOSPITAL, LUSAKA, ZAMBIA BY:

Background: Breast cancer is the second most common cancer 
worldwide and the second most common among Zambian women. 
Breast cancer diagnosis being a stressful experience, causes psychological and 
emotional disruption that can be abated by meeting information needs of the 
affected patients. In light of the escalating cases of Breast cancer among the 
Zambian women, the study examined a special aspect of cancer management which 
is usually neglected in most cases. Aim: The main objective of the study 
was to assess information needs of breast 
cancer patients at the Cancer Diseases Hospital in Lusaka, Zambia using 
a modified structured interview schedule adopted from the Toronto Information Needs Questionnaire-Breast Cancer 
(TINQ-BC). Methods: A descriptive 
cross-sectional design was used to elicit the information needs of breast cancer patients. One hundred and ten (97% response rate) participants were selected using simple random sampling method and data was collected using a modified structured 
interview schedule adopted from the Toronto Information Needs 
Questionnaire-Breast Cancer (TINQ-BC). Stata 10.0 
(StataCorp, 2008) was employed for all quantitative data analysis and graphical 
presentation of data. Results: The overall score for information needs was obtained by adding the 
scores across all the five information needs categories which were further divided into three categories namely: low important 
scores, of less than 50%, moderately important scores of 50% - 70% and 
highly important scores ranged above 70% of the 200 total scores. Out of the 
110 participants recruited, 88 (80%) 
indicated that the information across the five categories was moderately 
important. Logistic regression of information needs and posited determinants 
revealed that anxiety levels; education level; presence of co-morbidity; and 
being on treatment were significant determinants of patients’ informational 
needs (Effect’s p ≤ 0.05). Conclusion: The findings of this study 
support the idea that breast cancer patients are seeking more information on 
their illness, hence information provision is one of the most important factors for providing high quality 
cancer care across the whole cancer continuum. Therefore, appreciating 
the information needs of breast cancer patients is substantial in improving 
care.

"Information is a resource that is naturally needed in all human endeavors. One can readily infer that information is indispensable in human life, hence a basic human need, which has an overriding significance to all and diverse" (Olarongbe et al, 2013). Yusuf (2012) stated that "the growth of modern societies as well as individuals depends a great deal upon the provision of the right kind of information". When information is provided in a right form and and at the right time it is able to assist patients make right decisions and reduce uncertainty. Recognizing that the description of tumor characteristics is embedded in medical terminologies which are foreign to most people, the  (Daly, 2015). Therefore in view of the importance of information exchange and treatment decision-making in cancer care, the study assessed information needs as this is crucial in therapeutic intervention and quality cancer care.

Background
Cancer is a leading cause of disease worldwide with an estimated 14.  (2015) report indicates that breast cancer incidence has been increasing.
Cancer is a major life-threatening disease regardless of the stage at which the diagnosis is made.
People who are diagnosed with this disease become psychologically and emotionally stressed (Al-Amri, 2010;Katowa et al, 2015). Those diagnosed encounter stress, anxiety, fear of death and sense of loss of hope (Al-Amri 2010). The diagnosis of Breast Cancer is not an exceptional; it also creates emotional distress for patients as well as family members (Holmes, 2008;Ganz, 2008;Ankem, 2015). Although recent breast cancer treatments are advanced and cause less bodily distortion from surgery than before, the disease and more complex and prolonged treatments over a period of time cause patients to experience treatment-related distress, fear of recurrence, altered body image and sexuality, as well as physical toxicities that result from adjuvant therapy which alter the quality of life (Ganz, 2008;Holmes, 2008).
Since breast cancer and the consequent treatment is highly traumatizing the ability of patients to cope with the disease may be dependent on meeting their information needs. Although information satisfaction is a major predictor of quality of life, the patients' ultimate health outcome is greatly influenced by the way they deal with the information received during their illness. With several studies documenting the benefits of providing adequate information (Yi et al, 2007, Eheman, 2009, Li, 2011, Lei et al, 2011, unmet information needs are associated with negative health-related quality of life (Ladd, 2016); such as high levels of anxiety and depression (Halkett et al, 2012); negative illness perceptions, unrealistic expectations, sometimes costly legal actions and failure for patients to give an informed consent (pif, 2012). In order to mitigate these negative effects Breast Cancer patients' information needs should be met.
While information has the potential of helping Breast Cancer patients make sound decisions in their care, several views have been noted by different studies on the concept of information needs.
Researchers have stated that its definition is either "ambiguous" or it has "several meanings depending on the situation" (Calza et al, 2010;Pieper et al, 2015). Calza and others (2010) studied information needs of patients in Europe and found that information as a concept is related to "meaning, knowledge, instruction, communication, representation, and mental stimulus. In a systematic review of studies analysing the need for health-related information in Germany, information needs were defined as a patients' recognition of having insufficient knowledge to satisfy a goal within the context they found themselves in at a specific time (Pieper, 2015). In addition theories of information seeking refer to the concept of information needs, a state in which an individual is motivated to seek information because of the situation they find themselves in and this is done in order to lessen uncertainty, find answers or make sense of a situation (Case, 2002;Yusuf, 2012).
With the growing use of the internet in gathering health information, the idea of the informed patient has become very vital (Hans, 2010;Yusuf, 2012 Even with great efforts put across with regards to palliative care, radiotherapy and chemotherapy treatment in ensuring that patients receive quality care at Cancer Diseases Hospital, challenges still remain in meeting information needs of breast cancer patients and these include; Patchy and poor coverage of palliative care services due lack of trained personnel and increase in cancer burden though meeting the information needs of patients with progressive, life limiting conditions and their families, in a timely and appropriate way, is a key concern of palliative care. Shortage of oncology trained clinicians leading to insufficient information provision from the few who are stressed out and lack of training in breaking of bad news leading to insensitivity when breaking bad news and fear of scaring patients. Despite, literature showing an association between meeting information needs and quality cancer care (Shea-Budggel, 2014). In Zambia not many studies have been conducted to explore the information needs of Breast Cancer patients. In an effort to assist the clinicians in understanding and addressing the information needs of breast cancer patients, this study provided an insight on the health information needs of breast cancer patients.

