European Journal of Oncology Nursing 18 (2014) 571e577

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European Journal of Oncology Nursing journal homepage: www.elsevier.com/locate/ejon

Coping styles and social support among depressed Chinese family caregivers of patients with esophageal cancer Yanhong Han a, b, 1, Deying Hu a, 1, Yilan Liu a, Caihong Lu a, Zhiguo Luo c, Jing Zhao c, Violeta Lopez d, Jing Mao b, * a

Department of Nursing, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, Hubei Province 430022, China School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, Hubei Province 430030, China c Department of Clinical Oncology, Taihe Hospital, Hubei University of Medicine, 32 Renmin South Road, Shiyan, Hubei Province 442000, China d Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD 11, 10 Medical Drive, Singapore 117597, Singapore b

a b s t r a c t Keywords: Chinese Coping Depression Esophageal cancer Family caregivers Social support

Objectives: To determine the coping styles of family caregivers of patients with esophageal cancer and examine the relationships between depression, coping styles and social support. Methods: A descriptive and correlational survey was conducted in three university-affiliated oncology and thoraco-cardiac surgery departments in Shiyan, China. A convenience sample of 301 Chinese family caregivers of hospitalized patients with esophageal cancer were asked to respond to a set of four questionnaires including: Socio-demographic questionnaire, Center for Epidemiological Studies Depression, Brief COPE Inventory, and Multidimensional Scale of Perceived Social Support. Results: For the positive coping style, male caregivers used more problem-coping than female caregivers. However, for negative coping, both male and female caregivers used maladaptive coping styles. There were significant correlations between emotion-focused coping styles with adaptive coping, maladaptive coping, depression and social support. Conclusions: Family caregivers play a major role in caring for cancer patients and suffer from various psycho-social problems. What is lacking in the literature was to address the cultural differences in cancer caregiving burden, roles, and appropriate interventions to help them face the multiple demands of caregiving. Therefore, a need to develop and evaluate interventions using randomized clinical trials and sensitive instruments to measure the effectiveness of the intervention on patients' and caregivers' outcomes. © 2014 Elsevier Ltd. All rights reserved.

Introduction When a family member is diagnosed with cancer, a gamut of psychological emotions affects both the patients and their family members. Not only do the patients need support from their family but the family also needs support in order to cope with caring for the patient during this challenging time. However, much work is needed to examine the psychological burden, support and coping styles of the family as they take on the role of carers for the family member diagnosed with cancer.

* Corresponding author. Tel./fax: þ86 027 83692635. E-mail address: [email protected] (J. Mao). 1 The two authors contributed equally to the study. http://dx.doi.org/10.1016/j.ejon.2014.07.002 1462-3889/© 2014 Elsevier Ltd. All rights reserved.

In China, the incidence and mortality of esophageal cancer were 20.85 and 16.24 per 100,000 persons, the fifth most commonly diagnosed cancer and the fourth cause of cancer death (National Cancer for Cancer Registry (NCCR), 2012). According to the NCCR (2010), esophageal cancer was the fifth most common cancer in males and the sixth most common cancer in females with the mortality rate higher in males than in females. Esophageal cancer results from both the environment and lifestyle factors such as smoking, alcohol consumption, drinking tea at high temperature, fermented and pickled vegetables, mold pollution and environmental carcinogens (Chen et al., 2013; Lin et al., 2013). Esophageal cancer has a poor prognosis because of its asymptomatic nature and is not apparent until it has reached an advanced stage (Chen et al., 2013). The Chinese government is making great efforts in improving the quality of cancer registration data as well as

