International Journal of Nursing Practice 2016 ; 22: 79– 88
RESEARCH PAPER
The effectiveness of a rehabilitation programme for Chinese cancer survivors: A pilot study Hui Zhang MD Lecturer, School of Nursing, Harbin Medical University (Daqing), Daqing, Heilong Jiang Province, China
Yuqiu Zhou MD Professor, School of Nursing, Harbin Medical University (Daqing), Daqing, Heilong Jiang Province, China
Yuxia Cui MD Lecturer, School of Nursing, Harbin Medical University (Daqing), Daqing, Heilong Jiang Province, China
Jinwei Yang MD Lecturer, School of Nursing, Harbin Medical University (Daqing), Daqing, Heilong Jiang Province, China
Accepted for publication August 2014 Zhang H, Zhou Y, Cui Y, Yang J. International Journal of Nursing Practice 2016 ; 22: 79– 88 The effectiveness of a rehabilitation programme for Chinese cancer survivors: A pilot study Cancer survivors have experienced high stress which impairs psychological functioning and decreases quality of life (QOL). This study aims to assess the mediating effect of self-efficacy on mood disturbance and QOL, and determine the effectiveness of a 12 week rehabilitation programme to improve self-efficacy as well as improve mood disturbance and QOL in Chinese cancer survivors. A total of 47 cancer patients were randomly assigned into the experimental (n = 24) and control (n = 23) groups. The participants in the experimental group received cancer-related education, progressive muscle relaxation and emotional support. Self-reported questionnaires, including General Self-efficacy Scale (GSES), Profile of Mood States Scale–Short Form (POMS-SF) and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) were collected in pre- and post-intervention. Findings from this study indicated that self-efficacy was a complete mediator between mood disturbance and QOL, and the 12 week rehabilitation programme had a positive effect on self-efficacy, mood disturbance and QOL for Chinese cancer survivors. Key words: cancer survivor, mediator, mood disturbance, quality of life, rehabilitation programme, self-efficacy.
INTRODUCTION Cancer is a globally occurring, life-threatening disease. In the People’s Republic of China (PRC), cancer is the
Correspondence: Hui Zhang, School of Nursing, Harbin Medical University (Daqing), 205 Room, 39 Xinyang Road, Gaoxin District, Daqing City 163319, Hei Longjiang Province, China. Email: [email protected] doi:10.1111/ijn.12370
leading cause of death, accounting for 27.1% of all deaths among urban residents and 25.4% among rural residents.1 Early diagnosis and advanced treatments have contributed to an increasing cancer survival rate.2 Although cancer remission increased and lifespan prolonged, survivors might face difficulties associated with the nature of the disease process and treatments, including physical (e.g. physical activity, fatigue, pain, sleep disturbances), psychological (e.g. anxiety, depression, fear, © 2014 Wiley Publishing Asia Pty Ltd
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low confidence) and social problems (e.g. avoidance, job reintegration), which could decrease their quality of life (QOL).2–4 It has been suggested that rehabilitation should be an integral part of cancer care to help cancer patients regain control of their lives and further improve their QOL.5 Existing cancer rehabilitation programmes contain psychosocial intervention, physical exercise, nutrition and multidisciplinary intervention to improve QOL for cancer patients.6–10 In the PRC, clinical services for cancer patients mainly focus on managing cancer-related physical symptoms, routine health education and general emotional support. However, the services are mostly provided during hospitalization period for cancer patients. To date, no rehabilitation programme is available to assist Chinese cancer survivors, especially during the transition period from hospital to home, to ensure their QOL. In our previous qualitative study, we found that cancer survivors often reported they had suffered from negative emotions and lacked cancer-related rehabilitation information after they were discharged from hospital.11 The findings indicate that the Chinese cancer survivors need continue professional support at home because they have low self-efficacy during their rehabilitation period. According to Albert Bandura, self-efficacy is a person’s belief in his or her ability to succeed in a particular situation; it can also be regarded as an optimistic view of one’s capacity to deal with stress.12 To date, the existing cancer interventions have focused mainly on physical and psychological symptoms and QOL for cancer patients; a few studies have focused on how to improve self-efficacy for cancer survivors.13 Studies revealed that self-efficacy is a strong predictor of QOL for cancer patients and other disease populations, such as kidney transplant patients and coronary heart disease.14–16 In this study, we use Bandura’s Social Cognitive Theory to guide and design the rehabilitation programme. Accordingly, the sources of selfefficacy come from past experience, vicarious experience, verbal persuasion, and levels of arousal and distress.
AIMS The current study aims to assess the mediating effect of self-efficacy on mood disturbance and QOL, and to determine the effectiveness of rehabilitation programme to improve self-efficacy, mood disturbance and QOL among Chinese cancer patients during the transition period from hospital to home. © 2014 Wiley Publishing Asia Pty Ltd
METHODS Study design and samples A convenience sample of 57 cancer patients, within 1 year, was recruited and enrolled from two oncology units of a teaching hospital located in the northeast of PRC. The inclusion criteria included: (i) cancer patients aged 18 years or older and at the last session of chemotherapy; (ii) who were able to carry out activities of daily life evidenced by a score above 60 on the Karnofsky Performance Status (KPS)17; (iii) according to the doctor’s clinical routine assessment, who had at least 6 months life expectancy; and (iv) who lacked metastasis, mental disease and other types of physical illness. Participants were randomly assigned to either experimental or control group, according to their medical chart numbers (even numbers to the experimental group and odd numbers to the control group). We matched sex, age and types of cancer between the two groups. Five patients dropped out from each group due to their tiredness, had a recurrence of cancer, transferred to the other hospital and removed to another city. This study was approved by the ethics committee of Harbin Medical University in PRC.
Measurements A researcher-designed demographic and clinical data form was used to collect the participants’ age, gender, marital status, educational status, income status, employment status and diagnosis stage. Participants completed the following self-report assessments at two times over the course of the study: prior to the start of the rehabilitation programme (pretest) and after completion of the programme (post-test) when they returned for a routine 12-week follow-up hospital visit. The General Self-efficacy Scale (GSES), a 10-item scale, was used to evaluate an individual’s self-efficacy in coping with daily hassles or stressful events.18 It is a 4-point Likert scale that ranges from 1 (not at all) to 4 (exactly true); a higher score indicates higher self-efficacy of the individual. The Cronbach’s alpha for the GSES was 0.8.18 The GSES has been translated into a Chinese version and further validated by Wang et al.,19 with a Cronbach’s alpha of 0.87. The Cronbach’s alpha was 0.92 in the current study. The Profile of Mood States Scale–Short Form (POMS-SF) was used to measure emotional status of the participants. This 37-item instrument includes six subscales: tensio– anxiety, depression–dejection, anger–hostility, fatigue– inertia, confusion–bewilderment and vigour–activity.20 The POMS-SF uses a 5-point Likert scale that ranges from
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0 (not at all) to 4 (exactly true); higher scores indicate more mood disturbance. The Cronbach’s alpha for the whole scale was 0.87.20 The Cronbach’s alpha for the Chinese version was 0.93.21 In the current study, the Cronbach’s alpha was 0.91 for the whole scale, and ranged from 0.74 to 0.85 for the six subscales. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQC30) is a 30-item self-report questionnaire which is one of the most commonly used questionnaires to measure QOL in cancer patients. It includes a global QOL scale, five functional subscales (physical, role, cognitive, emotional social functioning), three symptom subscales (fatigue, pain, nausea and vomiting), and six single item subscales (dyspnoea, sleeplessness, lack of appetite, constipation, diarrhoea, financial difficulty). The reliability coefficients for the subscales ranged from 0.52 to 0.89.22 The Cronbach’s alpha for the Chinese version was 0.81.23 In the current study, the Cronbach’s alpha was 0.88 for the whole scale, and ranged from 0.72 to 0.91 for the subscales.