Problem Statement
The high burden of non-communicable diseases that Zambia is experiencing has significant consequences on mortality and morbidity and cancer has a substantial contribution among the major four non-communicable diseases (MOH, 2016 Due to the high burden of breast cancer patients seen at CDH, it is likely that information giving to patients maybe lacking. In view of this, it may not be possible to elicit for information needs of patients because as the number continues to grow at a steady pace health care workers are spending less time with patients leading to lower contact time. This leads to inadequacies in identifying information needs at the point of care, and accurately and efficiently meeting this need. In addition the human resource crisis can also be a hindrance to information giving. Inadequate numbers of trained specialized health care workers can lead to decreased attention towards information provision and needs due to the gap between the health care provider and patient ratio (MOH, 2016). Unpublished survey that was done at Cancer Diseases Hospital in 2016 revealed patients being inadequately informed about their condition. In addition patients observed that information provided was not standardized and the mode of transmission was limited. Therefore, there was need to assess the information needs among Breast Cancer patients as recognizing these needs is one of the important aspects in health care delivery because it makes the health care provider-patient encounters more meaningful.

Significance of the Study
This study was conducted to assess the information needs of breast cancer patients at CDH. The study of assessing the information needs of breast cancer patients was very important as it has brought out information needs of breast cancer patients which will help health care professionals to provide information that is important, in turn facilitating decision making and helping patients to cope with the whole cancer trajectory. In addition the study has provided useful information that will help in setting more effective models of delivering information and thereby providing support to breast cancer patients.

Conceptual Framework
Johnson's Comprehensive Model of Cancer Information Seeking (CMIS) was used to conceptualize information needs of patients with breast cancer (figure 1.1). CMIS is categorized into three components that include antecedent factors, information carrier factors and information seeking behaviors (Han et al, 2011). The CMIS theorizes that four health-related factors (demographics, direct experience, salience, and beliefs) and two information carrier factors (characteristics, utility) combine to influence information seeking. Studies have shown that demographic factors such as age, income status and education predict differential use of various health information resources (Han, 2011;Pang, 2014). In these studies age influenced information seeking as it was shown that younger aged Breast Cancer patients were more likely to seek information than the older ones. In the context of health information seeking, direct experience refers to an individual personally having the health issue motivating them to look for information (Han et al, 2011). This shows that direct experience with a stressor predicts health information seeking. Therefore a person's own symptoms or experience with the cancer diagnosis or treatment may influence information seeking.
Salience refers to the perceived threat of the health issue and personal significance of health information, and beliefs are individuals' perceptions that they can do something about the issue.
The challenges resulting from breast cancer diagnosis and its treatment are diverse and complex hence the need for information needs to be met. Salience and beliefs are motivational factors for seeking health information to fill a knowledge gap (Ladd, 2016). Pang (2014) explained that Salience is one of the concepts in CMIS which refers to the personal importance of health information that provides a key stimulus to seek information. For instance individuals may perceive risks with their health and how the missing information is recognized to be significant will result in seeking information to determine the implications of health events for themselves.
Beliefs on the other hand, can constrain or empower individuals to seek information. If an individual believes that the information accessed will be helpful in improving the condition they are in or coping with the crisis, they will likely seek information (Pang, 2014;Ladd, 2014).
Information carrier characteristics refer to the content and style of the message presented (e.g., quality), while utility refers to the perceived personal usefulness of the message. Information carrier factors determine the purpose to seek information from certain carriers. The term "carrier" in the CMIS model is used to describe any informational source or information channel which may  The main objective of the study was to assess information needs of breast cancer patients at Cancer Diseases Hospital in Lusaka, Zambia.

1.7.2.1
To determine the information that breast cancer patients' desire to know with regards to their disease.

Information
These are facts that are accurate and timely, specific and organized for a purpose, presented within a context that gives meaning and relevance and can lead to an increase in understanding and decrease in uncertainty (Online business dictionary, 2012).

Breast cancer
Breast cancer is a malignant (cancerous) growth that begins in the tissues of the breast (Williams et al, 2011).

Information needs
A patient information need is a recognition that knowledge is inadequate to satisfy a goal, within the context or situation that someone finds themselves in at a specific point in time (Ormandy. 2011).

Diagnosis
The identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history and the results of diagnostic tests and procedures (Potter and Perry, 2009).

Cancer treatment
Cancer treatment is the involvement of medical procedures to destroy, modify, control, or remove primary, regional, or metastatic cancer tissue (National Institutes of Health, 2015).

Prognosis
Guess of the likely order and outcome of an attack of a disease and the projections of recovery as indicated by the nature of the disease and symptoms of the case (Medical dictionary, 2012).

Information
These are facts concerning breast cancer diagnosis, treatment and prognosis given by medical personnel to breast cancer patients that gives it meaning and relevance, and can lead to an increase in understanding and decrease in uncertainty.

Information need
Information need is breast cancer patients' desire to locate and obtain information to satisfy a conscious or unconscious need and a requirement that drives them into information seeking. It evolves from an awareness of something missing, which necessitates the seeking of information that might contribute to understanding and meaning.

Dependent Variable
The dependent variable for this study was Information needs of breast cancer patients.

Independent Variable
The independent variables for this study were the following:

Variable cut off-points
Below is a table for variable cut-off points

LITERATURE REVIEW 2.1 Introduction
A literature review surveys books, scholarly articles, and any other sources relevant to a particular issue, area of research, or theory, and by so doing, provides a description, summary, and critical evaluation of these works in relation to the research problem being investigated (Arlene, 2014). It is designed to provide an overview of sources explored while researching a particular topic and to demonstrate how the research fits within a larger field of study. This chapter focuses on information needs of breast cancer patients. Various search engines were used to search for literature and these included; Pub Med, Google Scholar, Google books, Medline, online journals and others. In this study the literature review is arranged according to the study objectives.