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multidisciplinary prevention strategies to decrease the burden of esophageal cancer. Community health services are underdeveloped in China, especially in the developing remote areas, such as Shiyan, Hubei Province. Cancer patients can only receive treatment in big hospitals located in major cities as there are no community and home care services. Family members especially patient's spouse, children, parents and close relatives assume responsibilities of caring for the patients (Yang et al., 2012). The diagnosis of cancer is psychologically devastating to both patients and their caregivers (Nijboer et al., 1999). It was found that having a family member with cancer was a severe stressor leading to depression and grief among caregivers (Nijboer et al., 1999). The effects on cancer caregivers were more so for the Chinese family members because of their attention to family values and moral obligations (Chow and Ho, 2012; Mok et al., 2003). With the ongoing small family size and increasing employment of the younger generations, older spouses remain the primary caregivers. Strong cultural value of familism or feelings of solidarity and loyalty among family members was found to be positively associated with both negative and positive aspects of caregiving (Holroyd, 2003). Depression associated with caregiving A study by Given et al. (2004) found that depressive symptoms were one of the most significant caregiving problems in 12%e30% of patients with cancer. Family caregivers were found to experience emotional burden including managing the symptoms and treatment side effects, financial matters, daily household tasks and patients' emotions (Ruzyanei et al., 2014). Studies showed that when patients with cancer develop depression, the caregivers were 7.9 times more likely to also be affected (Baumbauerm et al., 2006). Kim et al. (2013) found that caregiving stress and lack of social support were significant predictors of depressive symptoms among family caregivers of colorectal cancer patients during the first year of diagnosis. In Korea, Park et al. (2013a) reported that the prevalence of depression among family caregivers of cancer patients was 82.2% and among them, 16.3% had severe depression. They found that caregiving burden, unemployment, financial concerns and being the spouse of the patient were significant predictors of depression. In another national survey in Korea, Park et al. (2013b) also found that 31.8% of depressed family caregivers of patients with cancer had suicidal ideation and 4.7% had attempted suicide. In China, Yang et al. (2012) reported a 67.3% prevalence of depressive symptoms among caregivers of patients with cancer. They found that the factors contributing to caregivers' depression were lower monthly household income, caregivers' relationship with the patient, and patients' distress. However, they did not find any significant differences in depression between the gender and the number of caregivers. Zou et al. (2004) reported that in China, family members were also the first to be informed of the patient's cancer diagnosis and consequently had to decide whether to tell or to conceal the diagnosis to protect the patient from distress. The study found that acting as a buffer for their loved ones resulted in them having depressive symptoms. Coping and social support Evidence suggests that certain coping styles are beneficial for the patients and caregivers. For example, in a study of family caregivers of esophageal cancer survivors, Dempster et al. (2011) found that positive coping was important in minimizing psychological distress. A number of studies were conducted in China that examined coping styles and social support among caregivers of patients with nasopharyngeal cancer (Li and Sun, 2011), liver

cancer (Chen et al., 2006), and breast cancer (Yang et al., 2007). Similar results were found in relation to the positive outcomes when caregivers were able to cope when a family member was diagnosed with cancer. There are, however, gender differences in caregiving experiences of patients with cancer. Kim and Given (2008) found that women were more likely to adopt the caregiving role and tend to be more emotionally expressive than men. Carlson et al. (2000) found that male caregivers of wives with breast cancer experienced uncertainty, and indecisiveness about treatment options. Male partners also experienced tension, decreased work performance and job satisfaction. Lopez et al. (2012) reported that male caregivers of patients with breast and gynecological cancer experienced varying degrees of interrelated cognitive, physical and psychological distress that extended over a period of one year. In summary, coping is among the most widely studied topic in health behavior psychology. In healthcare, majority of studies exploring the relationships between coping styles and depression have been conducted in patients with stroke, dementia, and cancer (breast, gastric, lung, leukemia). To date, no published studies that examined the relationships between depression, social support and coping especially among caregivers of patients with esophageal cancer in China were found. Understanding their coping styles could assist nurses to reinforce patients' positive coping strategies and change maladaptive coping strategies so as to develop a more adaptive coping strategy appropriate to their culture. The information gained from our study of the caregiving experiences in a racially different sample could also inform a cultural framework to direct caregiver research. Theoretical framework This study was guided by Folkman and Lazarus' coping theory who suggested that coping was the cognitive appraisal of the stressor and the behavioral efforts of the person to reduce or manage the impact of stress (Folkman, 1984; Folkman et al., 1986; Lazarus and Folkman, 1984). Lazarus (1993) reported two types of coping strategies: problem-focused coping (e.g. problem solving, decision-making and direct action) and emotion-focused coping (e.g. reframing, religion). Problem-focused coping refers to the person's self-appraisal to change the situation or recognize personal strengths and resources. Emotion-focused coping refers to the efforts of a person to decrease emotional stress such as venting emotions or seeking social support. Research suggested that positive coping styles were effective in maintaining psychological wellbeing whereas there was increased risk of depression when negative coping styles were used (Littleton et al., 2007). Different individuals use different coping strategies, some styles proving to be beneficial while maladaptive coping could lead to poorer health outcomes. For example, Hulbert-Williams et al. (2013) found that cognitive appraisal of the stressors by patients with cancer demonstrated better emotional outcomes. However, some patients used maladaptive coping strategies such as denial and self-blame to overcome the impact of stress (Carver et al., 1989). Since our study focus was on family caregivers of patients with esophageal cancer, the objectives of our study were to examine the coping styles used by the caregivers in managing their depression and examine the relationships between depression, coping styles and social support. The hypotheses for our study were: 1. There is a significant mean difference in coping style used by male and female caregivers. 2. There are statistically significant relationships between patients' demographic and clinical characteristics and caregivers' coping style.

