Coping and social support and health related quality of life in women with breast cancer in Turkey

This article was downloaded by: [University of Alberta]On: 26 October 2014, At: 14:28Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Psychology, Health & MedicinePublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/cphm20

Coping and social support and healthrelated quality of life in women withbreast cancer in TurkeyGulsen Filazoglu a & Konstadina Griva aa Department of Psychology , London Metropolitan University ,London, UKPublished online: 21 Oct 2008.

To cite this article: Gulsen Filazoglu & Konstadina Griva (2008) Coping and social support andhealth related quality of life in women with breast cancer in Turkey, Psychology, Health &Medicine, 13:5, 559-573, DOI: 10.1080/13548500701767353

To link to this article: http://dx.doi.org/10.1080/13548500701767353

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

http://www.tandfonline.com/loi/cphm20

http://www.tandfonline.com/action/showCitFormats?doi=10.1080/13548500701767353

http://dx.doi.org/10.1080/13548500701767353

http://www.tandfonline.com/page/terms-and-conditions

http://www.tandfonline.com/page/terms-and-conditions

Coping and social support and health related quality of life in women with

breast cancer in Turkey

Gulsen Filazoglu and Konstadina Griva*

Department of Psychology, London Metropolitan University, London, UK

(Received 11 June 2007; accepted 24 October 2007)

This study aims to investigate the role of social support and coping in explaining healthrelated quality of life (HRQoL) among Turkish breast cancer patients. A cross-sectionalsample of 188 women from three hospitals in Turkey completed the MultidimensionalScale of Perceived Social Support, the Ways of Coping Inventory, and the Short Form36 Health Survey. Socio-demographic and medical information was also collected.Results indicated high HRQoL levels, with 7 of the 10 SF-36 scores being within 1 SD ofpopulation mean. Correlations showed that helplessness coping was inversely associatedwith HRQoL whereas social support, religious coping, optimistic coping and problemfocused coping were positively associated with HRQoL. Multiple regressions indicatedthat time since diagnosis, time since operation, stage of cancer, post-operativetreatment, social support and problem solving coping were significant predictors ofHRQoL accounting for 54.7% to 46.4% of the variance in physical and emotionalHRQoL. Coping and social support have an independent effect on HRQoL over andabove sociodemographic and medical variables and should be targeted by appropriateinterventions.

Keywords: coping; quality of life; social support; breast cancer

Introduction

Breast cancer patients face a variety of stressors including the life threatening diagnosisitself, and stressful medical procedures and treatment related side-effects (Andrykowski,Cordova, Studts, & Miller, 1998; Hann, Jacobsen, Martin, Azzorello, & Greenberg, 1998).Besides the physical challenges, a breast cancer patient experience psychological threatsand loses such as reduced functioning and role performance, uncertainty about the futureand body image concerns (Carver & Antoni, 2004). As such, it hardly comes as surprisethat high levels of psychological morbidity and compromised health related quality of life(HRQoL) have been reported in women with breast cancer. HRQoL impairments areevident in both in physical and emotional dimensions (Krupski et al., 2006; Martinez,2006; Reid-Arndt, 2006) albeit somewhat more pronounced with respect to emotionalHRQoL.

Several studies have identified psychological predictors of HRQoL in this population.Lack of social support has consistently been found to be associated with emotional distressas signified by increased depressive affect, mood disturbances and poor emotional HRQoL

*Corresponding author. Email: [email protected]

Psychology, Health & Medicine

Vol. 13, No. 5, October 2008, 559–573

ISSN 1354-8506 print/ISSN 1465-3966 online

� 2008 Taylor & Francis

DOI: 10.1080/13548500701767353

http://www.informaworld.com

Dow

nloa

ded

by [

Uni

vers

ity o

f A

lber

ta]

at 1

4:28

26

Oct

ober

201

4

(Pandey, Thomas, Ramdas, & Ratheesan, 2006; Schou, Ekeberg, Sandvik, Hjermstad, &Ruland, 2005a).

Coping has also been found to predict long-term psychological adjustment andHRQoL (Grassi & Rosti, 1996; Heim, Valach, & Schaffner, 1997; Kershaw, Northouse,Kritpracha, Schafenacker, & Mood, 2004). Taken collectively findings indicate thatengagement-type coping strategies, namely problem solving, information seeking,cognitive restructuring, emotional ventilation are positively associated with HRQoL(Avis, Crawford, &Manuel, 2005; Kershaw et al., 2004; Manuel et al., 2007; Stanton et al.,2000; Wonghongkul, Dechaprom, Phumivichuvate, & Losawatkul, 2006) whereasdisengagement-type coping strategies or coping through behavioural or cognitiveavoidance such as denial, self criticism, social withdrawal are inversely associated withHRQoL (Carver et al., 1993; Epping-Jordan et al., 1999; Koopman et al., 2001; Schouet al., 2005a).

Several socio-demographic factors have also found to be positively associated withHRQoL. These include younger age, (Janz et al., 2005; Manuel et al., 2007), highereducation level (Uzun, Aslan, Selimen, & Koc, 2004), being in a marital or cohabitingrelationship, (Segrin et al., 2005; Wagner, Bigatti, & Storniolo, 2006), and maintainingemployment status (Uzun et al., 2004). Clinical indices of cancer severity are also linked toHRQoL, with patients diagnosed with more advanced stages of cancer experiencing morecompromised HRQoL compared to patients with less advanced stages of cancer (Janzet al., 2005; Schleinitz, De Palo, Bulme, & Stein, 2006).