Intervention The participants in the experimental group received a 12 week rehabilitation programme, including cancer-related education, progressive muscle relaxation (PMR) and emotional support. Each participant received an educational booklet based on the findings from our prior qualitative study of cancer survivors11 that included information on cancer-related treatment and recovery, nutrition and physical exercise (walking, jogging and lifting up), coping strategies, strengthening social support, and increasing self-confidence in managing their disease. The first author (HZ) scheduled appointments with the study participants for a daily 30 min, face-to-face cancer-related educational sessions (cancer-related education, PMR) at the hospital for a total of 3 days prior to participants being discharged. HZ discussed each specific topic included in the booklet with the experimental group participants, and participants kept the booklet throughout the home-based intervention period. After each topic of education, the participants were given 20 min one-on-one PMR instructions daily by HZ at the hospital for 3 days. The PMR training was based on the instructions from a relaxation audiobook produced by the John Tung Foundation,24 which was widely used by many researchers for the Chinese population.25,26 The relaxation audiobook was stored in a mini MP3 player and used a
gentle voice with a soft musical background to guide deep breathing and progressive muscle relaxation. At the third time, all the participants were asked for a returndemonstration to ensure that they were able to practice PMR at home by themselves. The audiobook was downloaded by the study participants’ preferred equipment (i.e. MP3, CD, cell phone) in order for them to practice every day at home for 12 weeks. The length of intervention was based on the recommendation of a meta-analysis.27 Emotional support was provided through a weekly phone call and two sessions of group support. Weekly 10 min telephone follow-up counselling was given to the participants by HZ to provide support; the researcher encouraged patients to raise their self-efficacy by providing positive emotional support. Two group supportive sessions were held at the fourth and eighth weeks during the intervention period when patients returned to the hospital for routine follow-ups. Group support (11 to 12 patients in each group) was provided by two models (successful cancer survivors). HZ provided topics (i.e. fatigue, coping with stress and anxiety, job reintegration) for the models to develop contents, which aimed to increase selfefficacy for the study participants. All control group participants received the usual care from the clinic; moreover, they all received the educational booklet and PMR training techniques after completing the post-test.
Data analysis Descriptive statistics were used to describe the characteristics of the study participants. Homogeneity of demographic and clinical characteristics between the experimental and control groups was evaluated by t-tests and chi-square. Pearson’s correlation and linear regression analysis were performed for mediation analysis. At pretest, no significantly different characteristics were found between the two groups. Therefore, independent sample t-tests were used to evaluate the outcome variables to determine the effectiveness of the rehabilitation intervention.
RESULTS Demographic and medical characteristics of the sample As shown in Table 1, demographic and clinical characteristics of the participants did not differ significantly between the two groups at pretest. The majority of the © 2014 Wiley Publishing Asia Pty Ltd
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Table 1 Demographic and clinical characteristics of the participants (N = 47) Characteristic Gender Male Female Age, MD (SD) Education level Junior high school Senior high school College Employment status Worker Farmer Techniques Others Income per month (China) Lower (≤ 1000) Medium (1000–3000) High (3000–5000) Diagnosis Breast cancer Lung cancer Gastric and intestine Thyroid cancer Stage of tumour (year) ≤1 2–3 4–5 Scores of KPS 60–69 70–79 80–89 90–100
Total (N = 47)
Intervention group (n = 24)
Control group (n = 23)
P value 0.917
16 (34%) 31 (66%) 51.3 (11.7)
8 (33.3%) 16 (66.7%) 50.9 (10.6)
8 (34.8%) 15 (65.2%) 51.7 (13.0)
8 (17%) 18 (38.3%) 21 (44.7%)
3 (12.5%) 11 (45.8%) 10 (41.7%)
5 (21.7%) 7 (30.4%) 11 (47.8%)
7 (14.9%) 3 (6.4%) 25 (53.2%) 11 (23.4%)
3 (12.5%) 2 (8.3%) 13 (54.2%) 5 (20.8%)
4 (17.4%) 1 (4.3%) 12 (52.2%) 6 (26.1%)
7 (14.9%) 28(59.6%) 12 (25.5%)
3 (12.5%) 16 (66.7%) 5 (20.8%)
4 (17.4%) 12 (52.2%) 7 (30.4%)
0.720 0.493
0.985
0.598
0.806 24 (51.1%) 10 (21.3%) 12 (25.5%) 1 (2.1%)
12 (50%) 5 (20.8%) 6 (25%) 1 (4.2%)
12 (52.2%) 5 (21.7%) 6 (26%) 0
28 (59.6%) 14 (29.8%) 5 (10.6%)
13 (54.2%) 9 (37.5%) 2 (8.3%)
15 (65.2%) 5 (21.7%) 3 (13%)
9 (19.1%) 17 (36.2%) 15 (31.9%) 6 (12.8%)
3 (12.5%) 11 (45.8%) 7 (29.2%) 3 (12.5%)
6 (26.1%) 6 (26.1%) 8 (34.8%) 3 (13%)
0.728
0.472
KPS, Karnofsky Performance Status.
study participants were women (66%), with a mean age of 51.3 (SD = 11.7), and with breast cancer (51.1%). The average time since cancer diagnosis was 2.0 (SD = 2.1) years, and for 92% of the participants was a first-time diagnosis for cancer. The mean score of KPS was 73.8 (SD = 9.5) (Table 2).