Y. Han et al. / European Journal of Oncology Nursing 18 (2014) 571e577

3. There are statistically significant relationships between caregivers' demographic characteristics and coping style. 4. There are statistically significant relationships between depression, social support and coping styles of caregivers.

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of the presence of significant or mild depressive symptomatology. We used the Chinese version of the CESD-10 by Qiu and Li (2009). The reported reliability of the CESD-10 scale was Cronbach alpha .78 in a large sample of community elderly in Hong Kong (Boey, 1999). In our study, the reliability was Cronbach alpha .91.

Methodology Brief coping inventory This study used a descriptive and correlational design. A convenient sample of Chinese family caregivers over 18 years of age caring for hospitalized and depressed patients (those patients who scored 10 or more using the CESD-10) with stage two to four esophageal cancer was recruited to participate in a face-to-face interview. Participants were recruited from the oncology and thoraco-cardiac surgery departments of three university affiliated-hospitals in Shiyan, Hubei Province, China. Only one primary caregiver of each patient was recruited. Of the 330 family caregivers who met the inclusion criteria, 29 refused to participate. The total number of participants was 301.

The 28-item Brief COPE Inventory (BCI) was used in this study (Carver et al., 1989). It consists of fourteen coping strategies divided into four groups: (1) problem-focused coping (3 subscales); (2) emotion-focused coping (3 subscales); (3) adaptive coping (2 subscales); and (4) maladaptive coping (6 subscales) (Carver, 1997). Participants were asked to respond to each item from 1 (I usually don't do this at all) to 4 (I usually do this at all). Carver (1997) stated that there was no overall score for coping and recommended looking at each scale separately to see its relation to other variables. The reported reliability of Chinese version of the BCI was Cronbach alpha .83 (Qiu and Li, 2009). In our study, the reliability Cronbach alpha was .85.

Outcome measures Multidimensional Scale of Perceived Social Support (MSPSS) Demographic characteristics The demographic questionnaire included caregivers' age, sex, marital status, relationship to the cancer patient, education level, employment status, and income per month. Esophageal cancer patients' information included age, sex, cancer stage (according to the 7th edition criteria proposed by the Union International for Cancer Control (UICC, 2009)), cancer duration (months since cancer diagnosis), number of hospitalizations for cancer, medical payment, and knowledge of diagnosis. Centre for Epidemiological Studies Depression The Center for Epidemiological Studies Depression (CESD-10) Scale was used in this study (Andresen et al., 1994). Participants were asked to rate each item on a 0e3 response scale. CESD-10 score ranged from 0 to 30, a score of 10 or greater is indicative

Table 1 Demographic characteristics of caregivers of patients with esophageal cancer (n ¼ 301). Variables Age (mean/SD) Sex Marital status Education

Relationship with patient

Income (RMB) (1 Euro ¼ 8.36 Renminbi)

Employment status

n (%) Male Females Male Female Single Married No education Primary Secondary College Spouse Daughter/son Daughter/son-in-law Grandchildren Other relatives 1000 >1000e3000 >3000e5000 >5000 Retired Employed Lost job

44.33 ± 13.9 48.09 ± 14.1 111 (37%) 190 (63%) 23 (8%) 278 (92%) 37 (12%) 62 (21%) 171 (57%) 31 (10%) 157 (52%) 119 (40%) 9 (3%) 3 (1%) 13 (4%) 79 (26%) 161 (54%) 52 (17%) 9 (5%) 77 (26%) 127 (42%) 97 (32%)