The majority of past research was conducted in either North America or NorthEuropean countries, which has implications on conclusions drawn on a wider,international level. Even though in the area of evidence based health care it is increasinglythe case that findings in one country are used to support health care practice in othercountries, it is possible that differences in cultural regulations, societal conditions/structures or differences in health care systems, settings and practices make it difficult togeneralise the reported study findings to other (non-western) countries and populations.Little is known about the psychosocial and HRQoL impact of breast cancer and the effectof coping and social support on these HRQoL outcomes among Turkish women.

With these issues in mind, the purpose of this study was to explore HRQoL outcomesin a sample of Turkish breast cancer patients. The aims of this study were twofold:

To document the HRQoL levels in women who undergo treatment for breast cancer inTurkey.

To identify predictors of HRQoL among socio-demographic medical and psycholo-gical variables. Emphasis was placed on examining the role of coping and social support inexplaining HRQoL in this patient population.

Method

The study was conducted at Demetevler Oncology Hospital, Ege University Hospital, andCukurova University Hospital. The participating hospitals were located in different partsof Turkey to ensure geographical representation.

Following ethical approval, eligible women attending the breast cancer outpatientclinics to receive post-operative treatment (n ¼ 226) were invited to participate. Eligibilitycriteria included: (a) age over 18 years, (b) first time diagnosis of breast cancer (relapsepatients were excluded), (c) to have been diagnosed with breast cancer and to haveundergone breast surgery (total or partial mastectomy) for a minimum of 3 months beforestudy. The 3-month interval was selected to ensure some distance from potential early

560 G. Filazoglu et al.

Dow

nloa

ded

by [

Uni

vers

ity o

f A

lber

ta]

at 1

4:28

26

Oct

ober

201

4

pronounced emotional reactions to diagnosis and surgery and to allow some time foradjustment and recovery post-operatively, (d) not being concurrently hospitalised, (e) notbeing diagnosed with or being currently treated for psychiatric conditions, and (f) fluencyin written and spoken Turkish.

Procedure

Eligible participants were identified by a nurse or doctor and then approached by theresearcher who explained the aims and procedures of the study.

Consenting eligible participants were asked to complete a set of questionnaires (listedbelow). The researcher was available to answer any queries or to read out thequestionnaires for patients if they so required or asked for. All assessments took placeimmediately after the patients’ routine check up by their consultant oncologist.

Measures

Demographic and medical history information form

Demographic information including age, ethnicity, education, marital and employmentstatus, was collected by questionnaire developed for the purposes of the study.

Medical data were also collected by reviewing patients’ medical records. Informationrelated to surgery, post-operative treatment, stage of cancer, and time elapsed sincediagnosis and operation was recorded and verified by patients’ doctor.

The multidimensional scale of perceived social support (MSPSS; Zimet, Dahlem, Zimet, &Farley, 1988)

Social support was assessed using the 12-item MSPSS (Zimet et al., 1988). The MPSS wasoriginally developed in US on a sample of 275 university students. The MSPSS was latervalidated in a range of samples, including pregnant women, adolescents, older adults,doctor-trainees and psychiatric patients and is widely used in studies with breast cancerpatients (Kazarian & McCabe, 1991; Koopman et al., 2001; Stanley, Beck, & Zebb, 1998;Winefield, Coventry, Pradhan, Harvey, & Lambert, 2003; Zimet, Powell, Farley,Werkman, & Berkoff, 1990). The MSPSS comprises three subscales measuring perceivedsocial support from three different sources (significant other, family and friends). MSPSShas been translated and adapted into Turkish by Eker and Arkar (1995). Using a samplecomprising surgical, psychiatric patients and healthy adults, Eker and Akar (1995) haveshown that the Turkish version of MSPSS has good psychometric properties (CronbachAlphas ranging between 0.85 and 0.91).

The ways of coping inventory

The ways of coping inventory (WCI) was developed and later revised by Folkman andLazarus (1985). It assesses the thoughts and behaviours that the person uses to manage theproblem and regulate the emotional response to the problem. The WCI has beentranslated into Turkish by Siva (Ucman, 1990). The Turkish WCI has high internalreliability (Cronbach alpha ¼ 0.91) and comprises eight subscales (derived through factoranalysis): planful problem solving, escape/avoidance, emotional control, growth, fatalisticapproach, self-blame, seeking refuge in supernatural forces and helplessness. The measurewas further revised and psychometrically validated by Gunes (2001). For the purposes of

Psychology, Health & Medicine 561

Dow

nloa

ded

by [

Uni

vers

ity o

f A

lber

ta]

at 1

4:28

26

Oct

ober

201

4

this study, the revised shorter version developed by Gunes (2001) was used. This contains42 items that form four subscales (identified through factor analysis): helplessness,problem solving, religious coping and optimistic coping. Internal reliability for the wholescale is 0.78.

Short form health survey

HRQoL was measured with the 36-item Medical Outcome Study Short Form HealthSurvey (Ware, Snow, Kosinski, & Gandek, 1993). The Turkish version of thequestionnaire, translated and standardised by Kocyigit, Aydemir, Fisek, Olmez, andMemis (1995) was used.

The SF-36 is a generic multidimensional measure of HRQoL that contains eightsubscales representing physical functioning, social functioning, role limitations due tophysical health, role limitations due to emotional problems, mental health, vitality, bodilypain and general health perceptions. Subscale scores were transformed to 0–100 scales withhigher scores indicating better HRQoL.