The mediation analysis of self-efficacy, mood and QOL At pretest, the mean score of self-efficacy measured by the GSES was 28.3 (SD = 6.2, median = 29), the total mood © 2014 Wiley Publishing Asia Pty Ltd
disturbance score measured by the POMS-SF was 35.6 (SD = 12.6, median = 33) and the global QOL score measured by EORTC QLQ-C30 was 47.9 (SD = 15.9, median = 41.7). Pretest data were used for mediation analysis. The correlations among self-efficacy, total mood disturbance, global QOL score and demographic/clinical characteristics were assessed prior to the mediation analysis. Higher self-efficacy was associated with better QOL (r = 0.57, P < 0.01), higher educational status (r = 0.45, P < 0.01) and less mood disturbance (r = −0.52, P < 0.01). Higher
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Table 2 Comparison of self-efficacy, POMS-SF, and QLQ-C30 between groups before the intervention Variable
Self-efficacy POMS-SF—TMD Tension–Anxiety Depression–Dejection Anger–Hostility Fatigue–Inertia Confusion–Bewilderment Vigour–Activity QLQ-C30 Globle QOL Physical function Role function Emotional function Cognitive function Social function Fatigue Nausea and vomiting Pain Dyspnoea Sleeplessness Lack of appetite Constipation Diarrhoea Financial difficulty
Total (N = 47)
Experimental (n = 24)
Control (n = 23)
X
SD
X
SD
X
SD
28.34 35.55 5.51 5.96 6.02 4.81 4.98 8.21 47.87 60.14 64.89 69.86 71.28 60.28 53.90 21.28 33.69 26.24 39.00 57.45 37.59 12.06 35.46
6.17 12.61 2.90 2.69 3.34 3.20 3.36 3.06 15.88 26.68 34.44 23.41 25.47 32.33 24.74 25.23 33.96 28.60 35.66 26.65 26.57 18.94 29.00
25.75 37.46 5.83 6.04 6.79 5.29 5.04 8.54 45.83 65.00 61.81 73.26 75.69 68.06 51.85 15.28 36.81 31.94 33.33 56.94 34.72 11.11 31.94
5.71 13.54 3.17 2.85 4.00 3.44 3.06 2.77 14.12 24.18 33.14 18.87 22.51 31.05 25.10 18.33 33.69 28.62 31.08 28.62 26.88 18.82 26.88
28.96 33.57 5.17 5.87 5.22 4.30 4.91 7.87 50.00 55.07 68.12 66.30 66.67 52.17 56.04 27.54 30.43 20.29 44.93 57.97 40.58 13.04 39.13
6.69 11.52 2.62 2.56 2.30 2.91 3.72 3.36 17.59 28.72 36.21 27.35 27.98 32.30 24.73 29.99 34.69 27.96 39.71 25.06 26.51 19.43 31.22
P value
0.509 0.295 0.442 0.829 0.105 0.295 0.897 0.457 0.374 0.206 0.536 0.314 0.228 0.093 0.567 0.101 0.526 0.165 0.273 0.897 0.456 0.731 0.402
POMS-SF, Profile of Mood States Scale–Short Form; QLQ-C30, Quality of Life Questionnaire Core 30; QOL, quality of life; TMD, total mood disturbance.
global QOL scores were associated with less mood disturbance (r = −0.46, P < 0.01). Also, participants with longer durations of cancer had worse mood disturbance (r = 0.29, P < 0.05). While controlling for demographic/clinical data, which were correlated with self-efficacy, mood disturbance and QOL, linear regression models were used to analyse the mediation effects of self-efficacy and mood disturbance on QOL among the participants (Table 3). We adopted the steps for evaluating a mediating effect as proposed by Baron and Kenny.28 Step 1 examined whether total mood disturbance was a significant predictor of QOL (c path). Step 2 examined whether total mood disturbance was a significant predictor of self-efficacy (a path). Step 3 examined whether self-efficacy was a significant predictor of QOL while
controlling for demographic/clinical data (educational status and stage which were significantly correlated with measurement variables) (b path) and whether total mood disturbance was a significant predictor of QOL (c' path). If self-efficacy was a complete mediator of the relationship between total mood disturbance and QOL, then the effect of total mood disturbance (c') should be zero.28 The findings indicated that the total mood disturbance (β = −0.457, P < 0.05) and self-efficacy (β = 0.450, P < 0.05) were the significant predictors of QOL. As shown in Table 3, the effect of total mood disturbance on the QOL was zero, which evidenced that self-efficacy was a complete mediator between mood disturbance and QOL (Fig. 1). The indirect effect of total mood disturbance on QOL through self-efficacy was 0.507. © 2014 Wiley Publishing Asia Pty Ltd
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Table 3 The regression analysis of quality of life, self-efficacy, and total mood disturbance Pathway
Adjusted R2
Beta
Se
t
P value
TMD → QOL (c path) TMD → SE (a path) SE → QOL (b path) TMD → QOL (c' path)
0.191 0.248 0.328 0
−0.457 −0.515 0.450 −0.225
0.167 0.063 0.362 0.177
−3.442 −4.025 3.195 −1.596
0.001 0.000 0.003 0.118
QOL, quality of life; SE, self-efficacy; Se, standard error; TMD, total mood disturbance.
Self-efficacy –0.515*
0.450*
Total mood score
Quality of life –0.225
Figure 1. The pathway of total mood disturbance, quality of life and self-efficacy. * means P < 0.05.
The effects of the rehabilitation programme on self-efficacy, mood disturbance and QOL in cancer survivors Independent sample t-tests were used to evaluate the effects of the intervention on self-efficacy, mood disturbance and QOL (Table 4). At the post-test, compared with the control group, the participants in the experimental group reported significantly higher scores in self-efficacy, lower total mood disturbance and higher global QOL (P < 0.05). Although the intervention improved the total mood disturbance measured by the POMS-SF, there were no significant differences in the areas of depression– dejection, anger–hostility, fatigue–inertia and vigour– activity (P > 0.05). In addition, almost half of the symptoms (role function, cognitive function, pain, dyspnoea, constipation and diarrhoea) measured by the QLQC30 were not significantly different between the two groups (P > 0.05).
DISCUSSION The first aim of this study was to assess the mediating effect of self-efficacy on mood disturbance and QOL for cancer survivors. The findings showed that self-efficacy had a direct positive effect on mood and QOL. In © 2014 Wiley Publishing Asia Pty Ltd
addition, self-efficacy was a complete mediator between mood disturbance and QOL, which was consistent with previous studies that showed cancer patients’ self-efficacy had been associated with psychological distress, and people with high self-efficacy were likely to have better psychological adjustment, less negative physical and psychological outcomes, better QOL, and might live longer compared with those with low self-efficacy.29–31 Therefore, increasing self-efficacy is the key to improving mood and QOL for cancer survivors. Our results concur with the previous research32 that self-efficacy should be given more attention in cancer patients’ care. The second aim of the current study was to evaluate the effectiveness of a 12 week rehabilitation programme to improve self-efficacy, QOL and mood disturbance in cancer survivors. Compared with the control group, participants in the experimental group scored significantly better in self-efficacy, mood disturbance and QOL at the end of the intervention. The results supported the 12 week rehabilitation programme which consisted of three components: cancer-related education, PMR and emotional support that had an effect on the Chinese cancer survivors. In the current study, these sessions encouraged the study participants to believe that they had the capability to deal with adverse psychological distress through successful experiences from themselves and other cancer survivors. The results concur with previous studies12,33 that self-efficacy could be enhanced by past experience, such as giving positive feedback when patients have performed a desired activity; vicarious experience include modeling who has successful performing activities in a similar situation; verbal persuasion is encouraging patients to believe that they have the ability to deal with disease and reduce the level of arousal and distress by teaching disease-related knowledge and coping strategies.