Overview of Information Needs for breast cancer patients
Information needs of breast cancer patients have been investigated by several studies especially in the western countries, which have revealed the importance of information provision in cancer care.
A study conducted in Switzerland on the exploration of cancer information-seeking experiences revealed that information is vital for patients in coping with the diagnosis of cancer and making decisions about treatment plans (Germeni et al, 2015). Information needs lead to information seeking and Germeni et al (2015) defined cancer information seeking behavior as the "purposive or goal driven acquisition of cancer related information" and identified it as a key coping strategy that can enable individuals to deal with stressful illness-related events, such as the shock of initial diagnosis. The concept of health information seeking behavior is an important notion in the field of health communication as information is an essential part of cancer management access to it is a basic fundamental right (Yusuf, 2012). Studies of information needs are not new in the field of health communication, both previous and current studies that have investigated the importance of meeting information needs of Breast Cancer patients have shown that these patients need information to help them understand the disease, its treatment and allow them to interpret the aversive events and action taken, so that the threat inherent from the diagnosis becomes lessened (Lee et al, 2004;Teriman et al, 2014).
Individuals in life-threatening situations need information to understand the implications for their well-being. Breast Cancer patients want more information on why and how they can expect to physically respond to treatment, the medical management of the disease, and side effects of treatments (Lee, 2004;Teriman et al, 2014). In a longitudinal study that was conducted in Malaysia by Lei et al (2011) they found that Breast Cancer patients have high levels of information needs and it is helpful for them to gather information because it empowers them to take control of their healthcare and comply with the treatment. Similarly Teriman and others (2014) noted that there is an association between patient empowerment in meeting information needs and satisfaction with care. Patients who have no access to quality information are more likely to seek information elsewhere from less trustworthy sources. Hence unreliable information can lead to incorrect selfdiagnosis and/or increased feelings of anxiety and stress (Macmillan Cancer Support, 2010).
However, much as studies in the field of health information have shown that a well-informed patient may also be better equipped to guard against medical error; other studies have shown that not all patients need information for fear of mental discomfort (Germeni et al, 2015). In a study conducted by Leydon (2000) among cancer patients on the factors affecting patients' uptake of information, He concluded that patients' orientations toward faith, hope and charity may cause them to avoid disease related information in order to maintain hope.

Information Needs of Breast Cancer Patients
The concept of information need is a complex and difficult notion to describe even though information has been around for ages and a basic fundamental right (Yusuf, 2012). According to Yusuf (2012), information need is described as a recognized mental state in which an individual's need causes the search behavior of information seeking in a given context. The diagnosis of breast cancer can be so disturbing that it causes several adverse reactions for the majority of women.
Many women develop symptoms of psychological distress such as anxiety, depression, fatigue and pain among others (Al-Aziri, 2014; Kalusopa, 2014). The situation necessitates an inquiry of the information cancer patients need. An understanding of their information needs can help tailor patient education to empower and to support coping. It can also guide health care professionals in delivery of care (Ankem, 2015). To cope with the stress of this diagnosis, women tend to adopt a number of strategies on how to deal with the diagnosis and redefine themselves and their lives accordingly. These may include turning to God through prayer, seeking for information and family support (Katowa, 2015). Abrahamson (2010) in United States of America conceptualized need in the context of cancer treatment as a resource necessary for patients and families to live and function with the diagnosis of cancer. Information needs are prevalent among Breast Cancer patients. The information needs of Breast Cancer patients are caused by a variety of factors including the disease itself, treatment, side effects, investigations, fear of death and social life. Therefore, information needs assessments are essential because they guide care planning, in that many caregivers and patients do not communicate concerns to their health professionals. In a European survey conducted by Maddock (2010) the study showed that patients are becoming more active consumers of health-related information. It is clear that information is vital in coping with breast cancer; therefore information is an important part of cancer care. With the improved cancer treatments Breast cancer patients are becoming long term survivors and are experiencing long term side effects from the treatments.
Assessing which information needs are of highest priority and prioritizing them has been reported to make patient encounters more meaningful ( In addition, researching on preferred information Mekuria et al (2016) also concluded that the principal information regarded as the most important by the majority of the patients was on the specific type of cancer (name and stage of cancer), followed by the side effects of chemotherapy and its management (63.29%) and "prognosis (survival)" (51.8%). They further added that the majority of their respondents (70.3%) were not satisfied at all or satisfied a little with the information regarding cancer. Therefore these findings suggest that breast cancer patients want information on disease, treatment and prognosis.

Treatment information needs
Diagnosis and disease have a significant bearing on patients' medicine-information desires (Duggan and Bates, 2008). In addition studies by Ladd (2016) and Greco et al (2016) reported patients searching for medical information which included facts on chemotherapy, radiotherapy, and surgery. Following 104 patients in a study on whether information needs decrease over the course of radiotherapy treatment, the researchers found that the needs remained high despite the duration between the initial consultation and first follow-up (Douma et al, 2012).

Prognostic information needs
Prognostic information is necessary for cancer patients to be fully informed about the likely course of their disease and the information is needed for practical planning and treatment decisions (Cartwright, 2014). Although it was important for cancer patients to be informed about their prognosis, this need was not met as the study found that it was uncomfortable for both the physicians and patients were quick to shift from discussing the patient's cancer and diagnosis to discussing treatment options (Ghandourh, 2016).

2.4: Factors influencing information needs
Studies suggest that there are several factors that have been found to influence information needs which include anxiety, age, education level, stage of cancer, presence of comorbidities and time since diagnosis (Ankem, 2012, Jensen et al, 2014, Tan et al, 2015. Demographics and clinical background of patients have contributed to different patients having various information needs. Tucker (2017) noted that understanding that demographics influence information needs and meeting them are crucial to improving the quality of care for Breast Cancer patients. Similarly in a study conducted in China by Bei (2015) demographic and clinical characteristics were shown to influence information needs.

Anxiety
In her study on defining information needs in health, Ormandy (2010) noted that psychological states of anxiety, depression and feelings of control affect information needs. She further stated that" an individual could experience cognitive uncertainty manifesting as anxiety resulting from their judgment of the knowledge required to overcome challenges or problems". A study by Beekers et al (2015) showed a relationship between the severity of the disease and the patients' anxiety and depression which they concluded that providing cancer patients with information decrease concerns about the adverse effects of psychological disorders on physical performance, life expectancy and personal and social relationships.
In another study Zadeh et al (2016) showed that some cancer patients prefer to first receive information about stress disorders, because many patients develop psychological complications such as anxiety and depression after the diagnosis of cancer which is intensified by difficult therapies such as surgery and chemotherapy.

Age
Younger age has been associated with actively seeking information (Eheman et al, 2009). In addition Chaudhuri et al (2013) noted in the study examining health information-seeking behaviors of older adults for cancer survivors that older women were less likely to seek information compared with their younger counterparts. Generational differences were also noted to affect information needs and source preferences as young patients were likely to seek information from other sources such as the internet compared to older women who prefer more passive roles and express less need for information (Tucker, 2017). She further found that younger women with breast cancer experience difficult situations that cause them to look for information such as treatment-related sexual dysfunction.