To facilitate interpretation and comparisons to the norms, normative-based scoringwas used (Ware, 2000). Normative-based scoring involves a linear t-transformation toensure that all SF-36 subscales and summary scores had a mean of 50 and a SD of 10 inthe general Turkish population. Subscales were combined into a physical component score(PCS) and a mental component score (MCS) (Ware, Kosinski, & Keller, 1994). The SF-36has been proved reliable and valid in various demographic and patient populations.

Statistical analysis

Statistical analysis was performed using the Statistical Package for the Social Sciences(SPSS, 1998) Version 14.0. The associations between socio-demographic, clinical variables,coping and social support were examined using correlations or ANOVA comparisons forcontinuous or categorical variables, respectively.

Predictors of HRQoL were identified with univariate analyses (ANOVAs, Pearson Rcorrelations or where appropriate their non-parametric equivalents) and hierarchicalmultiple regressions. All significant variables (set at p 5 0.05) identified fromunivariate analyses were included in the hierarchical multiple regressions using the entermethod and a level of p 5 0.05 as an entry criterion. Regressions were performedseparately for physical and mental component scores. Predictors entered the regressionequations in a specified order: (a) socio-demographic, (b) clinical and (c) psychologicalvariables.

Results

Sample

Two-hundred and twenty-six women identified by participating nurses were approachedby principal researcher to participate. Twenty-four women were excluded as they wererelapse breast cancer cases. Out of the remaining two-hundred and two (n ¼ 202) womencontacted, a total of n ¼ 188 women consented to the protocol (response rate ¼ 83.6%).Of them n ¼ 176 women were in adjuvant treatment post-surgery (n ¼ 137 onchemotherapy; n ¼ 17 on radiotherapy and n ¼ 22 on combined chemotherapy andradiotherapy) when they completed the questionnaires. Socio-demographic and clinicalcharacteristics of the study sample are presented in Table 1.


Dow

nloa

ded

by [

Uni

vers

ity o

f A

lber

ta]

at 1

4:28

26

Oct

ober

201

4

Descriptives

Means, SDs and Cronbach’s coefficient alphas for study variables are depicted inTable 2.

Table 1. Socio-demographic and clinical characteristics of the study sample.

Variables Mean (SD) Range % (N)

Age (years) 45.12 (5.6) 33–62Partner’s age (years) 46.2 (24.6) 37–69Time since diagnosis (months) 7.6 (3) 3–18Time since operation (months) 6.09 (2.51) 3–14Marital statusMarried 66.0 (124)Single 19.7 (37)Widowed 5.9 (11)Divorced 7.4 (14)Employment statusEmployed 62.2 (117)Unemployed 35.1 (66)Retired 2.7 (5)Education levelPrimary school 13.8 (26)High school 28.8 (54)University degree 45.2 (85)Postgraduate 12.2 (23)ReligionMuslim 89.9 (169)Christians 4.8 (9)Do not wish to answer 5.3 (10)Stage of illness*Stage 1 23.4 (44)Stage 2 55.9 (105)Stage3 18.6 (35)Stage4 2.1 (4)Treatment type after diagnosis*Chemotherapy 17.6 (33)Radiotherapy 38.8 (73)Chemotherapy þ radiotherapy 14.4 (27)No treatment 29.3 (55)Operation type**Radical mastectomy 11.2 (21)Modified radical mastectomy 66.5 (125)Partial mastectomy 11.7 (22)Lumpectomy 10.6 (20)Treatment type after operationChemotherapy 72.9 (137)Radiotherapy 9 (17)Chemotherapy þ radiotherapy 11.7 (22)No treatment 6.4 (12)

*Stage of the Illness: Stage 1, the earliest, most curable stage; Stage 2, some spreading of cancer to thesurrounding tissues; Stage 3, involves metastasis to distant lymph nodes; Stage 4, the most advantages stages ofbreast cancer that has spread to distant organs.

**Operation Type: Modified Radical Mastectomy: Removal of the entire breast. This is the most common formof mastectomy performed today. Radical Mastectomy: Removal of the entire breast, all underarm lymph nodesand major and minor muscles under breast. This strategy is rarely performed today. Partial Mastectomy:Removal of a portion of the breast tissue. Lumpectomy: Removal of the breast cancer tumour (1).


Dow

nloa

ded

by [

Uni

vers

ity o

f A

lber

ta]

at 1

4:28

26

Oct

ober

201

4

Mean HRQoL levels as measured by the eight SF-36 subscales were found to within 1SD of those reported for the general population (mean ¼ 50; SD ¼ 10) with the exceptionof general health, vitality and MCS.

The number of individuals who could be considered to have severely impairedHRQoL, defined as a component HRQoL score (PCS or MCS) of 2 or more SDs belowthe general population mean (corresponding to the lowest 2.5% scoring of the generalpopulation), was calculated. Using this criterion, sixty-six women (n ¼ 66; 28.4%) hadMCS scores and fifty-four women (n ¼ 54; 34.8%) out of the 188 participants were foundto have had PCS scores lower than 30, which were indicative of severe HRQoLimpairments.

Associations between socio-demographic, clinical and psychological variables

Univariate analyses showed that age, employment status, having children, marital status,time since diagnosis, stage of cancer and time since operation were significantly associatedwith coping and social support (see Tables 3 and 4).

Table 4 displays coping and social support scores for patient subgroups based onemployment, relationship, children status and clinical stage of cancer.