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Table 4 Comparison of self-efficacy, POMS-SF, and QLQ-C30 between groups after the intervention Variable
Self-efficacy POMS-SF—TMD Tension–Anxiety Depression–Dejection Anger–Hostility Fatigue–Inertia Confusion–Bewilderment Vigour–Activity QLQ-C30 Global QOL Physical function Role function Emotional function Cognitive function Social function Fatigue Nausea and vomiting Pain Dyspnoea Sleeplessness Lack of appetite Constipation Diarrhoea Financial difficulty
Experimental (n = 24)
Control (n = 23)
X
SD
X
SD
31.83 28.29 3.50 5.29 3.92 3.13 2.63 8.79 61.46 75.56 72.22 84.03 75.69 71.53 35.65 8.33 20.14 19.44 19.44 36.11 22.22 8.33 26.39
4.46 7.80 1.82 2.14 2.30 2.07 1.69 2.89 16.63 17.21 22.34 13.44 22.51 22.78 13.89 12.04 20.25 25.85 21.80 29.35 21.23 14.74 21.93
28.52 34.96 5.26 6.30 4.87 4.48 4.87 8.61 50.00 61.74 70.29 67.03 66.67 51.45 49.76 28.99 26.09 17.39 44.93 53.62 33.33 8.70 43.48
6.60 13.68 2.65 2.99 2.30 3.17 4.12 2.78 16.28 23.20 33.32 26.17 27.98 36.21 22.19 32.65 30.91 26.34 39.71 24.08 17.41 14.97 33.99
t
P value
2.01 −2.04 −2.67 −1.34 −1.42 −1.74 −2.43 0.22 2.39 2.33 0.23 2.78 1.22 2.27 −2.60 −2.85 −0.78 0.27 −2.71 −2.23 −1.97 −0.08 −2.04
0.049 0.049 0.011 0.187 0.163 0.089 0.022 0.826 0.021 0.025 0.816 0.009 0.228 0.030 0.013 0.008 0.442 0.789 0.009 0.031 0.056 0.934 0.049
POMS-SF, Profile of Mood States Scale–Short Form; QLQ-C30, Quality of Life Questionnaire Core 30; QOL, quality of life; TMD, total mood disturbance.
In the current study, the educational session provided information such as: cancer-related treatments, nutrition and physical exercise, coping strategies, and social support. Those might increase the participants’ selfefficacy which mediates mood and improves their QOL. Other studies34–36 documented that either face-to-face or phone counselling could improve breast cancer patients QOL by providing cancer-related rehabilitation education and counselling on stress-related problems through group support. The results from this study show that home-based daily PMR practice might have an effect on reducing mood disturbance and increasing QOL for Chinese cancer survivors. This might result from PMR, and an individual could reduce stress through breathing exercise and muscle relaxation.37 PMR training can be effective in reducing anxiety and distress, physiological
arousal, and allow patients to change the excitability of nervous system tension as well as enhance their ability to adjust their internal and external environment.38 PMR could reduce stress and anxiety among diverse cancer patients during chemotherapy period.39–41 In addition, findings from this study showed that a weekly 10 min phone follow-up counselling and group support from individuals who are successful cancer survivors might enhance study participants’ self-efficacy, further mediating mood status and QOL. A recent study has shown that emotional and informational support provided by peer survivors are very helpful for QOL in Chinese breast cancer survivors.42 Other research also showed that emotional support (e.g. group support, telephone counselling) could improve mood and QOL for cancer patients.43 © 2014 Wiley Publishing Asia Pty Ltd
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The current research has several limitations. Firstly, the attention control for the control group was not conducted; therefore, the actual effectiveness of the rehabilitation programme could not be determined precisely because of the placebo effects. Secondly, the intervention consisted of three components which improved selfefficacy, mood disturbance and QOL for cancer survivors; whether it is necessary to include all three components should be further discussed. Thirdly, the practice of PMR by patients for 20 min daily for 12 weeks was simply based on the literature review27; the dosage and interval of PMR training had not yet been decided in this study and the most effective dosage needs to be explored. There is no written record of patients’ home practice of PMR; thus, the adherence to the intervention could not be determined. Fourthly, the generalization of the findings to other setting should be cautious in the future. The use of a special self-efficacy scale for cancer patients is needed in future studies. Lastly, this is a pilot study; the effectiveness of the rehabilitation programme should be further evaluated in a bigger sample size and the clinical significances should be considered.
CONCLUSION The findings of the current study provide evidence to show that self-efficacy is the complete mediator between mood and QOL for Chinese cancer survivors. In addition, the 12 week rehabilitation programme could statistically significantly improve self-efficacy, mood disturbance and QOL for the study participants. We suggest that clinical nurses and health-care professionals should assess the level of self-efficacy for cancer survivors and provide intervention to enhance their self-efficacy. Clinical continuing education should include self-efficacy training for healthcare providers. Enhancing self-efficacy should be taken into consideration in rehabilitation programmes for cancer survivors so as to improve QOL.
ACKNOWLEDGEMENTS This study was awarded to the second author by the Hei Longjiang Health Bureau in PRC. The authors gracefully acknowledge Dr Shih-Yu Lee and Dr Hong Tao for their guidelines and consultations in developing this paper, Yunpeng Zhao and Chunling Shen for their assistance in data collection, Hongling Song for her revisions of the grammar and expression for this paper, and most importantly, we gracefully acknowledge those cancer patients for sharing their experiences. © 2014 Wiley Publishing Asia Pty Ltd
CONFLICT OF INTEREST No conflict of interest has been declared by the authors.
AUTHORS’ CONTRIBUTIONS Hui Zhang, study design, data collection and intervention, and manuscript writing. Yuqiu Zhou, study design, consultation for the research, researcher training. Yuxia Cui, data collection and manuscript writing. Jinwei Yang, data analysis.