Education
Higher educational attainment has been associated with actively seeking information beyond that available in the medical care setting (Tucker, 2017;Eheman et al, 2009). In a study on understanding health information seeking behaviors of adults with low literacy, it was found that the uneducated do not seek information as they are likely to miscommunicate with their health providers (Feinberg et al, 2015). Similarly Tucker (2017) stated "that inadequate health literacy poses barriers to patients' understanding of their disease and treatment options". Hence lower educational level has been found to be associated with less active information-seeking style.

Time since diagnosis and stage of cancer
The time since cancer diagnosis and the degree of illness have also been shown to influence how much and what information a patient desires (Eheman et al, 2009). According to a study by Zadeh et al (2016) they suggested that cancer patients' information needs are determined by the progress of the treatment and the time elapsed since the diagnosis of the disease. They further found that those who have been living with the disease for a long period and completed treatment have less information needs compared to the newly diagnosed. In addition King et al (2015) noted that patients' still receiving treatment had more information needs than those on palliative care or recovering. In another study the information needs were necessitated by the type of cancer and the need was more pronounced in patients with early-stage disease (Nagler et al, 2010).

Conclusion
Researchers have noted that health information seeking behaviour has become an important concept in the field of health communication and for people diagnosed with cancer, both the opportunity to provide input about their care and having information about their disease; prognosis and options for treatment are vital (Eheman, 2009, Germeni et al, 2015. Abrahamson et al (2010) stated that "Within the context of cancer treatment, needs are defined as resources necessary for patients and families to live and function with a diagnosis of cancer". These findings suggest that for breast cancer patients to be able to cope with the diagnosis and complex treatments they go through information is important. Hence Henselmans et al (2011) further suggested that physicians require insight in the type and content of these needs in order to improve the quality of cancer care.
Noting from above, a large number of studies have been conducted of cancer patients' information needs, how they seek information and how they use it. Almost all the literature that has been presented is from the western world and not much has been published from Zambia, hence a study in this area will help in identifying strategies that will help care providers offer relevant information needed by this patient population. METHODOLOGY

Introduction
This chapter describes the methodological techniques used in this study. They include details of the study design, study setting, sample criteria, instrument, pilot study, data collection tools, data management and analysis. Ethical considerations and plans for dissemination are equally presented.

Study Design
A descriptive, non-intervention, cross sectional design was used to investigate the problem under study. The study was non-intervention because the investigator did not introduce any form of intervention or any control group. A Cross-sectional design was used in this study because the designs of this nature are useful in assessing practices, attitudes, information and beliefs of a population in relation to a particular health related event. Therefore a descriptive study was used so as to collect rich data in large amounts that could be a basis for further research using different research techniques. The results from this study will not only give an indication of the information needs of breast cancer patients at CDH, but also provide a basis for designing appropriate planned and systematic approach of meeting information needs of cancer patients.

Research Setting
The study was conducted at Cancer Diseases Hospital (CDH), a government hospital serving patients from across the country and neighbouring countries. It offers specialist in-patient and out-patient services and serves as a referral hospital for all confirmed cancer cases in Zambia.
The hospital offers various services which include treatment with chemotherapy and radiotherapy as major treatment modalities for management of cancer. Other services offered are patient screening, laboratory, and follow-up care. There are two days in a week namely Tuesday and Wednesday allocated to breast cancer patients in terms of screening of new patients follow-up respectively.
Being the only Cancer Diseases Hospital in the country, the in-patient department was opened in 2016 with a bed capacity of 262 for admissions and has wards for paediatric, adult male and female patients. The study setting was the most suitable place for the researcher to capture the target population as cancer patients from all over the country are treated at this facility.

Study Population
The population for the study comprised all breast cancer patients aged 18 years and above who were being treated for cancer or being followed -up at Cancer Diseases Hospital from April 2006 to September 2017.

Sample Selection
Convenience sampling a non-probability sampling method was used to select the study setting because it is the only Cancer Diseases Hospital in the country. This was the most suitable place for the researcher to capture the target population as cancer patients from all over the country are referred and treated at this facility. Participants were selected using simple random sampling method. In simple random sampling each member of population is equally likely to be chosen as part of the sample. It has been stated that "the reasoning behind simple random sampling is that it removes bias from the selection procedure and should result in representative samples" (Gravetter and Forzano, 2011). At CDH twenty-five breast cancer patients are seen every week as out patients. Therefore twenty-five pieces of paper were written and put in a box, twenty of them had a YES written on them while the other five had a NO and those patients who picked a YES were recruited in the study excluding those with a NO.

Inclusion criteria
The inclusion criteria included all breast cancer patients seen at CDH from 2006 to September 2017. These included those who were aged 18 years and above, confirmed diagnosis of breast cancer and living with breast cancer diagnosis, those willing to participate in the study and those who were physically and cognitively able to participate in the interview process.

Exclusion Criteria
The study excluded new patients who were just being screened on the day for interviews. Those who were eligible but did not consent and the physically and cognitively unstable patients also excluded.

Sample Size
The sample size was calculated using the proportion precision formula; n = Z 2 x P (1-P) / d 2  The sample size was one hundred and thirteen respondents (113).