Anovas indicated that women in marital or cohabiting relationship (F(1,187) ¼ 1.62;p 5 0.001); women with children (F(2,186) ¼ 1.37; p 5 0.05), and those who wereemployed (F(2,187) ¼ 2.14; p 5 0.05) perceived greater levels of social support versussingle, childless or non-employed women.

Problem solving and optimistic coping were more frequently reported and used amongwomen in cohabiting relationship (F(2,187) ¼ 26.34; p 4 0.001; F(2,187) ¼ 18.26;p 4 0.001, respectively), women with children (F(2,187) ¼ 13.24; p 4 0.05; F(2,187) ¼9.12; p 4 0.001, respectively) and women who were employed (F(2,187) ¼ 1.08; p 4 0.05;F(2,187) ¼ 2.2; p 4 0.05, respectively).

Among clinical variables, stage of cancer was significantly associated with coping. Posthoc comparisons (using Turkey HND) indicated that women diagnosed with stage 3 or 4

Table 2. Cronbach alphas, means and SDs of study variables.

Variable N M SD a*

MSPSS 188 58.20 12 0.98Coping subscalesHelplessness coping 188 17.18 3.66 0.81Problems solving coping 188 19.88 4.61 0.66Optimistic coping 188 19.48 4.07 0.81Religious coping 188 29.66 5.94 0.87SF 36 subscalesPhysical component score 188 47.3 8.4Role limitations physical 188 77.5 19.5 0.95Physical functioning 188 52.12 37.13 0.80Bodily pain 188 48.4 21.8 0.86General health 188 32.07 19.85 0.81Mental component score 188 38.8 10.35Social functioning 188 60.34 28.17 0.90Role limitations emotional 188 42.12 29.01 0.96Mental health 188 52.34 19.39 0.78Vitality 188 38.5 16.1 0.98

MSPSS, the multidimensional scale of perceived social support.


Dow

nloa

ded

by [

Uni

vers

ity o

f A

lber

ta]

at 1

4:28

26

Oct

ober

201

4

cancer reported using more religious coping (F(4,187) ¼ 0.36; p 5 0.001) and lessproblem solving coping compared to women with early stages of breast cancer(F(4,187) ¼ 2.61; p 5 0.001).

Factors associated with HRQoL

Univariate analyses

Significant associations were found between HRQoL and sociodemographic, clinical andpsychological variables (Table 5).

Table 3. Pearson correlations between socio-demographic, clinical and psychological variables.

1 2 3 4 5 6 7

1. Age2. Time since diagnosis 70.0273. Time since operation 70.006 0.905*4. Religious coping 70.241* 0.241* 0.208*5. Optimistic coping 70.299* 0.207** 0.176** 0.747*6. Problem solving coping 70.281* 0.178* 0.153** 0.666* 0.711**7. Helplessness coping 70.257* 0.184* 0.160** 0.811* 70.716* 70.696**8. Social support 70.355** 0.196* 0.143** 0.728* 0.763* 0.655* 0.719*

*Correlation is significant at the 0.01 level (2 tailed).

**Correlation is significant at the 0.05 level (2 tailed).

Table 4. Means and standard deviations for coping and social support for patients subgroupsclassified on basis of relationship, employment, children status, breast cancer stage and postoperative treatment.

Religiouscoping

Optimisticcoping

Problemsolving

Helplessnesscoping

Socialsupport

M (SD) M (SD) M (SD) M (SD) M (SD)

Relationship statusMarried or cohabiting(n ¼ 114)

2.26 (0.36) 2.30 (0.39) 2.34 (0.50) 2.29 (0.41) 5.47 (1.32)

Single (n ¼ 74) 1.87 (0.40) 1.93 (0.44) 1.98 (0.43) 1.90 (0.42) 3.80 (1.81)Employment statusEmployed (n ¼ 116) 2.05 (0.44) 2.04 (0.47) 2.15 (0.64) 2.08 (0.49) 4.44 (1.83)Unemployed (n ¼ 72) 2.16 (0.40) 2.23 (0.42) 2.24 (0.40) 2.18 (0.43) 5.10 (1.67)

Children statusHaving children (n ¼ 128) 1.97 (0.42) 2.10 (0.44) 2.04 (0.42) 2.01 (0.47) 3.34 (1.87)Not having children (n ¼ 60) 2.17 (0.41) 2.22 (0.46) 2.28 (0.57) 2.21 (0.46) 2.65 (1.74)

Post operative treatmentChemotherapy (n ¼ 137) 1.11 (0.43) 1.23 (0.82) 1.67 (0.89) 1.74 (0.67) 2.11 (1.23)Radiotherapy (n ¼ 17) 2.16 (0.57) 1.87 (0.44) 2.17 (0.42) 1.56 (0.49) 0.98 (1.82)Combined (n ¼ 22) 1.98 (0.43) 1.23 (0.47) 1.93 (0.40) 1.24 (0.72) 2.34 (1.67)

Stage of cancerStage I (n ¼ 44) 2.27 (0.73) 2.67 (0.98) 2.34 (1.12) 2.17 (1.73) 2.76 (1.39)Stage 2 (n ¼ 105) 3.71 (0.67) 2.23 (1.14) 2.67 (0.92) 2.85 (0.50) 1.89 (1.56)Stage 3 (n ¼ 35) 1.56 (0.33) 1.77 (0.42) 1.48 (0.66) 1.44 (0.89) 2.39 (1.09)Stage 4 (n ¼ 4) 0.90 (0.56) 0.78 (1.07) 0.93 (1.01) 1.14 (0.63) 2.29 (1.87)


Dow

nloa

ded

by [

Uni

vers

ity o

f A

lber

ta]

at 1

4:28

26

Oct

ober

201

4

Both physical and emotional dimensions of SF-36 were associated with age, withscores deteriorating as a function of age.