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immediate and prolonged stress responses in women with preterm labour. Journal of Advanced Nursing 2012; 68: 170– 180. Manzoni GM, Pagnini F, Castelnuovo G, Molinari E. Relaxation training for anxiety: A tenyears systematic review with meta-analysis. BMC Psychiatry 2008; 8: 41. Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology 1986; 51: 1173–1182. Hirai K, Arai H, Tokoro A, Naka N. Self-efficacy, psychological adjustment and decisionalbalance regarding decision making for outpatient chemotherapy in Japanese advanced lung cancer. Psychology and Health 2009; 24: 149–160. Bandura A, Caprara GV, Barbaranelli C, Gerbino M, Pastorelli C. Role of affective self-regulatory efficacy in diverse spheres of psychosocial functioning. Child Development 2003; 74: 769–782. Fatima R. Counseling self-efficacy and its relationship to anxiety and problem-solving in United Arab emirates. International Journal for the Advancement of Counseling 2005; 27: 325–335. Kohno Y, Maruyama M, Matsuoka Y, Matsushita T, Koeda M, Matsushima E. Relationship of psychological characteristics and self-efficacy in gastrointestinal cancer survivors. Psychooncology 2010; 19: 71–76. Haugland T, Veenstra M, Vatn MH, Wahl AK. Improvement in stress, general self-efficacy,and health related quality of life following patient education for patients with neuroendocrine tumors: A pilot study. Nursing Research and Practice 2013; 2013: 695820. Meneses KD, McNees P, Loerzel VW, Su X, Zhang Y, Hassey LA. Transition from treatment to survivorship: Effects of a psychoeducational intervention on quality of life in breast cancer survivors. Oncology Nursing Forum 2007; 34: 1007–1016. Salonen P, Tarkka MT, Kellokumpu-Lehtinen PL, Koivisto AM, Astedt-Kurki P, Kaunonen M. Individual face-to-face support and quality of life in patients with breast cancer. International Journal of Nursing Practice 2011; 17: 396– 410. Sherman DW, Haber J, Hoskins CN et al. The effects of psychoeducation and telephone counseling on the adjustment of women with early-stage breast cancer. Applied Nursing Research 2012; 25: 3–16. Bernstein DA, Borkovec TD, Hazlett-Stevens H. New Directions in Progressive Relaxation Training. Westport, CT: Praeger, 2000. Molassiotis A, Yung HP, Yam BM, Chan FY, Mok TS. The effectiveness of progressive muscle relaxation training in managing chemotherapy-induced nausea and vomiting in Chinese breast cancer patients: A randomised controlled trial. Supportive Care in Cancer 2002; 10: 237–246. © 2014 Wiley Publishing Asia Pty Ltd
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39 Herizchi S, Asvadi I, Piri I, Golchin M, Shabanlui R, Sanaat Z. Efficacy of progressive muscle relaxation training on anxiety, depression and quality of life in cancer patients undergoing chemotherapy at Tabriz Hematology and Oncology Research Center, Iran in 2010. Middle East Journal of Cancer 2012; 3: 9–13. 40 Cheung YL, Molassiotis A, Chang AM. The effect of progressive muscle relaxation training on anxiety and quality of life after stoma surgery in colorectal cancer patients. Psychooncology 2003; 12: 254–266. 41 Yoo HJ, Ahn SH, Kim SB, Kim WK, Han OS. Efficacy of progressive muscle relaxation training and guided imagery
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in reducing chemotherapy side effects in patients with breast cancer and in improving their quality of life. Supportive Care in Cancer 2005; 13: 826–833. 42 Cheng H, Sit JW, Chan CW, So WK, Choi KC, Cheng KK. Social support and quality of life among Chinese breast cancer survivors: Findings from a mixed methods study. European Journal of Oncology Nursing 2013; 12: 2205–2214. 43 Schou Bredal I, Karesen R, Smeby NA et al. Effects of a psychoeducational versus a support group intervention in patients with early-stage breast cancer: Results of a randomized controlled trial. Cancer Nursing 2013; 17: 2034–3047.
RESEARCH PAPER
The effectiveness of a rehabilitation programme for Chinese cancer survivors: A pilot study Hui Zhang MD Lecturer, School of Nursing, Harbin Medical University (Daqing), Daqing, Heilong Jiang Province, China
Yuqiu Zhou MD Professor, School of Nursing, Harbin Medical University (Daqing), Daqing, Heilong Jiang Province, China
Yuxia Cui MD Lecturer, School of Nursing, Harbin Medical University (Daqing), Daqing, Heilong Jiang Province, China
Jinwei Yang MD Lecturer, School of Nursing, Harbin Medical University (Daqing), Daqing, Heilong Jiang Province, China
Accepted for publication August 2014 Zhang H, Zhou Y, Cui Y, Yang J. International Journal of Nursing Practice 2016 ; 22: 79– 88 The effectiveness of a rehabilitation programme for Chinese cancer survivors: A pilot study Cancer survivors have experienced high stress which impairs psychological functioning and decreases quality of life (QOL). This study aims to assess the mediating effect of self-efficacy on mood disturbance and QOL, and determine the effectiveness of a 12 week rehabilitation programme to improve self-efficacy as well as improve mood disturbance and QOL in Chinese cancer survivors. A total of 47 cancer patients were randomly assigned into the experimental (n = 24) and control (n = 23) groups. The participants in the experimental group received cancer-related education, progressive muscle relaxation and emotional support. Self-reported questionnaires, including General Self-efficacy Scale (GSES), Profile of Mood States Scale–Short Form (POMS-SF) and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) were collected in pre- and post-intervention. Findings from this study indicated that self-efficacy was a complete mediator between mood disturbance and QOL, and the 12 week rehabilitation programme had a positive effect on self-efficacy, mood disturbance and QOL for Chinese cancer survivors. Key words: cancer survivor, mediator, mood disturbance, quality of life, rehabilitation programme, self-efficacy.
INTRODUCTION Cancer is a globally occurring, life-threatening disease. In the People’s Republic of China (PRC), cancer is the
Correspondence: Hui Zhang, School of Nursing, Harbin Medical University (Daqing), 205 Room, 39 Xinyang Road, Gaoxin District, Daqing City 163319, Hei Longjiang Province, China. Email: [email protected] doi:10.1111/ijn.12370
leading cause of death, accounting for 27.1% of all deaths among urban residents and 25.4% among rural residents.1 Early diagnosis and advanced treatments have contributed to an increasing cancer survival rate.2 Although cancer remission increased and lifespan prolonged, survivors might face difficulties associated with the nature of the disease process and treatments, including physical (e.g. physical activity, fatigue, pain, sleep disturbances), psychological (e.g. anxiety, depression, fear, © 2014 Wiley Publishing Asia Pty Ltd
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low confidence) and social problems (e.g. avoidance, job reintegration), which could decrease their quality of life (QOL).2–4 It has been suggested that rehabilitation should be an integral part of cancer care to help cancer patients regain control of their lives and further improve their QOL.5 Existing cancer rehabilitation programmes contain psychosocial intervention, physical exercise, nutrition and multidisciplinary intervention to improve QOL for cancer patients.6–10 In the PRC, clinical services for cancer patients mainly focus on managing cancer-related physical symptoms, routine health education and general emotional support. However, the services are mostly provided during hospitalization period for cancer patients. To date, no rehabilitation programme is available to assist Chinese cancer survivors, especially during the transition period from hospital to home, to ensure their QOL. In our previous qualitative study, we found that cancer survivors often reported they had suffered from negative emotions and lacked cancer-related rehabilitation information after they were discharged from hospital.11 The findings indicate that the Chinese cancer survivors need continue professional support at home because they have low self-efficacy during their rehabilitation period. According to Albert Bandura, self-efficacy is a person’s belief in his or her ability to succeed in a particular situation; it can also be regarded as an optimistic view of one’s capacity to deal with stress.12 To date, the existing cancer interventions have focused mainly on physical and psychological symptoms and QOL for cancer patients; a few studies have focused on how to improve self-efficacy for cancer survivors.13 Studies revealed that self-efficacy is a strong predictor of QOL for cancer patients and other disease populations, such as kidney transplant patients and coronary heart disease.14–16 In this study, we use Bandura’s Social Cognitive Theory to guide and design the rehabilitation programme. Accordingly, the sources of selfefficacy come from past experience, vicarious experience, verbal persuasion, and levels of arousal and distress.
AIMS The current study aims to assess the mediating effect of self-efficacy on mood disturbance and QOL, and to determine the effectiveness of rehabilitation programme to improve self-efficacy, mood disturbance and QOL among Chinese cancer patients during the transition period from hospital to home. © 2014 Wiley Publishing Asia Pty Ltd
METHODS Study design and samples A convenience sample of 57 cancer patients, within 1 year, was recruited and enrolled from two oncology units of a teaching hospital located in the northeast of PRC. The inclusion criteria included: (i) cancer patients aged 18 years or older and at the last session of chemotherapy; (ii) who were able to carry out activities of daily life evidenced by a score above 60 on the Karnofsky Performance Status (KPS)17; (iii) according to the doctor’s clinical routine assessment, who had at least 6 months life expectancy; and (iv) who lacked metastasis, mental disease and other types of physical illness. Participants were randomly assigned to either experimental or control group, according to their medical chart numbers (even numbers to the experimental group and odd numbers to the control group). We matched sex, age and types of cancer between the two groups. Five patients dropped out from each group due to their tiredness, had a recurrence of cancer, transferred to the other hospital and removed to another city. This study was approved by the ethics committee of Harbin Medical University in PRC.