The 12-item Multidimensional Scale of Perceived Social Support (MSPSS) was used to measure the level of social support from family, friends and significant others (Zimet et al., 1988). Participants were asked to rate each item on a 7-point Likert type scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). Possible ranges for the total score is 12e84 (12e48 ¼ low degree; 48e68 ¼ moderate degree; 69e84 ¼ high degree) of perceived social support. Zimet et al. (1990) reported the coefficient alpha values ranging from .81 to .98 for the subscale, and from .84 to .92 for the whole scale. In our study, the Chinese version of MSPSS was used (Yang et al., 2009). The reliability Cronbach alpha was .92. Data collection procedure The review board for the protection of human subjects in Hubei University of Medicine and three affiliated hospitals approved the study. Permission to recruit participants was obtained from the administrators of the three hospitals. The researchers collected patients' demographic and clinical data from the medical records. Researchers also asked the caregivers if the patients were aware of their diagnosis. If the patients were not aware of their diagnosis, we explained that we were collecting data on their level of depression with their illness and being in hospital. The researchers explained the purpose of the study and informed them that their involvement was completely voluntary and that they could withdraw from the study at any time. Once informed consent was obtained from patients and their caregivers, data were then collected from July, 2011 to October, 2012. Data analyses The data were entered into SPSS 21.0. Descriptive statistics were used to analyze the socio-demographic and clinical characteristics of patients, caregivers' socio-demographic characteristics, levels of caregivers' depression, social support and coping styles. Independent t-test was used to compare the coping style of male and female caregivers. Pearson's (r) and Spearman's (rho) correlations were used to analyze the relationship between each independent and dependent variables when appropriate. The statistical significance was set at p < .05.

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Results There were 301 caregivers with a mean age of 47.13þ14.1, 63% were female caregivers. There was significant mean age difference between male (44.33 ± 13.9) and female (48.09 ± 14.1) caregivers (p < .05). More than half (52%) were spouses of patients with esophageal cancer, 57% completed secondary education, 42% were employed and 54% had a monthly income between 1000 and 3000 RMB (119e358 Euro) (Table 1). There were 301 patients with esophageal cancer with a mean age of 59.71 ± 11.0, 72% were male patients. There was significant mean age difference between male (60.71 ± 10.9) and female (57.64 ± 10.9) patients (p < .05). More than 60% were diagnosed with esophageal cancer within one year, 67% of them with stage three and 20.9% had a combination of cancer treatments, and 38.6% were hospitalized for two to three times since diagnosis. Nearly half (49%) of the participants' medical expenses were covered by rural cooperative and 89% were aware of their cancer diagnosis. Patients' CESD-10 mean score was 12.43 ± 7.8 (range ¼ 0e30), indicating that they had significant depressive symptomatology as suggested by Andresen et al. (1994). The caregivers' mean level of depression was 11.22 ± 6.2, which was indicative of clinical depression (higher than the cutoff point of 10) (Andresen et al., 1994). The total score for social support was 65.66 ± 10.3 (range ¼ 12e84), indicating moderate degree of perceived social support (Zimet et al., 1990). Participants had the highest degree of support from the family (20.20 ± 2.9) followed by significant others (18.15 ± 3.9) and lastly, friends (15.17 ± 3.8). There were no significant differences in the level of depression and perceived social support between male and female caregivers. Differences in coping styles between male and female caregivers

there were significant differences in problem-focused coping style for male (17.09 þ 3.4) and female (15.91 þ 3.3; 2.990 (299) ¼ .093, P ¼ .003) caregivers, the magnitude of the difference (eta square ¼ .03) indicated a moderate effect size (Cohen, 1988). There were also significant differences in adaptive-focused coping style for male (10.18 þ 2.1) and female (9.16 þ 1.9; 4.294 (299) ¼ .553, P ¼ .000) caregivers, the magnitude of the difference (eta square ¼ .06) indicated a moderate effect size. No significant differences were found between male and female caregivers in emotion-focused and maladaptive coping styles. Relationships between patients' demographic and clinical characteristics with caregivers' coping styles For the second hypothesis, Spearman correlations showed that among the patients' demographic and clinical characteristics, months since diagnosis (rho ¼ .247; P < .01) was negatively correlated with problem-focused coping style for the male caregivers. For the female caregivers, the stage of cancer was positively correlated with problem-focused (rho ¼ .171; P < .05), adaptive (rho ¼ .242; P < .01) and maladaptive (rho ¼ .200; P < .01) coping styles. The number of hospitalizations (rho ¼ .334; P < .01) was also positively correlated with maladaptive coping style of female caregivers. The strength of the relationships between these variables was small (rho ¼ .11e.18). Our results also illustrated that only 11% of the patients were not aware of their diagnosis. Spearman correlations showed that patients' awareness of their diagnosis had no correlations with caregivers' depression and coping styles. However, stage of cancer was positively correlated with caregivers' depression (rho ¼ .251; P < .01). Relationships between caregivers' demographic characteristics with coping styles