Anovas indicated that PCS was associated with employment status (F(3,187) ¼ 14.56;p 5 0.01), marital status (F(2,187) ¼ 6.74; p 5 0.05), and having children(F(2,186) ¼ 2.83; p 5 0.05). MCS was similarly associated with employment status(F(2,187) ¼ 2.11; p 5 0.05), marital status (F(2,187) ¼ 1.17; p 5 0.05) and havingchildren (F(2,186) ¼ 8.52; p 5 0.01). Women who were married and those with childrenand currently employed reported higher levels of physical and emotional HRQoL.

Stage of cancer and post-operative treatment were also associated with HRQoL.Anovas (followed by Turkey’s HND) indicated that women treated with a combination ofchemotherapy and radiotherapy had significantly poorer HRQoL than women treatedwith either chemotherapy or radiotherapy alone: MCS (F(3,87) ¼ 12.37; p 5 0.01), PCS(F(3,187) ¼ 8.41; p 5 0.01). Women with advanced stage cancer (Stage 3 and 4) reportedpoorer HRQoL as indexed by lower scores on MCS (F(3,186) ¼ 23.39; p 5 0.001); andPCS (F (3,187) ¼ 31.78; p 5 0.001) compared to women with stage 1 and 2 cancer.

Significant correlations were found between coping, social support and SF-36 scores(see Table 4). Coping strategies were differentially associated with HRQoL; helplessnesscoping was inversely associated with HRQoL whereas problems solving, religious andoptimistic coping were positively associated with HRQoL (see Table 5).

Multiple Regressions

The regression models to predict HRQoL explained a moderate amount of variance withsimilar set of predictors for physical and emotional HRQoL (see Table 6).

The final regression model to predict PCS accounted for R2 ¼ 54.7% (adj.R2 ¼ 51.3%) of variance, with breast cancer stage, time since operation, time sincediagnosis, social support and problem solving coping emerging as significant predictors.Clinical variables made the strongest contribution to overall prediction with the inclusionof psychological variables in the last block adding DR2 ¼ 11.9% (DAdj. R2 ¼ 10.2%) intotal variance explained.

The multiple regression model to predict MCS indicated that type of treatment, stage ofbreast cancer, time since operation, social support, problem solving and helplessness copingexplained R2 ¼ 46.4% (Adj. R2 ¼ 42.9%) in MCS variance. Coping and social supportwere the strongest predictors, contributing an additional DR2 ¼ 11.8% (DAdj. R2 ¼11.2%) to total variance explained.

Discussion

The aim of this study was to examine HRQoL and its determinants among Turkishwomen with breast cancer.

Contrary to previous studies (Hopwood, Haviland, Mills, Sumo, & Bliss, 2007;Kershaw et al., 2004; Segrin et al., 2005; Uzun et al., 2004), our results indicate highHRQoL in our Turkish sample, equivalent to that of general population. Lack ofconsiderable HRQoL impairments may be related to sample characteristics. The recruitedsample consisted of fairly young women compared to previous studies (Hopwood et al.,2007; Schou, Ekeberg, & Ruland, 2005b). There is evidence that young women are resilientfollowing a diagnosis of breast cancer and have similar HRQoL to women who have nothad breast cancer (Casso, Buist, & Taplin, 2004; Dorval, Maunsell, Deschenes, Brisson, &Masse, 1998; Ganz et al., 2002). All women recruited into the study were also clinically


Dow

nloa

ded

by [

Uni

vers

ity o

f A

lber

ta]

at 1

4:28

26

Oct

ober

201

4

Table

5.

Pearsoncorrelationcoeffi

cients

forHRQoL

subscales,summary

scoresandpredictors.

GH

VT

SF

MH

BP

PF

Rem

RPh

PCS

MCS

Religiouscoping

0.232*

0.383*

0.448*

0.440*

0.351**

0.387*

0.325*

0.360**

0.455**

0.399**

Optimisticcoping

0.323*

0.451**

0.495*

0.560*

0.432**

0.400*

0.423**

0.452**

0.541**

0.504*

Problem

solving

0.382*

0.448**

0.461*

0.508*

0.374**

0.363**

0.383**

0.412**

0.503**

0.475**

Helplessness

70.233*

70.351*

70.448*

70.431*

70.306*

70.353*

70.326

70.389

70.446**

70.394

Socialsupport

0.406**

0.603**

0.694**

0.673**

0.803**

0.396**

0.448**

0.489**

0.605**

0.649**

Age

70.217*

0.211*

70.278*

70.293*

70.256*

70.168*

70.097

70.131

70.216**

70.225**

Tim

esince

diagnosis

0.156*

0.208**

0.134

0.214*

0.319*

0.197*

0.238**

0.204*

0.277**

0.190**

Tim

esince

operation

0.220**

0.234*

0.16*

0.218*

0.366*

0.216*

0.293**

0.271*

0.341**

0.214**

GH,generalhealthperceptions;VT,vitality;SF,socialfunctioning;MH,mentalhealth;BP,bodilypain;PF,physicalfunctioning;Rem

,role

limitationdueto

emotional

problems;RPh,role

limitationdueto

physicalproblems;PCS,physicalcomponentscore;MCS,mentalcomponentscores.

*Correlationissignificantatthe0.05level

(2tailed).