Data Collection Tool
A structured interview schedule was used to collect data for this study. The tool had five sections which included (a) Demographic data, (b) Medical related data, (c) Anxiety rating scale, (d) information needs and (e) Barriers to information provision. The interview schedule was constructed in English. Translation of the information sheets was done into the four common languages in Lusaka and these were Nyanja, Bemba, Tonga and Lozi so as to help the participant's understand the purpose, benefits and risks of the study.
Two separate tools were adopted and used which contained constructed questions. These were the Hamilton Anxiety Rating Scale (HAM-A) which was used to measure the anxiety section and the Toronto Information Needs Questionnaire-Breast Cancer (TINQ-BC) which was used to evaluate the informational needs of breast cancer patients). The Hamilton Anxiety Rating Scale (HAM-A) was also adopted from occupational medicine and used in measuring the patient's anxiety (Thompson, 2015). It is a widely used and well-validated tool for measuring the severity of a patient's anxiety. The scale consists of 14 items, each defined by a series of symptoms and measures both psychic anxiety (mental agitation and psychological distress) and somatic anxiety (physical complaints related to anxiety) with the sensitivity of 85.7% and specificity of 63.5% (Thompson, 2015) Each item is scored on a 5-point scale, ranging from 0 = not present to 4 = severe with a total score range of 0-56, where 14 -27 indicates mild anxiety, 28-39 moderate anxiety and more than 40 as severe anxiety. The HAM-A was one of the first rating scales developed to measure the severity of anxiety symptoms, and is still widely used today in both clinical and research settings (Shear et al, 2001;Thompson, 2015).
A modified structured interview schedule adopted from the Toronto Information Needs Questionnaire-Breast Cancer (TINQ-BC) was used to evaluate the informational needs of breast cancer patients (Galloway et al, 1997). The tool was developed to assess the specific information needs of women with breast cancer and comprised five subscales which included disease, investigative tests, treatment options, physical, and psychosocial needs. Each item on the questionnaire began with the stem: "To help me with my illness it is important for me to know." Participants were asked to rate the importance of each item on a Likert-type scale with one = "not important", two, = "slightly important", three = "moderately important", four = "very important", and five = "extremely important". The overall score for information needs was obtained by adding all the scores across all the 5 information needs categories. Therefore, for each patient the information needs score was between minimum 40 units and maximum 200 units. Further, the scores on the information needs were divided into three categories; low important scores were less than 50% of 200, moderately important was from 50%-70% and highly important scores ranged above 70% . This tool was chosen for this study because it meets the criteria of measuring the information needs of breast cancer patients as it had been tested and found effective by many researchers. It also afforded patients to rate the important information that they need. The operational definitions of the subscales are shown below as adopted from Spittler (2011).  , 2006). To ensure the validity of the instrument, the questionnaire had content validity based on findings in the literature and opinions of expert resarchers and questions were constructed in a simple and specific way in order for the respondents to understand clearly so as to avoid vagueness. The instrument used was adopted from the Toronto Information needs questionnaire-breast cancer which was developed and tested in Canada and had been successfully utilized by various studies (Yi, 2007;Ankem,2005; Galloway et al, 1997).

Reliability
To ensure reliability of the research instrument, a pilot study was conducted to test the research instrument before the main study. Adjustments were made to the questionnaire as only those question which where applicable were included.

Data Collection Techniques
After the ethical clearance was granted from the University of Zambia, Biomedical Research Ethics Committee and permission sought from CDH, each interview was conducted by the researcher over a period of six weeks. The researcher introduced herself to the participants in order to make them feel at ease and participate without fear. The purpose, benefits and risks of the study were explained to the participants to enable them to get involved in a study that they are aware of.
To enable the participants participate without fear, confidentiality was assured and they were informed that the interview was face to face in a private room. Written permission was sought from the participants to conduct interviews.
Participants were given time to go through the information sheet (appendix I) and afterwards were availed with the consent form (appendix II) on which they appended their signatures as endorsement to participate in the study. Assurances were given that all the information that was provided by the participants was treated with confidentiality. The researcher read the questions carefully to the participant so as to make them understand. Questions that were not understood were repeated without giving answers to the participants. All the responses were immediately noted down on the interview schedule to avoid missing out any information. The interview took approximately 20 minutes.

Pilot Study
A pilot study was conducted at Cancer Diseases Hospital to determine the reliability and validity of research instruments and test for feasibility of the study.CDH was used for testing the tool as it is the only hospital providing cancer services. The sample size of the pilot study was 10% of the actual study sample population, which translated to 11 respondents. The pilot study was conducted on patients who had come for review. Breast cancer patients who have finished treatment come for follow-up every three, four, six months or annually, therefore patients who participated in the pilot study could not be interviewed again within the six weeks in which the researcher collected data.

Ethical Considerations
Ethical clearance was obtained from the University of Zambia Biomedical Research Ethics Committee. Permission to conduct the study was also obtained from the CDH Management. Verbal and written consent was obtained from the participants who participated in the study following a brief explanation on the purpose, procedure, discomforts and benefits of the study. Respondents were reassured of the right to participate or withdraw from the study and that no privileges were to be taken away if they decided not to take part while those who were willing to participate were made to sign the consent form.
The participants were assured of anonymity and confidentiality of personal information that was to be shared with the researcher, as no name was written on the interview schedule and the information given was not attached to any name.
Participants were not subjected to any physical harm as the research was not involving any invasive procedures. Since cancer is a traumating chronic disease some patients who experienced discomfort or stress due to the interview, were made to receive counselling immediately or afterwards depending on the need. Counselling was done by researcher who is a psychosocial counsellor and has been involved in counselling cancer patients and their families and thus the psychological needs were met as well as appropriate referrals. The participants might have been inconvenienced by the time that was spent when collecting data as collecting from an individual over a prolonged period might have affected them and this was addressed by making sure that the interview was conducted within twenty minutes or less. No rewards or monetary incentives were given to participants.

Data Analysis
After data was collected, the questionnaires were checked for completeness, consistency, legibility and accuracy in order to correct mistakes.
Categorization of the open-ended questions, which involved reading through all responses and grouping answers that belonged together, was done.
This enabled the researcher to report percentage of respondents giving answers that fell in each category. Codes were assigned to each category, entered and analysed using Stata10.0. The crude strength of association between having information needs and posited predictors information needs was estimated with Pearson's chi-squared test. All the variables determined to be having a statistically significant association with the primary outcome (significant level of p < 0.05 on the Chi 2 Statistic) were employed to conduct multivariate analysis in a logistic regression model. These variables also present as a priori determinants in future research. However, variables that do not indicate a crude association with the information needs (i.e. p>0.05) were all included in the final logistic regression multivariate model to be examined as possible confounders of information needs.

PRESENTATION OF FINDINGS 4.1 Introduction
Chapter four presents the results of this study. The aim of the study was to assess the information needs of breast cancer patients at Cancer Diseases Hospital, in Lusaka. One hundred and ten (110) participants took part in the study representing the response rate of 97%. Structured interview schedules adopted from the Hamilton Anxiety Rating Scale (HAM-A) and the Toronto Information Needs Questionnaire-Breast Cancer were used in measuring the patient's anxiety and evaluating the information needs of Breast Cancer patients respectively.

Data Presentation
Research findings have been presented according to the sections of the questionnaire. Some data were grouped together to give an overall picture. Data were presented using frequency tables, percentages and histograms to communicate research findings.

Section A: Socio-Demographic Data
The Social-demographic data that was collected comprised of age, marital status, education level and occupation. Findings have been presented in table 4:1 below.