Table 2 illustrates the four coping styles and each of the 14 strategies used by caregivers. The four leading coping strategies utilized were: active coping (5.64), planning (5.56), acceptance (5.20) and use of emotional support (5.15). Among the six maladaptive coping, female caregivers used denial (male ¼ 4.01 ± 1.1; female ¼ 4.18 ± 1.4; P < .000) and self-blame (male ¼ 4.04 ± .84; female ¼ 4.14 ± 1.5; P < .000) more often than male caregivers. For the first hypothesis, Table 3 displays the differences in male and female caregivers' coping style. Independent t-test showed that

For the third hypothesis, Spearman correlations showed that male caregivers' marital status was positively correlated with emotion-focused (rho ¼ .203; P < .05) and adaptive (rho ¼ .368; P < .01) coping styles and income was positively correlated (rho ¼ .237; P < .05) with emotion-focused coping style. For the female caregivers, relationship with the patients was positively correlated with problem-focused (rho ¼ .159; P < .05) and emotion-focused (rho ¼ .281; P < .01) coping styles. The strength of the relationships between these variables was small (rho ¼ .12e.24).

Table 2 Coping style scores among depressed caregivers (n ¼ 301).

Relationships between caregivers' depression, social support and coping styles

Brief coping style

Mean/SD

Problem-focused coping Active coping Planning Use of instrumental support Emotional-focused coping Use of emotional support Positive reframing Religion Adaptive coping Acceptance Humor Maladaptive coping Self-distraction Venting Denial Self-blame Behavioral disengagement Substance use

16.34 5.64 5.56 5.14 13.15 5.15 4.71 3.28 9.53 5.20 4.33 24.09 4.87 4.60 4.12 4.11 3.75 2.64

± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±

4.29 1.35 1.49 1.33 2.24 1.29 1.23 1.42 2.15 1.15 1.29 4.34 1.33 1.02 1.29 1.29 1.11 1.06

Range 8e24 2e8 2e8 2e8 7e19 2e8 2e8 2e7 5e15 2e8 2e8 14e34 2e8 2e7 2e8 2e8 2e7 2e8

For the fourth hypothesis, correlations between depression, social support and coping styles of caregivers were examined using Pearson productemoment correlation coefficient. The results showed that there were strong correlations between problemfocused coping (r ¼ .56, n ¼ 301, P < .01) with adaptive-focused, maladaptive coping (r ¼ .42, n ¼ 301. P < .05) and emotionfocused coping (r ¼ .39, n ¼ 301, P < .01) but no correlation with social support and depression. The results also showed that there was a 31.69% calculated shared variance that meant adaptive coping explained nearly 32% of the variance in the caregivers' score on problem-focused coping style. The strength of the relationship was large (r ¼ .56). The results also showed that there were strong relationships between emotion-focused coping style (r ¼ .53, n ¼ 301, P < .01) with adaptive coping, maladaptive coping, social support and depression, adaptive coping explained 28% of the variance (Table 4).