**Correlationissignificantatthe0.01level

(2tailed).


Dow

nloa

ded

by [

Uni

vers

ity o

f A

lber

ta]

at 1

4:28

26

Oct

ober

201

4

stable and ambulatory at the time of assessment, which may explain the uncompromisedHRQoL particularly with respect to physical dimensions.

Furthermore, eighty-nine percent (89%; n ¼ 169) of study participants were Muslim.The religion of Islam would make women more resilient to adversity, because in theMuslim religion people accept whatever they experience in their life as destiny and god’swill and this belief brings about more acceptance of challenging and adverse situationssuch disease (Taleghani, Yekta, & Nasrabadi, 2006). Unfortunately the low prevalence ofother religious affiliations in our sample, meant that the role of religion as a determinant ofHRQoL could not been adequately explored in our dataset. Although comparativeanalyses between Muslim and non-Muslim participants revealed no significant differences(data not shown), the small number of non-Muslim women and the variability in thereported religious affiliations meant that study was not sufficiently powered to compare‘religion’ subgroups. This issue clearly warrants further investigation as religious affiliationhas consistently been linked to HRQoL (Brady, Peterman, Ficheet, Mo, & Cella, 1999;Manning-Walsh, 2005; Pandey et al., 2005).

Whether the differences in the prevalence of HRQoL impairments in Turkish patientsassessed in this study and samples recruited in US and other European studies truthfullyreflect cultural differences or differences in health care settings and procedures cannot beclearly determined here – this is an issue that warrants further investigation in cross-cultural studies that simultaneously assess patient samples in different cultural settings.

Finally, the paradoxically high HRQoL may be the result of response shift, i.e.phenomenon of internal adaptation that results from recalibration of internal standardsand re-conceptualisation of the frame of references used to produce HRQoL judgements.As breast cancer is commonly perceived as a life threatening diagnosis (Arman,Rehnsfeldt, Carlsson, & Hamrin, 2001; Laubmeier, Zakowski, & Bair, 2004), womenwho have survived breast cancer operation and are currently disease free are likely tochange their internal standards and values and hence rank their post-operative HRQoL

Table 6. Hierarchical multiple regressions for physical and emotional HRQoL.

PCS MCS

b R2 Adj. R2 b R2 Adj. R2

Block 1 0.119 0.100 0.103 0.083Age 0.034 (p ¼ 0.556) 0.022 (p ¼ 0.720)Marital status 0.004 (p ¼ 0.974) 70.017 (p ¼ 0.545)Employment status 0.082 (p ¼ 0.103) 70.018 (p ¼ 0.770)Having children 0.050 (p ¼ 0.472) 0.058 (p ¼ 0.443)

Block 2 0.428 0.411 0.346 0.317Treatment status 0.017 (p ¼ 0.147) 0.305 (p ¼ 0.070)Type of treatment 70.148 (p ¼ 0.435) 70.267 (p ¼ 0.014)Time since diagnosis 0.351 (p ¼ 0.038) 0.217 (p ¼ 0.167)Stage of cancer 70.329 (p ¼ 0.002) 70.223 (p ¼ 0.001)Time since Operation 0.382 (p ¼ 0.000) 0.107 (p ¼ 0.016)

Block 3 0.547 0.513 0.464 0.429Religious coping 70.126 (p ¼ 0.135) 70.192 (p ¼ 0.064)Optimistic coping 0.077 (p ¼ 0.548) 0.018 (p ¼ 0.576)Problem solving coping 0.210 (p ¼ 0.001) 0.215 (p ¼ 0.007)Helplessness coping 70.045 (p ¼ 0.646) 70.279 (p ¼ 0.026)Social support 0.42 (p ¼ 0.001) 0.530 (p ¼ 0.000)

HRQoL, health related quality of life; PCS, physical component score; MCS, mental component scores.


Dow

nloa

ded

by [

Uni

vers

ity o

f A

lber

ta]

at 1

4:28

26

Oct

ober

201

4

higher than anticipated. Longitudinal studies indicate that breast cancer survivors whoremain free of disease long-term report high HRQoL (Casso et al., 2004; Dorval et al.,1998; Ganz et al., 2002; Gupta, Granich, Grutsch, & Lis, 2006).

The second aim of the study was to identify determinants of HRQoL. This studyexamined multifactorial models of HRQoL that included socio-demographic, clinical andpsychological variables.

Problem solving coping and social support consistently emerged as significantmultivariate predictors of MCS and PCS independently adding to the variance explainedby clinical variables.

Although there is consensus in previous literature that engagement coping confersbetter outcomes relative to disengagement/avoidance coping, the evidence on the role ofspecific engagement coping strategies remains far from conclusive. In line with numerousstudies on breast cancer patients (Kershaw et al., 2004; Lehto, Ojanen, Kellokumpu-Lehtinen, 2003; Osowiecki & Compas, 1999; Schou et al., 2005b), our study findingshighlight the importance of problem solving coping in determining HRQoL. Other breastcancer studies, however, failed to find a significant effect for problem solving. Theirfindings indicate that other engagement coping strategies, namely emotional ventilation,seeking social support, acceptance and humour were significant predictors of emotionaldistress (Carver et al., 1993; Epping-Jordan et al., 1999). Ransom, Jacobsen, Schmidt, &Andrykowski (2005) investigated the links between various forms of problem focusedcoping and HRQoL and noted that only information seeking predicted HRQoL whereasother forms of problem focused coping were unrelated with HRQoL.

