Correlations of resilience with coping styles and quality of life in patients with malignancies

Abstract

BACKGROUND

Resilience is an individual’s ability and psychological rebound capacity to adapt well after experiencing adversity, trauma, etc. Patients with strong resilience can face illnesses actively.

AIM

To determine the association of resilience with coping styles and quality of life in patients with malignancies.

METHODS

This study included patients with malignant tumors who were hospitalized at Fuyang Hospital Affiliated to Anhui Medical University from March 2022 to March 2024. The Connor-Davidson Resilience Scale, Medical Coping Modes Questionnaire, Social Support Rating Scale, and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 were utilized to assess patients’ resilience, coping styles, social support, and quality of life, respectively. Pearson correlation analysis was conducted to assess the correlations.

RESULTS

A total of 175 patients with malignant tumors demonstrated no marked difference in terms of age, education level, employment status, monthly household income, and disease staging (P < 0.05). Further, patients with malignancies demonstrated scores of 17.49 ± 1.20, 17.27 ± 1.46, and 11.19 ± 1.29 points in terms of coping styles in confrontation, avoidance, and resignation dimensions, respectively. Subjective support, objective support, and support utilization scores in terms of social support were 10.67 ± 1.80, 11.26 ± 2.08, and 9.24 ± 1.14 points, respectively. The total resilience score and tenacity, self-improvement, and optimism dimension scores were positively correlated with the confrontation coping style score, whereas the total resilience score and tenacity and self-improvement scores were negatively associated with avoidance and resignation coping style scores (P < 0.05). The total resilience score and the tenacity dimension score were positively associated with physical, role, cognitive, emotional, and social functions, as well as global health status (P < 0.05), and were inversely related to fatigue, insomnia, and economic difficulties (P < 0.05).

CONCLUSION

The resilience of patients with malignancies is positively associated with the confrontation dimension in the coping style, the total and various social support domain scores, and the overall quality of life. Clinical medical staff need to pay attention to the effect of medical coping styles and social support on the resilience level of patients with malignancies to further improve their quality of life.

Key Words: Malignant tumor; Resilience; Coping style; Quality of life; Correlation

Core Tip: A cancer diagnosis can be a turning point, with negative effects on mental health, treatment, and prognosis. This study, considering the importance of psychological variables in health-related processes, investigated the role of resilience and coping strategies in health-relatedness. It aimed to determine the potential associations between these aspects to better understand the effect of psychosocial variables on the mental health of patients with cancer.

INTRODUCTION

Cancer, with population growth and aging intensification, has become one of the major diseases that seriously threaten public health. It is one of the leading causes of human mortality globally[1,2]. Cancer treatment consumes numerous medical resources, and the resulting morbidity and mortality are a great social burden[3], making cancer a serious economic and social problem that is faced globally. Cancer, as an increasingly prevalent disease, poses a huge challenge to the healthcare system in China[4], with an estimated 4824700 new cancer cases and 2574200 cancer deaths in 2022[5]. Cancer is a broad global disease that spans the breadth of human experience[6], affecting the daily lives of individuals and their way of interacting and experiencing the world. Further, the overwhelming treatment increases the burden on patients and their families. In addition to physical suffering, patients with cancer may also experience mental symptoms or pre-existing condition exacerbation, which are considered crucial distressing factors[7,8].

The mental health of patients with cancer needs to be considered. Psychological services and support for patients with cancer have lagged despite progress in treatment options and outcomes. Notably, psychological distress negatively affects the quality of care and quality of life of patients[9]. It has adversely influenced the physical health and treatment of patients with cancer[10]. In several cases, patients with cancer experience high emotional distress levels, including symptoms of anxiety, depression, stress, etc., although only a few individuals will develop severe long-term psychological disorders in reaction to this stressful event[11,12]. A cross-sectional study of 1011 patients with cancer in the Middle East reported the prevalence of depressive and anxious symptomatology among all patients at 23.4% and 19.1%-19.9%, respectively[13]. Depression and anxiety are more predominant in patients with cancer than in those without chronic disease. However, the prevalence widely varies across studies. Among patients with cancer, the estimated prevalence of depression ranges from 11% to 57%, and that of anxiety ranges from 6.5% to 23%[14]. However, the literature indicates that individuals can cope and adapt to highly stressful situations[15].