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Table 3 Differences in male and female caregivers' coping style, social support and depression (n ¼ 301). Coping style

Male (n ¼ 111)

Problem-focused coping Emotion-focused coping Adaptive-focused coping Maladaptive coping Social support Depression

17.09 13.19 10.18 24.27 65.92 10.94

± ± ± ± ± ±

3.4 2.1 2.1 3.9 11.6 5.6

Female (n ¼ 190) 15.91 13.12 9.16 23.97 65.51 11.39

± ± ± ± ± ±

3.3 2.1 1.9 4.2 9.8 6.6

t

df

P < .05

Mean difference

CI ¼ 95% lower

CI ¼ 95% upper

2.990 .265 4.294 .571 .333 .607

299 299 299 299 299 299

.003 .792 .000 .568 .732 .544

1.184 .068 1.022 .291 .414 .453

.40504 .43863 .55373 .71221 2.008 1.919

1.96462 .57480 1.49085 1.29485 2.835 1.014

Discussion Family caregivers' mean level of depression was indicative of clinical depression. This may be explained because in China, caregivers mostly take on more and more responsibilities in caring for the cancer patients even while in hospital, which they may not be prepared to manage. In China, family members are allowed to stay with the patients while in hospitals to assist in routine patient care such as bathing, feeding and assisting with mobility. Furthermore, witnessing their family members who were experiencing cancer treatment-related symptoms could also have added to their depression and helplessness as they may not have been prepared on how to deal with these symptoms. Johannessen-Henry et al. (2013) stated that as caregivers take on the responsibility as caregivers of patients with increasing dependency needs, caregivers' ability to care for themselves while trying to maintain the level of caring for the patients were also negatively affected. It was also reported in other studies that there was an increasing evidence of cancer caregivers suffering from the psychological fear of cancer recurrence and death of their family members (Demspter et al., 2011; Kasi et al., 2007; McCorry et al., 2009) especially if they were the only ones who knew the cancer diagnosis of the patient (Zhao et al., 2010). In our study, Chinese caregivers withholding the cancer diagnosis from the patient could also have impacted on their level of depression. Withholding the diagnosis was also found in a qualitative study in the United Kingdom among caregivers of patients after esophagectomy because they acted as a buffer to protect the patients from distress (McCorry et al., 2009). Therefore, early recognition of caregivers' psychological problems and implementation of appropriate interventions are crucial. When we explored the coping styles used by caregivers, we found that not all of them used maladaptive coping, which is consistent with previous study (Qiu and Li, 2009). The findings demonstrated that Chinese caregivers of hospitalized esophageal cancer patients usually used positive methods to deal with their difficulties. We also found that male caregivers used more problemfocused and adaptive coping styles. The results may be explained by the major role males play within the Chinese kinship system as protector for the family by active planning and acceptance of the cancer patients' diagnosis, treatment, and prognosis. Problemfocused coping style was also found in other cancer caregiver studies (Chen et al., 2006; Cui, 2010; Hulbert-Williams et al., 2013), Table 4 Correlations between caregivers' depression, social support and coping style (n ¼ 301). 1

2

3 .393a

4

Problem-focused Emotion-focused Adaptive coping Maladaptive coping Social support Depression

a

Correlation significant at p < .01 (2-tailed). Correlation significant at p < .05 (2-tailed).

b

1

.563a .525a

1. 2. 3. 4. 5. 6.

1

.417b .382a .358a

1 1

5

6

.105 .306a .014 .041 1

.100 .147b .151a .401a .395a 1

however, these studies did not compare male and female caregivers. In our study, male and female caregivers used emotion-focused coping such as positive reframing, use of emotional support, and religion. In the study by Johannessen-Henry et al. (2013), they found positive relationships between faith, distress and mental adjustment among Danish cancer survivors. Vonarx and Hyppolite (2013) and Son et al. (2012) also found that religion was useful in providing solace among caregivers. The use of religious coping strategies among the Chinese caregivers in our study could have enabled them to face day-to-day fears or to count their blessings as their family member progressed through their cancer journey. Another emotion-focused coping style used by caregivers in our study was the emotional support from other family members and friends. The positive effect of social support was also found in Bowman et al.'s (2009) study in protecting, maintaining health and acting as moderators to alter the depressive effects of caregiving (Nijboer et al., 2001) and improve their quality of life (DowneWambot et al., 2006). Although with the one-child policy in China, in our study, the social support network could be small but it is not the number of people that was reported as being important to caregivers but the frequency of their active involvement in supporting the caregivers. In our study, self-distraction was the most highly employed maladaptive coping strategies. However, we considered selfdistraction as a positive coping strategy as in the Chinese community, it is common to find people doing Tai Chi or Qi Gong first thing in the morning. These exercises were not only aimed at improving their physical mobility but also practiced as a form of relaxation and distraction from worries (Mishra et al., 2012). A study using these exercises is therefore needed to examine the effectiveness of such intervention as a coping strategy. Compared to the other caregiving studies, substance use was less used as maladaptive coping, which concurred with the study among Chinese stroke caregivers (Qiu and Li, 2009). For the fourth hypothesis, we found significant correlations between coping, social support and depression. In particular, emotion-focused coping style was positively correlated with social support, depression, and maladaptive coping style. Among the 148 caregivers of Turkish patients with cancer, Tan (2007) found that as the mean social support scores increased, the mean emotionalfocused coping strategies scores decreased and the mean problem-focused coping strategies scores increased. Limitations Our study was limited due to the cross-sectional design at one point in time during which data were collected when patients with esophageal cancer were still in hospital. It would have been beneficial if a longitudinal study is carried out to examine whether the caregivers' level of depression, social support, and coping style change after the patients are discharged home. Our study only focused on Chinese caregivers therefore, further research is needed to explore caregiving burden in different ethnic groups, the impact