Inconsistent findings may be related to methodological differences in samplescharacteristics, the coping measure used or the specific outcome under investigation.For instance, the sample in the Ransom et al. (2005) investigation was composed of olderwomen who were diagnosed with early stage cancer (mainly stage I cancer) and were at theend of their treatment. Given that coping is conceptualised as highly contextual/situationalvariable (Lazarus & Folkman, 1984), it is likely that information seeking might constitutea more ‘adaptive’ coping response for this specific patient group, i.e. older women facing a‘less advanced’ and potentially perceived as ‘less threatening’ type of cancer. Moreover,Ransom’s study was designed as a prospective investigation focusing on changes inHRQoL across a 6-month interval rather than absolute levels of HRQoL whereas ourstudy findings are based on cross-sectional data and hence only provide a snap-shot of theassociations between coping and HRQoL. Finally, most of the studies that report nosignificant effect for problem solving coping (e.g. Carver et al., 1993; Epping-Jordan et al.,1999), have focused on indices of emotional distress (e.g. symptoms of anxiety anddepression) whereas the focus of this study was on HRQoL. In line with the ‘copingspecificity hypothesis’ one should expect that the value of coping is dependent on outcomein question. It is therefore plausible that problem solving may have minimal role inregulating emotional response and/or that other coping strategies may become moresalient for emotional regulation. Problem solving may gain more importance in HRQoLevaluations overwhelming the influence of other coping strategies.

It is, however, important to note that despite the variation in observed associations allof the abovementioned studies indicate that coping responses reflecting an engagement orproblem-focused approach are associated with more favourable outcomes with respect toboth emotional wellbeing and HRQoL.

Study findings have shown that helplessness, a disengagement-type coping strategy wasinversely associated with emotional HRQoL, a finding repeatedly reported in the literature(Gidron, Magen, & Ariad, 2001; Schou et al., 2005a). Thus, in face of a negative and


Dow

nloa

ded

by [

Uni

vers

ity o

f A

lber

ta]

at 1

4:28

26

Oct

ober

201

4

stressful life event like breast cancer, adopting a helpless approach/outlook may amplifyemotional concerns and worries, lead to perception of greater emotional burden and threatand therefore adversely impact upon emotional wellbeing (Anagnostopoulos, Kolokotroni,Spanea, & Chryssochoou, 2006). These findings support the notion that task or engagementtype coping may be more effective than disengagement coping in dealing with post-operative psychosocial and physical challenges and demands among breast cancer patients.

Study results also confirmed the importance of social support, a finding in line withoverwhelming evidence attesting to the beneficial effects of social support (Kormblith,Hemdon, & Zuckenman, 2001; Sammarco, 2001; Schou et al., 2005b). Social support candirectly influence the adjustment process and HRQoL in two ways; tangible orinstrumental social support may aid patients in the process of physical recovery or indealing with the physical challenges of illness and associated treatments hence allowingthem to maintain a reasonable level of physical HRQoL; emotional support can providereassurance in the process of dealing the emotional upheaval of cancer diagnosis andtreatment and by making patients feel loved and valued in these times of hardship henceminimising emotional distress and impairments in emotional HRQoL.

The similarity of observed findings to that of previous research highlights therelevance, applicability and importance of the coping and social support concepts in breastcancer outcomes across countries and cultural settings.

Study findings should be interpreted in light of methodological limitations. Theprimary limitation is the cross-sectional design that precludes clear causal inferences to bedrawn. Longitudinal designs are recommended for more insight into the causality ofrelationships or the stability of observed findings. Given that a significant association hasbeen noted between time elapsed since operation and HRQoL, it is plausible that HRQoLand its determinants would change over time as adaptation takes place or new challengesare faced and/or disease progresses. The second methodological issue relates to the samplerepresentiveness. The study eligibility criteria and the resulting study sample character-istics limit the generalisability of observed findings on the broader breast cancerpopulation. Further studies are needed to explore whether the observed effects arereplicated in relapse breast cancer patients or those with more advanced stages of cancer.

Despite its limitations, this study demonstrates the importance of coping and socialsupport in determining HRQoL in breast cancer, a finding that appears to be robust acrossstudies conducted in different countries and cultural settings. The results underline theneed and potential value of psychosocial interventions to promote adaptive copingstrategies and to ensure the provision of psychosocial support for women who undergotreatment for breast cancer.

Acknowledgements

The authors thank Dr. M. Aytac Cokluk for his co-operation and all the patients who took part inthis study.

References

Anagnostopoulos, F., Kolokotroni, P., Spanea, E., & Chryssochoou, M. (2006). The mini-mentaladjustment to cancer (mini-mac) scale: construct validation with a Greek sample of breast cancerpatients. Psycho-oncology, 15, 79–89.

Andrykowski, M.A., Cordova, M.J., Studts, J.L., & Miller, T.W. (1998). Posttraumatic stressdisorder after treatment for breast cancer: prevalence of diagnosis and use of the PTSD checklist-Civilian Version (PCLC-C) as a screening instrument. Journal of Consulting and ClinicalPsychology, 66, 586–595.


Dow

nloa

ded

by [

Uni

vers

ity o

f A

lber

ta]

at 1

4:28

26

Oct

ober

201

4

Arman, M., Rehnsfeldt, A., Carlsson, M., & Hamrin, E. (2001). Indications of change in lifeperspective among women with breast cancer admitted to complementary care. European Journalof Cancer Care, 10, 192–200.

Avis, N.E., Crawford, S., & Manuel, J. (2005). Quality of life among younger women with breastcancer. Journal of Clinical Oncology, 23, 3322–3330.