Resilience is an individual’s ability to adapt well to adversity, trauma, etc., as well as their capacity to bounce back psychologically. Patients with better resilience face the disease positively[16]. Coping styles are primarily individualized methods and strategies that are adopted by individuals to reduce or avoid stress and adapt to the environment, with positive coping styles being conducive to promoting their treatment[17]. Social support is the emotional experience of being understood, respected, and supported by others that an individual feels in society[18]. Different resilience, coping styles, and social support exert varying effects on the patient’s condition. High-level resilience is particularly important in disease treatment under the bio-psycho-social medical model. Literature has revealed that medical coping styles and social support exert a direct effect on the resilience of patients with tumors[19]. Positive medical coping styles and strong social support provide psychological and spiritual support to patients with tumors, thereby encouraging them to bravely face the disease, prolonging their survival, and boosting their quality of life[20]. Clinical reports on the correlation of resilience with coping style and quality of life in patients with malignancies are lacking; thus, this article conducts relevant discussions to provide a theoretical basis for the clinical formulation of nursing interventions.

MATERIALS AND METHODS

Research subjects

This study included patients with malignancies who were admitted to Fuyang Hospital Affiliated to Anhui Medical University from March 2022 to March 2024. Inclusion criteria were patients: (1) Who were admitted to the hospital and were clinically and pathologically diagnosed with malignancies; (2) With clear thinking and normal communication abilities that enable an accurate understanding of the survey content; (3) Aged ≥ 18; (4) With an expected survival of > 6 months, and (5) With complete clinical data. Exclusion criteria were: (1) Other serious life-threatening diseases; (2) Inflammatory somatic diseases and an unstable condition; (3) Other serious complications; (4) Cognitive and communication disorders; and (5) Missing clinical data.

Survey tools

General information: A self-designed questionnaire was employed to obtain data on the age, gender, educational level, marital status, employment status, family income, medical expense payment mode, disease awareness, and disease staging of the surveyed patients.

Resilience: The Connor-Davidson Resilience Scale[21] was used, which is a 25-item tool that mainly includes three dimensions: Tenacity, self-improvement, and optimism. Each item is rated on a five-point Likert scale and ranges from 0 (“not true at all”) to 4 (“true nearly all the time”). Possible scores range from 0 to 100, with the score being proportional to the patient’s resilience level. The Cronbach’s α coefficient of this scale is 0.892, indicating favorable reliability and validity.

Coping styles: The Medical Coping Modes Questionnaire[22], a 20-item tool, consists of three dimensions: Confrontation (8 items), avoidance (7 items), and resignation (5 items). Each item adopts a 1-4 point scoring method (among which eight are reverse scoring items, including items 1, 4, and 9), with the score range of each dimension at 8-24, 7-21, and 5-15 points, respectively. A higher score indicates a higher inclination of the patient to adopt this coping style. Medical Coping Modes Questionnaire exhibits good reliability and validity, as evidenced by a Cronbach’s α coefficient of 0.825.

Social support: The Social Support Rating Scale[23] was employed to evaluate the degree of psychological support and support utilization that patients receive in social life. This is a 10-item measure with three dimensions: Subjective support (items 1, 3, 4, and 5), objective support (items 2, 6, and 7), and support utilization (items 8, 9, and 10). The total score is the sum of the scores of each item, with < 20 points indicating less social support, ≥ 20 to < 30 points denoting normal social support, and 30-40 points representing satisfied social support. The Social Support Rating Scale exhibited good reliability and validity, with a Cronbach’s α coefficient of 0.901.

