Discussion

A substantial proportion (52·4%) of the participants were between 41 and 60 years old, consistent with previous studies indicating that HNCs are more common in middle-aged and older adults. ^{Reference Siegel, Miller and Jemal3} A retrospective study by Bansal et al. (2017) on patients receiving radiotherapy for HNCs in a resource-limited setting similarly reported a majority of patients in their 40s and 50s. ^{Reference Bansal, Puri and Mehta4} This age group often represents individuals at the peak of their socioeconomic responsibilities, which can further amplify their anxiety about the impact of HNCs and treatment on their livelihoods. ^{Reference Harris, Gorman and Guttman5} Interestingly, 4·8% of the participants were ≤ 20 years old, which is relatively high for this age group. Also, 2·1% were over 80 years, reflecting the bimodal age distribution sometimes seen in HNCs. ^{Reference Saba, Wong and Kim6} Also, significant associations were found between age and anxiety at both baseline and mid-treatment stages (p = 0·001) as well as general daily anxiety (p = 0·027), suggesting that younger patients tend to experience higher levels of anxiety at these stages, possibly due to differences in emotional resilience or coping capacity across age groups. ^{Reference Stiegelis7} After applying Bonferroni correction for multiple comparisons, reassessment of the statistical significance of these findings ensured that they were not driven by an inflated Type I error rate. The adjusted results remained statistically significant, reinforcing the observed association between younger age and heightened anxiety levels. This highlights the importance of tailoring anxiety interventions to different age groups, particularly in resource-limited settings where structured psychological support may be lacking.

The predominance of advanced-stage presentation (stages IIIA, IIIB and IIIC—72·4%) is alarming but expected. In Low and Middle Income Countries (LMICs), several factors contribute to the late presentation of cancer patients, including low health literacy, cultural beliefs and financial barriers that delay medical consultation. ^{Reference Adeloye8} Early detection rates of cancer in low-resource settings are lower due to limited access to health care, diagnostic delays and lack of routine screening programmes. ^{Reference Sankaranarayanan, Swaminathan and Brenner9} Advanced-stage disease is typically associated with more aggressive treatment regimens, which often result in greater physical and psychological distress, which can exacerbate procedural anxiety, including that related to thermoplastic mask usage during radiotherapy. ^{Reference Kiyohara, Maehar and Motegi10,Reference Sharma, Tripathi and Garg11}

The prevalence of thermoplastic mask-induced anxiety was notably high during both the mask-moulding process (93·8%) and radiation therapy sessions (94·5%). These anxiety levels were notably higher than reported in studies from resource-rich settings, where thermoplastic mask-induced anxiety prevalence tends to range from 50 to 70%. ^{Reference Kiyohara, Maehar and Motegi10} Several factors may have contributed to the exceptionally high thermoplastic mask-induced anxiety levels. First, in limited-resource settings, where access to psychological support services may be minimal or absent, patients often face the psychological demands of cancer treatment without adequate counselling or anxiety-reducing interventions, ^{Reference Bansal, Puri and Mehta4} which could explain the near-universal anxiety levels in the study population.

In contrast, studies from Nixon et al. (2019) in more resource-equipped settings also found high levels of mask-related anxiety, with their interventions including pre-treatment education and psychological support to mitigate such distress. ^{Reference Nixon, Brown and Pigott12} These studies suggest that when patients are educated about what to expect, anxiety levels tend to decrease, which aligns with the findings of Bokmand et al. (2019), where providing clear explanations of the treatment process reduced patient anxiety. ^{Reference Bokmand, Andersson and Kjær13} In settings where this education is lacking, the fear of the unknown and uncertainty about the treatment process may amplify anxiety. Additionally, the physical discomfort associated with the use of thermoplastic masks, such as the pressure on the face and breathing difficulty, can increase anxiety. This is especially true for patients with pre-existing claustrophobia or respiratory difficulties, which may have been prevalent in our study population. It is worth noting that the self-reported nature of the anxiety data in this study means that recall bias could have influenced the findings, with patients potentially overstating their anxiety or adjusting their recollection of earlier experiences. However, other studies support the notion that mask-related anxiety is a common challenge across different settings, reinforcing the validity of our findings. ^{Reference Nixon, Cartmill and Turner14,Reference Dhillon and Halkett15}