Measurements A researcher-designed demographic and clinical data form was used to collect the participants’ age, gender, marital status, educational status, income status, employment status and diagnosis stage. Participants completed the following self-report assessments at two times over the course of the study: prior to the start of the rehabilitation programme (pretest) and after completion of the programme (post-test) when they returned for a routine 12-week follow-up hospital visit. The General Self-efficacy Scale (GSES), a 10-item scale, was used to evaluate an individual’s self-efficacy in coping with daily hassles or stressful events.18 It is a 4-point Likert scale that ranges from 1 (not at all) to 4 (exactly true); a higher score indicates higher self-efficacy of the individual. The Cronbach’s alpha for the GSES was 0.8.18 The GSES has been translated into a Chinese version and further validated by Wang et al.,19 with a Cronbach’s alpha of 0.87. The Cronbach’s alpha was 0.92 in the current study. The Profile of Mood States Scale–Short Form (POMS-SF) was used to measure emotional status of the participants. This 37-item instrument includes six subscales: tensio– anxiety, depression–dejection, anger–hostility, fatigue– inertia, confusion–bewilderment and vigour–activity.20 The POMS-SF uses a 5-point Likert scale that ranges from
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0 (not at all) to 4 (exactly true); higher scores indicate more mood disturbance. The Cronbach’s alpha for the whole scale was 0.87.20 The Cronbach’s alpha for the Chinese version was 0.93.21 In the current study, the Cronbach’s alpha was 0.91 for the whole scale, and ranged from 0.74 to 0.85 for the six subscales. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQC30) is a 30-item self-report questionnaire which is one of the most commonly used questionnaires to measure QOL in cancer patients. It includes a global QOL scale, five functional subscales (physical, role, cognitive, emotional social functioning), three symptom subscales (fatigue, pain, nausea and vomiting), and six single item subscales (dyspnoea, sleeplessness, lack of appetite, constipation, diarrhoea, financial difficulty). The reliability coefficients for the subscales ranged from 0.52 to 0.89.22 The Cronbach’s alpha for the Chinese version was 0.81.23 In the current study, the Cronbach’s alpha was 0.88 for the whole scale, and ranged from 0.72 to 0.91 for the subscales.
Intervention The participants in the experimental group received a 12 week rehabilitation programme, including cancer-related education, progressive muscle relaxation (PMR) and emotional support. Each participant received an educational booklet based on the findings from our prior qualitative study of cancer survivors11 that included information on cancer-related treatment and recovery, nutrition and physical exercise (walking, jogging and lifting up), coping strategies, strengthening social support, and increasing self-confidence in managing their disease. The first author (HZ) scheduled appointments with the study participants for a daily 30 min, face-to-face cancer-related educational sessions (cancer-related education, PMR) at the hospital for a total of 3 days prior to participants being discharged. HZ discussed each specific topic included in the booklet with the experimental group participants, and participants kept the booklet throughout the home-based intervention period. After each topic of education, the participants were given 20 min one-on-one PMR instructions daily by HZ at the hospital for 3 days. The PMR training was based on the instructions from a relaxation audiobook produced by the John Tung Foundation,24 which was widely used by many researchers for the Chinese population.25,26 The relaxation audiobook was stored in a mini MP3 player and used a
gentle voice with a soft musical background to guide deep breathing and progressive muscle relaxation. At the third time, all the participants were asked for a returndemonstration to ensure that they were able to practice PMR at home by themselves. The audiobook was downloaded by the study participants’ preferred equipment (i.e. MP3, CD, cell phone) in order for them to practice every day at home for 12 weeks. The length of intervention was based on the recommendation of a meta-analysis.27 Emotional support was provided through a weekly phone call and two sessions of group support. Weekly 10 min telephone follow-up counselling was given to the participants by HZ to provide support; the researcher encouraged patients to raise their self-efficacy by providing positive emotional support. Two group supportive sessions were held at the fourth and eighth weeks during the intervention period when patients returned to the hospital for routine follow-ups. Group support (11 to 12 patients in each group) was provided by two models (successful cancer survivors). HZ provided topics (i.e. fatigue, coping with stress and anxiety, job reintegration) for the models to develop contents, which aimed to increase selfefficacy for the study participants. All control group participants received the usual care from the clinic; moreover, they all received the educational booklet and PMR training techniques after completing the post-test.
Data analysis Descriptive statistics were used to describe the characteristics of the study participants. Homogeneity of demographic and clinical characteristics between the experimental and control groups was evaluated by t-tests and chi-square. Pearson’s correlation and linear regression analysis were performed for mediation analysis. At pretest, no significantly different characteristics were found between the two groups. Therefore, independent sample t-tests were used to evaluate the outcome variables to determine the effectiveness of the rehabilitation intervention.
RESULTS Demographic and medical characteristics of the sample As shown in Table 1, demographic and clinical characteristics of the participants did not differ significantly between the two groups at pretest. The majority of the © 2014 Wiley Publishing Asia Pty Ltd
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Table 1 Demographic and clinical characteristics of the participants (N = 47) Characteristic Gender Male Female Age, MD (SD) Education level Junior high school Senior high school College Employment status Worker Farmer Techniques Others Income per month (China) Lower (≤ 1000) Medium (1000–3000) High (3000–5000) Diagnosis Breast cancer Lung cancer Gastric and intestine Thyroid cancer Stage of tumour (year) ≤1 2–3 4–5 Scores of KPS 60–69 70–79 80–89 90–100
Total (N = 47)
Intervention group (n = 24)
Control group (n = 23)
P value 0.917
16 (34%) 31 (66%) 51.3 (11.7)
8 (33.3%) 16 (66.7%) 50.9 (10.6)
8 (34.8%) 15 (65.2%) 51.7 (13.0)
8 (17%) 18 (38.3%) 21 (44.7%)
3 (12.5%) 11 (45.8%) 10 (41.7%)
5 (21.7%) 7 (30.4%) 11 (47.8%)
7 (14.9%) 3 (6.4%) 25 (53.2%) 11 (23.4%)
3 (12.5%) 2 (8.3%) 13 (54.2%) 5 (20.8%)
4 (17.4%) 1 (4.3%) 12 (52.2%) 6 (26.1%)
7 (14.9%) 28(59.6%) 12 (25.5%)
3 (12.5%) 16 (66.7%) 5 (20.8%)
4 (17.4%) 12 (52.2%) 7 (30.4%)
0.720 0.493
0.985
0.598
0.806 24 (51.1%) 10 (21.3%) 12 (25.5%) 1 (2.1%)
12 (50%) 5 (20.8%) 6 (25%) 1 (4.2%)
12 (52.2%) 5 (21.7%) 6 (26%) 0
28 (59.6%) 14 (29.8%) 5 (10.6%)
13 (54.2%) 9 (37.5%) 2 (8.3%)
15 (65.2%) 5 (21.7%) 3 (13%)
9 (19.1%) 17 (36.2%) 15 (31.9%) 6 (12.8%)
3 (12.5%) 11 (45.8%) 7 (29.2%) 3 (12.5%)
6 (26.1%) 6 (26.1%) 8 (34.8%) 3 (13%)
0.728
0.472
KPS, Karnofsky Performance Status.
study participants were women (66%), with a mean age of 51.3 (SD = 11.7), and with breast cancer (51.1%). The average time since cancer diagnosis was 2.0 (SD = 2.1) years, and for 92% of the participants was a first-time diagnosis for cancer. The mean score of KPS was 73.8 (SD = 9.5) (Table 2).