Section B: Breast Cancer Medical Information
This section included respondent's medical related information such as, how long the respondents had lived with the diagnosis of breast cancer, the stage of the tumour at diagnosis, if they were on any treatment and the type of treatment they were receiving and if they had any co-morbidities.
Findings have been presented in table 4:2 below

Section C: Anxiety Levels of the Participants
This section consists of findings on the anxiety levels of the paricipants after the diagnosis. The Hamilton Anxiety Rating Scale (HAM-A) was adopted and used in measuring the patient's anxiety (Thompson, 2015). This section covered 14 questions on a five point Likert scale: 0-Not present 1-mildly present, 2-Moderately present, 3-Severely present, 4-Very severe. This part of the questionnaire was giving a minimum score of 14 and maximum of 56. Further, the scores were divided into three categories; mild anxiety ranged from 14-28 scores, moderate anxiety from 29-39 and severe anxiety ranged above 39 scores.
A histogram below was used to present the results of the respondents' anxiety levels .

Section D: Information Needs
This section consists of findings on the information needs of Breast Cancer Patients. In order to assess the information needs of the participants, Item analysis determined that 41 items in five subscales should be retained in the questionnaire. The subscales were categorized as Disease,  Tables and histograms below were used to present the level of respondents' information needs.  Out of the 110 participants that were recruited in the study, 71.8% of the participants were of the opinion that information was moderately important, 21.8% of them attached great importance to most indications of the disease process information needs and 6.4% were of the opinion that the information was of low importance.  Out of the 110 participants who took part in study 76.4% of them were of the opinion that the information was moderately important whereas 18.2 % of the participants indicated that the information was highly important and only 5.5% indicated that it was of low importance.  Out of the 110 participants who wer recruited in the study, most 73.6% of the participants indicated that the treatment modalities information was of moderate importance whereas 18.2% of them indicated that it was highly important and 8.2% indicated it was of low importance.  participants who were recruited in the study, 70% of the participants indicated that the information was moderately important, 17.3% indicated the information was highly important and 12.7% participants'were of the opinion that the information was of low importance.

Overall informational needs among Breast Cancer patients -Cancer Diseases Hospital, Lusaka
Low Importance Moderately Important Highly Important

4.2.5: Section E. Association of Information needs and posited determinants.
This section presents results of the Logistic regression of information needs and posited determinants. After conducting the Logistic Regression, from the measures of effect (Odds Ratio, p values) and confidence intervals in it was determined that anxiety levels; education level; presence of co-morbidity; and whether on treatment or not were significant determinants of patients' informational needs (Effect's p=<0.05). Tables of the association between information needs and posited needs determinants are presented below.    27.2% Table 4.8 above showsm most respondents (81%) cited health providers' lack of ample time to attend to them as a common barrier to accessing information.75.9% of the respondents alluded to health care providers as being to busy to give them information. 72.9% thought there were too many patients and 50% of the respondents thought patients were scared to ask questions.

Introduction
This chapter discussed the results of this study. The main objective of the study was to assess information needs of breast cancer patients at cancer diseases hospital in Lusaka. Information needs of breast cancer patients, age, educational level, stage of cancer, time since diagnosis comorbidities and anxiety were variables under analysis.

Demographic characteristics of the respondents
These were included so that they provide the researcher with a better understanding of how they may influence the information needs of breast cancer patients. Most of the respondents were in the age group of 50 years and above (57.3%). This could be attributed to the fact that cancer affects the elderly more than the young ones. This has been affirmed by White et al (2014) who suggested that cancer can be considered an age-related disease because the incidence of most cancers increases with age. In addition Anders et al (2009) also noted that breast cancers diagnosed among premenopausal women was relatively uncommon. About (50.9%) of the respondents were married. This could be attributed to the spousal support enjoyed by married couples which help them seek medical attention early for worrisome symptoms. This reason is in support with Adekolujo et al (2016) in a study conducted in the United States that reported similar results.
The findings revealed that there were 11 (9.6%) respondents with no education, 34 (29.6%) with primary level education, 36 (31.3%) with secondary level education, and 34 (29.6%) with tertiary level education (Table 4.1). Using the odd ratio there was an association between information needs and level of education for those who had reached University education (OR=44.8; p Value 0.027). It was determined that patients with University Education were 46 times more likely to have information needs. There was no difference between those with no formal education and those with primary, secondary and college education (Table 4.5). This could be attributed to good health seeking behaviour of the educated people. Educated people are well informed hence can ask more questions and are able to communicate with the health care providers freely.

Medical characteristics
This section discusses the medical characteristics of the respondents. A greater majority of the respondents, 92 (83.6%), reported having been living with breast cancer for at least 1 -4 years.
The duration that they had lived with cancer did not influence the information needs of the participants in this study (Table 4.4).This could have been influenced by the hope that these patients had towards recovery as most of them could have had faith that they will be cured of there disease. In contrast (Tucker, 2017) reported that those who had lived with cancer for a short duration had more information needs compared to those who had it for longer years. Most of the participants (84.6%) were on treatment either chemo-radiation or hormonal and only (15.4 %) had completed their treatment and were just on reviews. This is attributed to the fact that Breast cancer treatment takes long as a patient has to go through all the common four modalities namely Surgery, chemotherapy, radiation and hormonal treatments.
More than half of the participants (61.8%) did not suffer from any conditions such as hypertension and diabetes. Using the odd ratio there was an association between information needs and presensce of co-morbidities (OR=39.0; pValue 0.028). The patients who had other conditions such as hypertention and diabetes were 39 times likely to have information needs compared to those who had none. This could have been due to the reason that cancer is already a distressing diagnosis, having another diseases could be a sorce of extra stress which needs to be allevited by having more information.