Quality of life: Quality of life assessment was conducted with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30[24]. The instrument has 30 items, of which, entries 29 and 30 are categorized into seven grades, recorded as 1-7 points based on their response options, and the other items are classified into four grades rated as 1-4 points indicating “none”, “a little”, “more”, and “a lot”, respectively. The 30 items are categorized into 15 dimensions, consisting of 5 functional subscales (physical function, role function, cognitive function, emotional function, and social function), 3 symptom subscales (fatigue, pain, and nausea and vomiting), 6 individual measurement items (polypnea, appetite loss, insomnia, constipation, diarrhea, and economic difficulties), and 1 patient self-assessment item (global health status). A higher Quality of Life Questionnaire Core 30 score implies better functional status in the functional domain, and a greater score in the symptom domain denotes more severe patient symptoms and worse quality of life.

Survey methods

This questionnaire survey was conducted by our interns as investigators. Before the survey began, the investigators underwent unified training to clarify the purpose and significance of this survey, the main content of the study, the method of filling out the questionnaire related to the survey, and the provisions to obtain consent from the subject of the survey before the survey, and most importantly, to pay attention to their communication with the patients in the survey process. The questionnaires were distributed using a standardized guide and, when available, were self-completed by patients using anonymous response measures in the hospital interview room. If the patient was unable to write or was illiterate, the investigator orally read the questions and options for each item and filled out the questionnaire on behalf of the patient following his/her answers. Data entry was performed using Excel software. Two people repeated the same questionnaire, and the data was then cross-checked to avoid reducing the objectivity and authenticity of the data owing to entry errors. In this survey, 198 questionnaires were distributed, of which 179 were collected. After excluding four invalid questionnaires, 175 valid questionnaires were obtained, with an effective rate of 88.4%.

Statistical analysis

Statistical Package for the Social Sciences version 25.0 was used for data analysis. Count data were presented as frequencies and percentages, whereas measurement data were expressed as mean ± SD and tested by independent samples t-tests and analysis of variance. Spearman correlation analysis was employed for correlation analysis. A P value of < 0.05 indicated statistical significance.

RESULTS

Resilience score

Statistical significance was observed among the 175 patients with malignancies in terms of age (F = 20.29, P < 0.0001), education level (t = 4.674, P < 0.0001), employment status (F = 11.07, P < 0.0001), monthly household income (F = 14.40, P < 0.0001), and disease staging (t = 5.068, P < 0.0001). However, no marked differences were determined in gender (t = 0.240, P = 0.811), marital status (F = 0.417, P = 0.660), medical expense payment mode (F = 0.620, P = 0.539), and disease awareness (t = 0.964, P = 0.336) (Table 1).

Table 1 Comparison of patients’ demographic data and resilience scores.

Characteristic	n = 175	Resilience score	F/t	P value
Age
≤ 45	31	60.97 ± 3.67	20.29	< 0.0001
46-59	95	67.51 ± 5.11
≥ 60	49	69.12 ± 7.81
Sex			0.240	0.811
Male	84	66.68 ± 6.35
Female	91	66.91 ± 6.51
Marital status			0.417	0.660
Single	24	67.50 ± 7.27
Married	119	66.50 ± 5.45
Divorced or widowed	32	67.41 ± 5.51
Education level			4.674	< 0.0001
Junior high school or below	58	63.76 ± 6.32
Senior high school or above	117	68.31 ± 5.93
Employment status			11.07	< 0.0001
Employed	96	67.23 ± 5.95
Retired	45	68.93 ± 7.41
Unemployed	34	62.58 ± 3.30
Monthly household income			14.40	< 0.0001
< 3000	21	63.10 ± 4.15
3000-6000	64	65.80 ± 5.90
6001-10000	60	66.18 ± 6.78
> 10000	30	72.77 ± 3.97
Medical expense payment mode			0.620	0.539
Medical insurance	79	66.94 ± 6.59
Cooperative medical care	51	66.02 ± 6.14
Self-supporting	45	67.44 ± 6.45
Disease awareness			0.964	0.336
With	81	66.30 ± 5.97
Without	94	67.23 ± 6.78
Disease staging			5.068	< 0.0001
I-II	102	68.75 ± 5.71
III-IV	73	64.08 ± 5.82

Coping style and social support scores

Among the 175 patients with malignancies, the scores of confrontation, avoidance, and resignation coping styles were 17.49 ± 1.20, 17.27 ± 1.46, and 11.19 ± 1.29 points, respectively. The score of social support was 10.67 ± 1.80, 11.26 ± 2.08, and 9.24 ± 1.14 for subjective support, objective support, and support utilization, respectively (Table 2).