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of caregiving across different types of cancer, and the types of psychosocial interventions to support coping in family caregivers. Conclusion Our study supported Lazarus and Folkman's (1984) theory on stress and coping and the incorporation of emotional reactions into stress-coping framework (Hulbert-Williams et al., 2013). Our study of Chinese caregivers demonstrated the transaction between a person's cognitive appraisal of the stressor and his/her coping response. There were a number of Chinese patients' sociodemographic and clinical characteristics and Chinese caregivers' socio-demographic characteristics associated with coping styles and the positive and negative correlations between coping styles, social support, and depression. Our study partially supported that male and female Chinese caregivers have different coping styles. Therefore, knowing caregivers' coping styles could prepare nurse practitioners to reinforce positive and adaptive forms of coping. Implications for cancer caregivers' research Families will eventually play a major role in caring for cancer patients that is expected to expand due to improvements in cancer diagnostics and treatment, change in lifestyle behaviors, early stage cancer awareness and increasing cancer survivorship. There were significant evidences that caregivers suffer from various physical and psychosocial problems but what is needed is to address the cultural differences in cancer caregiving burden, roles and initiate appropriate interventions to help caregivers face the multiple demands of caregiving in a more positive way. There is also a need to develop and evaluate other interventions such as Chinese meditation and exercise practices using randomized clinical trials and sensitive instruments to measure the effectiveness. Conflicts of interests All authors have no conflicts of interests to disclose. Acknowledgements Source of funding: This study was supported by the Fundamental Research Funds for the Central Universities, HUST (01-18-530162), and grant from Taihe Hospital, Hubei University of Medicine affiliated hospital (2011D29). References Andresen, E.M., Malmgren, J.A., Carter, W.B., Patrick, D.L., 1994. Screening for depression in well older adults: evaluation of a short form of the Centre for Epidemiologic Studies Depression Scale (CES-D). American Journal of Preventive Medicine 10, 77e84. Bambauerm, K., Zhang, B., Maciejewski, P., Sahay, N., Pirl, W.F., Block, S.D., et al., 2006. Mutuality and specificity of mental disorders in advanced cancer patients and caregivers. Social Psychiatry and Psychiatric Epidemiology 41, 819e824. Boey, K.W., 1999. Cross-validation of a short form of the CES-D in Chinese elderly. International Journal of Geriatric Psychiatry 14, 608e617. Bowman, K.F., Rose, J.H., Radziewicz, R.M., O’Toole, E.E., Berila, R.A., 2009. Family caregiver engagement in a coping and communication support intervention tailored to advanced cancer patients and families. Cancer Nursing 32, 73e81. Carlson, L.E., Bultz, B.D., Speca, M., Pierre, M.S., 2000. Partners of cancer patients: part 1. Impact, adjustment, and coping across the illness trajectory. Journal of Psychosocial Oncology 18, 39e55. Carver, C.S., 1997. You want to measure coping but your protocol's too long: consider the brief COPE. International Journal of Behavioral Medicine 4, 92e100. Carver, C.S., Scheier, M.F., Weintraub, J.K., 1989. Assessing coping strategies: a theoretically based approach. Journal of Personality and Social Psychology 56, 267e283.

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