5.3: Information Needs of Breast Cancer Patients
The first objective was to assess the information that breast cancer patients desired to know about their disease. The findings of this study revealed that the majority of the participants 80% showed significant information needs on all the categories of information (Figure4.7). The participants were interested in receiving moderate information in all the categories of information needs. This could have been attributed to the questions asked in the adapted TINQ -BC questionnaire were participants may be comfortable rating themselves neither low no high. This is supported by McLeod (2008) who stated that sometimes the "validity of Likert Scale attitude measurement can be compromised due social desirability" meaning that "individuals may lie to put themselves in a positive light". This finding could also be attributed to the fact that patients want to retain hope and therefore only want to receive positive information. In a study conducted in London by Leydon et al, (2000) it was suggested that patients may not be interested in information beyond what their physicians could offer in order to maintain hope. In addition Holmes (2008) noted that women placed a high importance on information that is tailored to meet their specific need in managing their illness.
Among the five categories of the information needs that were presented in this study, the findings In this study information on Investigative tests were positioned as first in priority of information needs. This could be attributed to that investigative tests in cancer management are done so often in order to monitor patients' treatment. The findings corresponds with the study findings of Holmes (2008) which revealed that women desire information regarding the rationale for the test as blood work often signifies how their body is adapting to treatment. This study found information regarding treatment as the second priority. The reason could be that these patients want to know what is involved with treatment, including the benefits and risks, any options, and what may happen if the patient chooses not to go ahead with treatment. The findings are similar to the finding by Holmes (2008) who found that treatment information is necessary to help women cope with and understand what is ahead in their cancer trajectory. Information regarding the disease process provides women with the information needed to make informed decisions regarding their treatments.
Findings of this study were that the information regarding the disease and physical needs was fouth in priority. This could be due to that the disease items were assessing information needs about the nature and process of the disease and physical items assessed information need about the preventive, restorative and maintenance care that may be needed as a result of the disease and treatments. Hence Breast Cancer patients in this study were already aware of their diagnosis and could have started coming to terms with what they were going through therefore making both the disease and physical needs fouth in priority. This was contraly to what Teriman et al (2010) found in their study where the information on the disease was second in priority. The study suggested that was natural for patients to want to know what type of cancer and what stage of the disease they have, as most patients fear certain types of cancer and advanced stage of the disease since they are usually associated with shorter survival.

5.4: Factors influencing information needs
The second objective was to establish the factors influencing information needs of breast cancer patients. In order to establish this, strength of association between having information needs and suggested predictors of information needs was estimated with Pearson's chi-squared test. From the Chi-squared association only anxiety (p-value 0.018) was significally associated with information needs startistically. Therefore in order to obtain the true effects of these variables we conducted a multivariate analysis with logistic regression and controlled for the confounding effects (Tables 4.4-Table 4.7). The final results in the multilevel model showed the presence of confounding effects as some of the variables that showed no association on crude chi square analysis were significantly effecting the information needs after logistic regression multivariate analysis. In this study, anxiety, attaining university education, presence of co-morbidities and being on treatment were significantly associated with information needs.
In our study, after adjusting for the confounding effects of education level, level of co-morbidity, whether patient was on treatment or not, and treatment length, compared to patients reported to have no anxiety, patients with high anxiety were 12 times more likely to have information needs (OR=11.7; p Value 0.028). This finding shows that a diagnosis of breast cancer causes a state of anxiety as breast cancer is a life-threatening disease. The findings of this study agree with the findings of You (2017) which revealed that approximately 30% to 54% of patients suffer from anxiety within two years after diagnosis and 13% to 15% have symptoms of anxiety that persist for years. When a client experiences anxiety the need for information increases and consequently health care providers should provide the necessary information.This study suggests that anxiety is common in cancer patient populations, and it's essential for health care professinals to recognize and manage it. The finding of this study suggest that increased information supply to cancer patients can be used as a management strategy by cancer care professionals, Therefore the result of this study collaborates with results by Faller et al (2016) who found that there was a relationship between information satisfaction and symptoms of depression and anxiety. Hence, stating that "provision of information may reduce subsequent depression and anxiety, while reducing depression and anxiety levels may increase satisfaction with received information".
In this study, attaining university education was found to affect the information needs of the participants (OR 45.8, pvalue-0.027). This finding suggests that educated patients have more information needs than those who are not. This could be attributed to that those who are educated are able to communicate with health professional freely hence they ask questions where they are not clear. The other reason could be that the educated patients seek medicak attention early and are usually involved in their care and would want to understand whatever the health professionals are doing on them. The results are similar to a study conducted by Eheman (2009) which indicated that higher education attainment did influence the importance ratings of information needs and influenced coping skills and those. These findings therefore have an implication for how health professinal interact with well-and less-educated patients.
The findings in this study were that the presence of other diseases such as hypertention and diabetes were associated with information needs (OR=39; p Value 0.028). This could be that breast cancer is already a distressing disease, having two conditions makes the patient stressful hence having a lot of questions on hoe they will cope. The results are similar to a study conducted by Baine et al (2011) which showed that the psychological stress caused by other diseases were the motivating factor forseeking more information. Further more patients with comorbidity have poorer survival; poorer quality of life, and higher health care costs was the most important determinant of information seeking.
In this after adjusting for the confounding effects of anxiety; education level, presence of comorbidity, and treatment length, patients who were not on treatment compared to patients on treatment were 99% times less to seek for information (OR=0.01; p Value 0.004). This could be due to that patients on treatment were still experiencing the fear of whether they will recover or not, probably they could have been still experiencing side effects of treatment. This reason is in support with Adekolujo et al (2016) in a study conducted in the United States that reported that married women on cancer treatment needed information. ). In addition studies by Ladd (2016) and Greco et al (2016) reported patients searching for medical information which included facts on chemotherapy, radiotherapy, and surgery. Therefore the study suggests that special attention should be paid to the breast cancer patients as information and social support may help improve their prognosis In this study the other factors such as age (p value-0.271), stage of cancer (p value-0.281), and length of illness (p value-0.331) did not affect the information needs of breast cancer patients. This could have been probably due to the current trends in cancer treatment modalities or the accessibility to cancer treatment which has led to individuals living as normal as possible.These results are in contrast with some previous studies which reported that information needs in breast cancer patients are associated with patients' demographic characteristics such as age, education, stage of cancer, duration of illness, presence of co-morbidities and occupation (Omady, 2008;Eheman, 2009;Nolke, 2015;Tucker, 2017). The current findings suggest that the patients' information needs could have decreased slowly with time as they came to terms with their diagnosis.

5.5: Barriers to accessing information
Respondents were asked to state the problems they encountered when looking for information as shown in Table 4.8 above. The study revealed that respondents indicated that the health providers did not have adequate time to attend to patients as a common barrier to accessing information.
Respondents noted that there were few doctors to attend to too many patients; hence they were mindful of the time to talk and ask questions. Thus, most respondents cited limited interaction time with doctors due to high patient volume as a barrier to accessing information, as doctors were too busy. The findings are similar to those conducted by Eames et al (2010) in the United States of America who noted similar results which included not knowing what to ask, patients being "pushy" to get information, and busy or inadequate numbers of health professionals.