Table 2 Scores of coping styles and social support.

Characteristic	Scores
Coping styles
Confrontation	17.49 ± 1.20
Avoidance	17.27 ± 1.46
Resignation	11.19 ± 1.29
Social support
Subjective support	10.67 ± 1.80
Objective support	11.26 ± 2.08
Support utilization	9.24 ± 1.14

Quality of life scores

The quality of life scores of 175 patients with malignancies covered five functional subscales: Physical (53.49 ± 23.91 points), role (49.05 ± 31.85 points), cognitive (54.00 ± 30.64 points), emotional (53.48 ± 29.31 points), and social functions (57.05 ± 27.70 points); three symptom subscales, i.e., fatigue (48.85 ± 30.68 points), pain (54.29 ± 30.07 points), and nausea and vomiting (51.24 ± 28.92 points); six single measurement items: Polypnea (50.29 ± 32.34 points), appetite loss (48.76 ± 33.67 points), insomnia (50.10 ± 32.73 points), constipation (48.57 ± 31.91 points), diarrhea (50.67 ± 33.87 points), and economic difficulties (55.43 ± 32.86 points); and one self-reported global health score (58.67 ± 28.75 points) (Table 3).

Table 3 Quality of life scores of patients.

Characteristic	Scores
Physical function	53.49 ± 23.91
Role function	49.05 ± 31.85
Cognitive function	54.00 ± 30.64
Emotional function	53.48 ± 29.31
Social function	57.05 ± 27.70
Fatigue	48.85 ± 30.68
Pain	54.29 ± 30.07
Nausea and vomiting	51.24 ± 28.92
Polypnea	50.29 ± 32.34
Appetite loss	48.76 ± 33.67
Insomnia	50.10 ± 32.73
Constipation	48.57 ± 31.91
Diarrhea	50.67 ± 33.87
Economic difficulties	55.43 ± 32.86
General health	58.67 ± 28.75

Correlation between dimensions of resilience and coping styles

Table 4 shows that the total resilience score and tenacity, self-improvement, and optimism dimension scores of the 175 patients with malignancies were positively correlated with the confrontation coping style score (P < 0.05). Further, the total resilience score and tenacity and self-improvement scores were inversely associated with avoidance and resignation coping style scores (P < 0.05), whereas the optimism dimension exhibited no significant correlation with avoidance and resignation coping styles (P > 0.05). The results indicated that the higher the total score of mental resilience, the more active the coping style.

Table 4 Correlation between resilience dimensions and coping styles.

Characteristic	Resilience, r	Resilience, P value	Tenacity, r	Tenacity, P value	Self-improvement, r	Self-improvement, P value	Optimism, r	Optimism, P value
Confrontation	0.649	< 0.0001	0.539	< 0.0001	0.371	< 0.0001	0.224	0.003
Avoidance	-0.560	< 0.0001	-0.461	< 0.0001	-0.358	< 0.0001	-0.125	0.098
Resignation	-0.668	< 0.0001	-0.608	< 0.0001	-0.338	< 0.0001	-0.121	0.110

Correlation between resilience and social support

The total resilience score and tenacity, self-improvement, and optimism dimension scores of the 175 patients with malignancies were positively correlated with subjective support and support utilization scores (P < 0.05). Further, the objective support score was positively correlated with resilience score (P < 0.05), but not with tenacity, self-improvement, or optimism scores (P > 0.05) (Table 5). The results indicated that the higher the degree of social support, the higher the psychological resilience.