The mediation analysis of self-efficacy, mood and QOL At pretest, the mean score of self-efficacy measured by the GSES was 28.3 (SD = 6.2, median = 29), the total mood © 2014 Wiley Publishing Asia Pty Ltd
disturbance score measured by the POMS-SF was 35.6 (SD = 12.6, median = 33) and the global QOL score measured by EORTC QLQ-C30 was 47.9 (SD = 15.9, median = 41.7). Pretest data were used for mediation analysis. The correlations among self-efficacy, total mood disturbance, global QOL score and demographic/clinical characteristics were assessed prior to the mediation analysis. Higher self-efficacy was associated with better QOL (r = 0.57, P < 0.01), higher educational status (r = 0.45, P < 0.01) and less mood disturbance (r = −0.52, P < 0.01). Higher
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Table 2 Comparison of self-efficacy, POMS-SF, and QLQ-C30 between groups before the intervention Variable
Self-efficacy POMS-SF—TMD Tension–Anxiety Depression–Dejection Anger–Hostility Fatigue–Inertia Confusion–Bewilderment Vigour–Activity QLQ-C30 Globle QOL Physical function Role function Emotional function Cognitive function Social function Fatigue Nausea and vomiting Pain Dyspnoea Sleeplessness Lack of appetite Constipation Diarrhoea Financial difficulty
Total (N = 47)
Experimental (n = 24)
Control (n = 23)
X
SD
X
SD
X
SD
28.34 35.55 5.51 5.96 6.02 4.81 4.98 8.21 47.87 60.14 64.89 69.86 71.28 60.28 53.90 21.28 33.69 26.24 39.00 57.45 37.59 12.06 35.46
6.17 12.61 2.90 2.69 3.34 3.20 3.36 3.06 15.88 26.68 34.44 23.41 25.47 32.33 24.74 25.23 33.96 28.60 35.66 26.65 26.57 18.94 29.00
25.75 37.46 5.83 6.04 6.79 5.29 5.04 8.54 45.83 65.00 61.81 73.26 75.69 68.06 51.85 15.28 36.81 31.94 33.33 56.94 34.72 11.11 31.94
5.71 13.54 3.17 2.85 4.00 3.44 3.06 2.77 14.12 24.18 33.14 18.87 22.51 31.05 25.10 18.33 33.69 28.62 31.08 28.62 26.88 18.82 26.88
28.96 33.57 5.17 5.87 5.22 4.30 4.91 7.87 50.00 55.07 68.12 66.30 66.67 52.17 56.04 27.54 30.43 20.29 44.93 57.97 40.58 13.04 39.13
6.69 11.52 2.62 2.56 2.30 2.91 3.72 3.36 17.59 28.72 36.21 27.35 27.98 32.30 24.73 29.99 34.69 27.96 39.71 25.06 26.51 19.43 31.22
P value
0.509 0.295 0.442 0.829 0.105 0.295 0.897 0.457 0.374 0.206 0.536 0.314 0.228 0.093 0.567 0.101 0.526 0.165 0.273 0.897 0.456 0.731 0.402
POMS-SF, Profile of Mood States Scale–Short Form; QLQ-C30, Quality of Life Questionnaire Core 30; QOL, quality of life; TMD, total mood disturbance.
global QOL scores were associated with less mood disturbance (r = −0.46, P < 0.01). Also, participants with longer durations of cancer had worse mood disturbance (r = 0.29, P < 0.05). While controlling for demographic/clinical data, which were correlated with self-efficacy, mood disturbance and QOL, linear regression models were used to analyse the mediation effects of self-efficacy and mood disturbance on QOL among the participants (Table 3). We adopted the steps for evaluating a mediating effect as proposed by Baron and Kenny.28 Step 1 examined whether total mood disturbance was a significant predictor of QOL (c path). Step 2 examined whether total mood disturbance was a significant predictor of self-efficacy (a path). Step 3 examined whether self-efficacy was a significant predictor of QOL while
controlling for demographic/clinical data (educational status and stage which were significantly correlated with measurement variables) (b path) and whether total mood disturbance was a significant predictor of QOL (c' path). If self-efficacy was a complete mediator of the relationship between total mood disturbance and QOL, then the effect of total mood disturbance (c') should be zero.28 The findings indicated that the total mood disturbance (β = −0.457, P < 0.05) and self-efficacy (β = 0.450, P < 0.05) were the significant predictors of QOL. As shown in Table 3, the effect of total mood disturbance on the QOL was zero, which evidenced that self-efficacy was a complete mediator between mood disturbance and QOL (Fig. 1). The indirect effect of total mood disturbance on QOL through self-efficacy was 0.507. © 2014 Wiley Publishing Asia Pty Ltd
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Table 3 The regression analysis of quality of life, self-efficacy, and total mood disturbance Pathway
Adjusted R2
Beta
Se
t
P value
TMD → QOL (c path) TMD → SE (a path) SE → QOL (b path) TMD → QOL (c' path)
0.191 0.248 0.328 0
−0.457 −0.515 0.450 −0.225
0.167 0.063 0.362 0.177
−3.442 −4.025 3.195 −1.596
0.001 0.000 0.003 0.118
QOL, quality of life; SE, self-efficacy; Se, standard error; TMD, total mood disturbance.
Self-efficacy –0.515*
0.450*
Total mood score
Quality of life –0.225
Figure 1. The pathway of total mood disturbance, quality of life and self-efficacy. * means P < 0.05.
The effects of the rehabilitation programme on self-efficacy, mood disturbance and QOL in cancer survivors Independent sample t-tests were used to evaluate the effects of the intervention on self-efficacy, mood disturbance and QOL (Table 4). At the post-test, compared with the control group, the participants in the experimental group reported significantly higher scores in self-efficacy, lower total mood disturbance and higher global QOL (P < 0.05). Although the intervention improved the total mood disturbance measured by the POMS-SF, there were no significant differences in the areas of depression– dejection, anger–hostility, fatigue–inertia and vigour– activity (P > 0.05). In addition, almost half of the symptoms (role function, cognitive function, pain, dyspnoea, constipation and diarrhoea) measured by the QLQC30 were not significantly different between the two groups (P > 0.05).