The elevated anxiety during mask moulding highlights the distress patients feel when encountering a thermoplastic mask for the first time. Anxiety levels varied significantly during different stages of the radiotherapy process, decreasing progressively as treatment progressed. This could have been partly because of a lack of familiarity and experience with the radiotherapy process. Cancer patients who are new to radiotherapy may feel anxious due to unfamiliarity with the procedures and equipment involved. This trend suggests that while the initial phases of radiotherapy are highly anxiety-inducing, patients tend to adapt over time, resulting in lower anxiety levels as they become more accustomed to the treatment process. These findings highlight the importance of providing psychological support, especially during the early stages of treatment, to help manage and mitigate anxiety in HNC patients undergoing radiotherapy. Studies from similar resource-limited environments have shown that when patients are adequately informed and prepared, anxiety levels decrease significantly. ^{Reference Schoenfeld16} Simple interventions such as pre-treatment tours of the radiation therapy unit or brief relaxation exercises before mask moulding can significantly reduce anxiety levels, even in resource-constrained settings. ^{Reference Hu17} The progressive reduction in anxiety reflects the adaptability of patients over time and aligns with findings from other studies, where patients reported becoming more accustomed to the treatment environment, reducing their anxiety levels over time. ^{Reference Nixon, Brown and Pigott12,Reference Spalding18} The most significant reduction in anxiety was observed at the end of treatment, with 85·5% of participants reporting no anxiety, suggesting that completing the prescribed radiotherapy regimen may evoke a sense of relief and accomplishment in patients. Additionally, patients might feel reassured by the completion of their prescribed treatment, reducing uncertainty and emotional distress. ^{Reference Kumar19} There were significant associations between age and anxiety at both baseline and mid-treatment stages of radiotherapy (p = 0·001), as well as general daily anxiety (p = 0·027), suggesting that younger patients tend to experience higher levels of anxiety at these stages, possibly due to differences in emotional resilience or coping capacity across age groups. ^{Reference Stiegelis7}

While nearly all patients (97·2%) were able to express their discomfort and anxiety, only 62·8% felt that the healthcare professionals adequately addressed these challenges. This gap between communication and resolution highlights a significant challenge in resource-constrained environments: even when patients can articulate their anxiety, providers may lack the time, training or resources to respond effectively. ^{Reference Batista20} In all, 92·4% of the participants sought counselling or other forms of support, which indicates that patients are not only aware of their need for help but are also proactive in seeking it. Despite the high utilization of coping mechanisms (95·2%) and the willingness of most patients to communicate their concerns, there remains a need for structured psychological interventions, which would not only reduce treatment-related anxiety but also increase adherence to therapy. ^{Reference Wu21} This finding is consistent with the findings of a study that emphasized the need for systematic screening and psychological support in radiotherapy settings. ^{Reference Holtzman, Pereira and Yeung22}

Many HNC patients employed more than one strategy simultaneously, which aligns with the understanding that coping is a dynamic and multifaceted process, particularly in high-stress situations like radiotherapy. Distraction (58%) was the most frequently employed coping mechanism, encompassing techniques such as focusing on specific thoughts, memories or tasks that effectively divert attention away from sources of distress and anxiety. Distraction offers a practical and accessible strategy that patients can adopt independently. In the context of radiotherapy, where patients must remain immobile and may experience feelings of confinement due to the thermoplastic mask, distraction offers a way to manage both the physical discomfort and emotional distress. Visualization was the second most popular strategy, employed by 46%, which involved mentally imagining pleasant or relaxing scenarios to counteract the stress and discomfort of being in the immobilized position required for radiotherapy. Visualization is a self-administered, cost-free coping mechanism that can be easily taught to patients during pre-treatment consultations. Encouraging the use of such techniques can help enhance patient comfort during radiotherapy. Social support also plays a crucial role in alleviating anxiety in medical settings, particularly for patients undergoing long-term treatments like radiotherapy. ^{Reference Kandasamy23} In all, 34% adopted the strategy of talking to a loved one or friend during radiotherapy sessions. Having someone to talk to can provide emotional comfort, reassurance and a sense of connection, which can counteract the anxiety and isolation patients may feel during their treatment sessions.

The widespread use of informal coping mechanisms underscores the importance of empowering patients with self-help strategies. Healthcare providers need to play a proactive role in educating patients about coping strategies before treatment begins, to ensure they have practical tools to manage their anxiety and discomfort, particularly in settings with limited mental health services. Training of healthcare providers on effective communication strategies to address patient discomfort and anxiety is very essential.