Table 5 Correlation between resilience dimensions and social support.

Characteristic	Resilience, r	Resilience, P value	Tenacity, r	Tenacity, P value	Self-improvement, r	Self-improvement, P value	Optimism, r	Optimism, P value
Subjective support	0.410	< 0.0001	0.323	< 0.0001	0.241	0.001	0.195	0.009
Objective support	0.149	0.048	0.139	0.065	0.046	0.541	0.077	0.308
Support utilization	0.379	< 0.0001	0.266	0.0004	0.260	0.0005	0.267	0.003

Correlation between resilience and quality of life

Table 6 shows that the total resilience score and the tenacity dimension score of 175 patients with malignancies were positively correlated with physical, role, cognitive, emotional, and social functions and the global health status (P < 0.05), and negatively correlated with fatigue, insomnia, and economic difficulties (P < 0.05), but not with pain, nausea and vomiting, polypnea, appetite loss, constipation, and diarrhea (P > 0.05).

Table 6 Correlation between various resilience dimensions and quality of life.

Characteristic	Resilience, r	Resilience, P value	Tenacity, r	Tenacity, P value	Self-improvement, r	Self-improvement, P value	Optimism, r	Optimism, P value
Physical function	0.406	< 0.0001	0.358	< 0.0001	0.207	0.006	0.112	0.142
Role function	0.464	< 0.0001	0.368	< 0.0001	0.255	0.0006	0.250	0.0008
Cognitive function	0.449	< 0.0001	0.316	< 0.0001	0.323	< 0.0001	0.225	0.003
Emotional function	0.382	< 0.0001	0.360	< 0.0001	0.188	0.013	0.032	0.674
Social function	0.374	< 0.0001	0.341	< 0.0001	0.159	0.035	0.128	0.093
Fatigue	-0.399	< 0.0001	-0.415	< 0.0001	-0.113	0.138	-0.068	0.372
Pain	-0.102	0.179	-0.108	0.156	-0.034	0.655	0.002	0.978
Nausea and vomiting	-0.097	0.200	-0.125	0.099	0.026	0.729	-0.043	0.576
Polypnea	-0.044	0.567	-0.078	0.306	0.039	0.610	-0.043	0.576
Appetite loss	0.028	0.716	0.043	0.576	-0.015	0.845	0.002	0.984
Insomnia	-0.368	< 0.0001	-0.290	< 0.0001	-0.239	0.001	-0.123	0.106
Constipation	0.106	0.164	0.084	0.272	0.019	0.801	0.147	0.052
Diarrhea	-0.007	0.928	-0.011	0.885	-0.027	0.726	0.071	0.354
Economic difficulties	-0.408	< 0.0001	-0.390	< 0.0001	-0.194	0.010	-0.025	0.739
Global health status	0.621	< 0.0001	0.511	< 0.0001	0.348	< 0.0001	0.249	0.0009

DISCUSSION

Several literature reviews have investigated the role of health technology in supporting nursing outcomes, communication, and quality of care[25]. However, the mental health of patients with cancer and the role of technology in supporting their mental health gained little attention. Hence, the existing knowledge base needs to be expanded to better understand how to support the mental health of patients with cancer. Resilience is not only the basis for developing an individual’s innate characteristics, but it is also affected by acquired education, training, and environmental factors. A higher resilience level has been associated with stronger adaptability, and vice versa. The higher the degree of abnormality in the resilience of patients with cancer, the worse their immunity against anti-tumor cells[26]. Therefore, patients are clinically encouraged to adopt positive and effective coping styles to improve their disease awareness, accept the disease, and re-recognize themselves, thereby improving their psychological endurance and boosting their self-confidence.