DISCUSSION The first aim of this study was to assess the mediating effect of self-efficacy on mood disturbance and QOL for cancer survivors. The findings showed that self-efficacy had a direct positive effect on mood and QOL. In © 2014 Wiley Publishing Asia Pty Ltd
addition, self-efficacy was a complete mediator between mood disturbance and QOL, which was consistent with previous studies that showed cancer patients’ self-efficacy had been associated with psychological distress, and people with high self-efficacy were likely to have better psychological adjustment, less negative physical and psychological outcomes, better QOL, and might live longer compared with those with low self-efficacy.29–31 Therefore, increasing self-efficacy is the key to improving mood and QOL for cancer survivors. Our results concur with the previous research32 that self-efficacy should be given more attention in cancer patients’ care. The second aim of the current study was to evaluate the effectiveness of a 12 week rehabilitation programme to improve self-efficacy, QOL and mood disturbance in cancer survivors. Compared with the control group, participants in the experimental group scored significantly better in self-efficacy, mood disturbance and QOL at the end of the intervention. The results supported the 12 week rehabilitation programme which consisted of three components: cancer-related education, PMR and emotional support that had an effect on the Chinese cancer survivors. In the current study, these sessions encouraged the study participants to believe that they had the capability to deal with adverse psychological distress through successful experiences from themselves and other cancer survivors. The results concur with previous studies12,33 that self-efficacy could be enhanced by past experience, such as giving positive feedback when patients have performed a desired activity; vicarious experience include modeling who has successful performing activities in a similar situation; verbal persuasion is encouraging patients to believe that they have the ability to deal with disease and reduce the level of arousal and distress by teaching disease-related knowledge and coping strategies.
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Table 4 Comparison of self-efficacy, POMS-SF, and QLQ-C30 between groups after the intervention Variable
Self-efficacy POMS-SF—TMD Tension–Anxiety Depression–Dejection Anger–Hostility Fatigue–Inertia Confusion–Bewilderment Vigour–Activity QLQ-C30 Global QOL Physical function Role function Emotional function Cognitive function Social function Fatigue Nausea and vomiting Pain Dyspnoea Sleeplessness Lack of appetite Constipation Diarrhoea Financial difficulty
Experimental (n = 24)
Control (n = 23)
X
SD
X
SD
31.83 28.29 3.50 5.29 3.92 3.13 2.63 8.79 61.46 75.56 72.22 84.03 75.69 71.53 35.65 8.33 20.14 19.44 19.44 36.11 22.22 8.33 26.39
4.46 7.80 1.82 2.14 2.30 2.07 1.69 2.89 16.63 17.21 22.34 13.44 22.51 22.78 13.89 12.04 20.25 25.85 21.80 29.35 21.23 14.74 21.93
28.52 34.96 5.26 6.30 4.87 4.48 4.87 8.61 50.00 61.74 70.29 67.03 66.67 51.45 49.76 28.99 26.09 17.39 44.93 53.62 33.33 8.70 43.48
6.60 13.68 2.65 2.99 2.30 3.17 4.12 2.78 16.28 23.20 33.32 26.17 27.98 36.21 22.19 32.65 30.91 26.34 39.71 24.08 17.41 14.97 33.99
t
P value
2.01 −2.04 −2.67 −1.34 −1.42 −1.74 −2.43 0.22 2.39 2.33 0.23 2.78 1.22 2.27 −2.60 −2.85 −0.78 0.27 −2.71 −2.23 −1.97 −0.08 −2.04
0.049 0.049 0.011 0.187 0.163 0.089 0.022 0.826 0.021 0.025 0.816 0.009 0.228 0.030 0.013 0.008 0.442 0.789 0.009 0.031 0.056 0.934 0.049
POMS-SF, Profile of Mood States Scale–Short Form; QLQ-C30, Quality of Life Questionnaire Core 30; QOL, quality of life; TMD, total mood disturbance.
In the current study, the educational session provided information such as: cancer-related treatments, nutrition and physical exercise, coping strategies, and social support. Those might increase the participants’ selfefficacy which mediates mood and improves their QOL. Other studies34–36 documented that either face-to-face or phone counselling could improve breast cancer patients QOL by providing cancer-related rehabilitation education and counselling on stress-related problems through group support. The results from this study show that home-based daily PMR practice might have an effect on reducing mood disturbance and increasing QOL for Chinese cancer survivors. This might result from PMR, and an individual could reduce stress through breathing exercise and muscle relaxation.37 PMR training can be effective in reducing anxiety and distress, physiological
arousal, and allow patients to change the excitability of nervous system tension as well as enhance their ability to adjust their internal and external environment.38 PMR could reduce stress and anxiety among diverse cancer patients during chemotherapy period.39–41 In addition, findings from this study showed that a weekly 10 min phone follow-up counselling and group support from individuals who are successful cancer survivors might enhance study participants’ self-efficacy, further mediating mood status and QOL. A recent study has shown that emotional and informational support provided by peer survivors are very helpful for QOL in Chinese breast cancer survivors.42 Other research also showed that emotional support (e.g. group support, telephone counselling) could improve mood and QOL for cancer patients.43 © 2014 Wiley Publishing Asia Pty Ltd
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The current research has several limitations. Firstly, the attention control for the control group was not conducted; therefore, the actual effectiveness of the rehabilitation programme could not be determined precisely because of the placebo effects. Secondly, the intervention consisted of three components which improved selfefficacy, mood disturbance and QOL for cancer survivors; whether it is necessary to include all three components should be further discussed. Thirdly, the practice of PMR by patients for 20 min daily for 12 weeks was simply based on the literature review27; the dosage and interval of PMR training had not yet been decided in this study and the most effective dosage needs to be explored. There is no written record of patients’ home practice of PMR; thus, the adherence to the intervention could not be determined. Fourthly, the generalization of the findings to other setting should be cautious in the future. The use of a special self-efficacy scale for cancer patients is needed in future studies. Lastly, this is a pilot study; the effectiveness of the rehabilitation programme should be further evaluated in a bigger sample size and the clinical significances should be considered.
CONCLUSION The findings of the current study provide evidence to show that self-efficacy is the complete mediator between mood and QOL for Chinese cancer survivors. In addition, the 12 week rehabilitation programme could statistically significantly improve self-efficacy, mood disturbance and QOL for the study participants. We suggest that clinical nurses and health-care professionals should assess the level of self-efficacy for cancer survivors and provide intervention to enhance their self-efficacy. Clinical continuing education should include self-efficacy training for healthcare providers. Enhancing self-efficacy should be taken into consideration in rehabilitation programmes for cancer survivors so as to improve QOL.
ACKNOWLEDGEMENTS This study was awarded to the second author by the Hei Longjiang Health Bureau in PRC. The authors gracefully acknowledge Dr Shih-Yu Lee and Dr Hong Tao for their guidelines and consultations in developing this paper, Yunpeng Zhao and Chunling Shen for their assistance in data collection, Hongling Song for her revisions of the grammar and expression for this paper, and most importantly, we gracefully acknowledge those cancer patients for sharing their experiences. © 2014 Wiley Publishing Asia Pty Ltd
CONFLICT OF INTEREST No conflict of interest has been declared by the authors.
AUTHORS’ CONTRIBUTIONS Hui Zhang, study design, data collection and intervention, and manuscript writing. Yuqiu Zhou, study design, consultation for the research, researcher training. Yuxia Cui, data collection and manuscript writing. Jinwei Yang, data analysis.
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