5.6: Implications to Nursing
The implications are going to be discussed under the following headings: nursing practice, nursing administration, nursing education and nursing research.

Nursing Practice
The findings have provided information on the information needs of breast cancer patients. This study found that women with breast cancer at Cancer Diseases Hospital need information related to their diseasey. An understanding of the information needs from the patients' perspective is an important aspect in improving quality care. This study also demonstrates that patients with breast cancer are psychologically distressed and need information ( Table 4: 4) and because distress is a common symptom among this patient population, it is important to include measurement of psychological distress into nursing assessment procedures. The study has also revealed that educated patients have more information needs than those who are less educated but because they easily communicate with healthcare providers, there needs may easily be met. Therefore there is need to engage those with less education as they may not be able to easily give out their views.

Nursing Administration
The study has shown that provision of information that match patients' informational needs assists patients with recovery as some studies suggests that information seeking among breast cancer patients was associated with improved quality of life. The study also has shown that there is shortage of health staff compared to the number of patients hence making it impossible for health professinals to spend a lot of time with patients. Therefore nurse managers should influence development of strategies related to information delivery to breast cancer patents where the information giving session will be based on the needs of the patients themselves, considering the appropriate ways that information is delivered to them using various forms like in a written form, oral communication, using graphic display or multimedia presentation.

Nursing Education
The findings of this study show that there is need for Nursing Training Institutions to design educational resources and clinical services that enhance acquisition of skills in information provision that is necessary in clinical practice. This will in the long run lead to improvements in the training of nursing students; hence producing competent graduates who will be able to deliver comprehensive and quality care to cancer patients.

Nursing Research
The literature review during this study reveals that a lot of studies have been done in assessing the information needs of breast cancer patients but all these are done in the western countries. More research is to be done in information needs of cancer patients as there is a need for further knowledge on patient information in lifelong disease trajectories. The information obtained by a nurse researcher can be disseminated to nurses who work directly with the individuals to whom the research applies. Practice that has shown to be effective through research allows nurses to better advocate for patients and provides the best possible care.

5.7: Conclusion
The study was conducted to assess the information needs of breast cancer patients at Cancer Diseases Hospital, in Lusaka. The findings of this study and literature support the idea that breast cancer patients are seeking more information on their disease. The study findings may show that there were some relationships between the findings of this study with other studies that could be generalised to all breast cancer patients although the patients in this study could have their own experiences. The findings also have provided information that breast cancer patients are anxious and need information about their disease, investigations, treatment, physical and psychosocial needs which should not just start when the patients start receiving treatment but ought to begin from the period of testing to diagnosis to prognosis. Although shortage of human resource may compromise the need for information our study shows that time-relevant information and support in susceptible stages may be as significant as adequate information. Thus researchers and health professionals need to consider the role of information in improving patient outcomes when designing interventions for these clients. However future research should include expanding the questionnaire to include an exploration of whether informational needs are met or not and whether patients are satisfied with the information received as this is an important step to improving the breast cancer patient experience.

5.8: Recommendations
Based on this study the following recommendations have been made: 1. The government through the Ministry of Health should effect the decentralization of cancer services to all provincial headquarters for easy accessibility, reduction in patient overload and cost effectiveness of cancer services.
2. The Ministry of health to train more oncology health workers so as to increase on the staffing levels that will in turn reduce on the clinician patient ratio.
3. It is required for CDH to develop an assessment tool to detect the information needs of breast cancer patients and to encourage oncology nurses to actively assess the information needs of patients.
4. There is need for CDH to develop a training module for educating medical professionals in disclosing bad news so as to enhance communication with cancer patients.

5.9: Limitation of the study
The study was a cross-sectional study, therefore it couldn't measure the information needs of patients in different stages of the disease trajectory and further longitudinal studies will be needed in this area. The other limitation was the adopted TINQ-BC collection tool which could compromise the quality of data because the respondents may only give the answers they thought were socially acceptable. Another limitation is that respondents were not asked about satisfaction with information received medical professionals therefore it was difficult to elicit if their needs were met or not so as to know which information they needed.

5.10: Dissemination of study findings
The findings of this study will be disseminated as dissertations submitted to the University of Zambia participate, no privileges will be taken away from you as you seek treatment or support from any organization or individual. If you agree to participate you will be asked to sign this consent form in the presence of a witness. Agreement to participate will not result in any immediate benefits.

Purpose of the Study
A diagnosis of cancer is a fearful experience that has cultural, social and psychological consequences and many patients and their relatives experience physical, psychological, spiritual and family problems (Ankem, 2006;Motlagh et al, 2014). Newly diagnosed patients embark on a journey with uncertain destination, laden with stress and anxiety and desperate for hope and support. Provision of information can help these patients in terms of physiological as well as psychological outcomes enabling them to regain control over their lives and participate fully with treatment. Therefore this study will obtain information on what breast cancer patients desire to know during the illness trajectory. This information will be identified by analyzing participants' information lived experience. The identified desired information will be used in developing more culturally effective models to deliver information and support to breast cancer patients. Identifying the actual needs of the patients will produce better resource allocation and provide health services more efficiently to meet the needs hence improving the coping mechanism of patients and in turn quality of life.

Procedure
After you have signed the informed consent form and have had a chance to ask questions, you will be requested to answer the questions concerning the information you would desire to know concerning your diagnosis, treatment and prognosis. Then thereafter, you will be asked to make a recommendation on how you want the information delivered to you and how we can improve information delivery to patients.

Risks and Discomforts
No risks are involved in this study; however you might become emotional during the interview as some questions or the process of recalling past experiences may cause discomfort. Should you become emotional and wish not to continue, I will stop and reschedule the interview. With your permission, I will counsel you myself or ask the counsellors who work in the clinic to counsel you.

Benefits
There are no direct benefits to you as a participant, however, the findings will increase our understanding of the desired information that breast cancer patients need. The information provided will help relevant authorities and policy makers to come up with strategies that will be used in developing more culturally effective models to deliver information and support to breast cancer patients.

Confidentiality
I will keep information confidential. The people who will know that you are a research participant are members of the resear research team and all the research materials will be kept in strict confidence. For the purpose of anonymity, you will be identified by a number not by name and personal information will not be released without your written permission.

SECTION D: BREAST CANCER INFORMATION NEEDS QUESTIONNAIRE
Please read each of the following sentences tick in the space that best describes how important it is for you to have this information.
To help me with my illness it is important for me to know.