In this study, the psychological resilience of all patients was first scored, and the scores of patients with different demographic characteristics were compared. The results revealed the presence of statistical significance among the 175 patients with malignancies in terms of age, educational level, employment status, monthly household income, and disease staging. The older the patients, the higher their resilience. Further, younger patients anticipate more severe problems beyond their coping capacity that may have caused their relatively lower resilience level. This result is consistent with a finding that younger patients with cancer experience more mental health problems than elderly individuals[27]. Further, economic conditions are crucial to the treatment and recovery of patients with cancer, which also confirms higher resilience and smaller economic pressure and life instability caused by the illness in employed and retired patients as well as those with higher family monthly incomes compared to those unemployed and with lower family monthly incomes. Besides, patients with a higher educational level demonstrate greater resilience, consistent with some studies. Fahey et al[28] revealed that a higher educational level indicates better coping skills, stress management, and problem-solving abilities among Indian women. Moreover, Bonanno et al[29] demonstrated that the higher the educational level, the stronger the adaptability.

Subsequently, we conducted a correlation analysis of patients’ resilience with their coping styles, social support, and quality of life. The resilience level was strongly positively related to the confrontation coping style and inversely associated with avoidance and resignation; this is because resilience is primarily the ability of individuals to adjust their psychological state to the original state through self-regulation after suffering a major psychological trauma. Coping styles are mainly a means for patients to promptly handle stressful events and maintain psychological balance under stressful conditions. A positive coping style plays a crucial role in the physical and mental health of patients. Conversely, a negative coping style is detrimental to physical and mental health development. The resilience level is a dynamic form that varies with the environment. A higher resilience score is associated with a better ability to cope with trauma and a more positive response[30]. Patients with malignant tumors are highly susceptible to negative emotions and psychological trauma caused by the illness. They may experience despair in treatment and life, have lower resilience, and are more likely to adopt coping strategies such as “avoidance” and “resignation”. Our results indicated a positive association of the resilience score with subjective support, objective support, and support utilization scores in patients with malignancies. Research has revealed that poor resilience reduces the perceived social support level of patients with malignancies[31]. This is primarily because social support is subjectively felt by individuals, mainly the emotional experience of being supported, understood, and respected. Strong social support is crucial in improving the mental health of patients. Patients with malignant tumors endure extreme physical and psychological pain and therefore need more social support. Good social support helps to improve the patient’s resistance and resilience and reduce psychological stress. Thus, the higher the social support level, the more it assists patients in establishing resilience as an internal protective factor, thereby improving their psychological adaptability and preventing the emergence of negative emotions[32]. Hence, some resources, such as coping strategies and seeking social support, are considered appropriate means to face such events. Finally, a strong positive association between the total resilience score and global health status and various functional domain scores was identified in this study. That is, the higher the global health status and the better the functional domains, the greater the patient’s quality of life. Therefore, targeted health education for patients with cancer should be strengthened, and the purpose of improving the patients’ resilience level and quality of life can be achieved through relaxation training, psychological counseling, and stress relief.

Expectedly, the use of some coping strategies or other modalities is important considering the characteristics of cancer, which can be a life-threatening disease, causing patients to make rapid decisions about their health, particularly regarding their oncological treatment and other aspects related to the disease. The use of specific coping strategies affects patients’ perceptions of their illness, thereby influencing their mental health and quality of life levels[33]. Coping generally facilitates adaptation to change, which is important for achieving or maintaining mental health. Resilient individuals are characterized by their ability to emerge stronger from adverse situations, improve their coping strategies, and increase their resilience level and well-being. Resilient individuals may demonstrate protective personal attributes that enable them to adapt to cancer, including cognitive flexibility, positive emotions, and positive coping[34]. In clinical practice, appropriate coping and good adjustment need to be encouraged, considering the importance of adapting to the oncologic disease process. The assessment of predictive risk variables helps identify suffering patients. However, the variables that positively affect the health level of patients with cancer need to be understood to guide clinical interventions.

CONCLUSION

In summary, patients with malignancies demonstrated low resilience levels, poor positive coping, and low social support levels. Correlation analysis revealed that the resilience level of such patients is inversely correlated with “avoidance” and “resignation” coping styles. Clinically, attention should be paid to the resilience level of patients, and corresponding intervention measures should be considered to improve their resilience, coping styles, and social support.