Brady, M.C., Peterman, A.H., Fitcheet, G., Mo, M., & Cella, D. (1999). A case for includingspirituality in quality of life measurement in oncology. Psycho-Oncology, 8, 417–428.

Carver, C.M., & Antoni, M.H. (2004). Finding benefit in breast cancer during the yearafter diagnosis predicts better adjustment 5 to 8 years after diagnosis. Health Psychology, 6,595–598.

Carver, C.S., Pozo, C., Harris, S.D., Noriego, V., Scheier, M.F., Robinson, D.S., Ketcham, A.S.,Moffat, F.L., & Clarck, K.C. (1993). How coping mediates the effect of optimism on distress: astudy of women with early stage breast cancer. Journal of Personality and Social Psychology, 65,375–390.

Casso, D., Buist, D.S., & Taplin, S. (2004). Quality of life of 5-10 year breast cancer survivorsdiagnosed between age 40 and 49. Health Quality Life Outcomes, 2, 25.

Dorval, M., Maunsell, E., Deschenes, L., Brisson, J., & Masse, B. (1998). Long-term quality of lifeafter breast cancer: comparison of 8-year survivors with population controls. Journal of ClinicalOncology, 16, 487–494.

Eker, D., & Arkar, H. (1995). Perceived social support psychometric properties of MSPSS in normaland pathological groups in a developing country. Psychiatry Epidemiology, 30, 121–126.

Epping-Jordan, J.E., Compas, B.E., Osowiecki, D.M., Oppedisano, G., Gerhardt, C., Primo, K., &Krag, D.N. (1999). Psychological adjustment in breast cancer: processes of emotional distress.Health Psychology, 18, 315–326.

Folkman, S., & Lazarus, R.S. (1985). If it changes it must be process: study of the emotion andcoping during three stages of a college examination. Journal of Personality and SocialPsychology, 48, 150–170.

Ganz, P.A., Desmond, K.A., Leedham, B., Rowland, J.H., Meyerowitz, B.E., & Belin, T.R. (2002).Quality of life in long-term, disease-free survivors of breast cancer: a follow-up study. Journal ofthe National Cancer Institute, 94, 39–49.

Gidron, Y., Magen, R., & Ariad, S. (2001). The relation between hopelessness and psychologicaland serological outcomes in Israeli women with breast cancer. Psychology and Health, 6, 289–296.

Grassi, L., & Rosti, G. (1996). Psychosocial morbidity and adjustment to illness among long-termcancer survivors. A six-year follow-up study. Psychosomatics, 37, 523–532.

Gunes, H. (2001). Gender differences in distress, coping strategies, stress-related growth and factorsassociated with psychological distress and perceived growth following 1999, MarmaraEarthquake. Dissertation, Turkey: Middle East Technical University.

Gupta, D., Granich, J., Grutsch, J.F., & Lis, C.G. (2006). The prognostic association ofhealth-related quality of life scores with survival in breast cancer. Support Care Cancer, 6, 96–123.

Hann, D.M., Jacobsen, P., Martin, S., Azzorello, L., & Greenberg, H. (1998). Women experiencebetter HRQOL with radiotherapy. Clinical Psychology in Medical Settings, 5, 235–247.

Heim, L., Valach, L., & Schaffner, M. (1997). Coping and psychosocial adaptation: longitudinaleffects over time and stages in breast cancer. Psychosomatic Medicine, 59, 408–418.

Hopwood, P., Haviland, J., Mills, J., Sumo, G., & Bliss, J.M. (2007). The impact of age and clinicalfactors on quality of life in early breast cancer: an analysis of 2208 women recruited to the UKstart trial (Standardisation of Breast Radiotherapy Trial). Breast, 16, 241–251.

Janz, N.K., Mujahid, M., Lantz, P.M., Fagerlin, A., Salem, B., Morrow, M., Deapen, D., & Katz,S.J. (2005). Population-based study of the relationship of treatment and socio-demographics onquality of life for early stage breast cancer. Quality of Life Research, 14, 1467–1479.

Kazarian, S.S., & McCabe, S.B. (1991). Dimensions of social support in MSPSS: factorial structure,reliability, and theoretical implications. Journal of Community Psyhology, 19, 150–160.

Kershaw, T., Northouse, L., Kritpracha, C., Schafenacker, A., & Mood, D. (2004). Copingstrategies and quality of life in women with advanced breast cancer and their family caregivers.Psychology and Health, 19, 139–155.

Kocyigit, H., Aydemir, O., Fisek, G., Olmez, N., & Memis, A. (1995). Kisa Form-36’nin TurkceVersiyonu guvenirliligi ve gecerliligi uzerine bir calisma. Turk Psikiatri Dergisi, 34, 22–37.


Dow

nloa

ded

by [

Uni

vers

ity o

f A

lber

ta]

at 1

4:28

26

Oct

ober

201

4

Koopman, C., Angell, K., Turner-Cobb, J., Kresha, M.A., Donnelly, P., McCoy, R., Turkseven, A.,Graddy, K., Giese-Davis, J., & Spiegel, D. (2001). Distress, coping and social support amongrural women recently diagnosed with primarily breast cancer. The Breast Journal, 7, 25–33.

Kormblith, A.B., Hemdon, J.E., & Zuckenman, E. (2001). Social support as a buffer to thepsychological impact of stressful life events in women with breast cancer. Cancer, 91, 443–454.

Krupski, T.L., Kwan, L., David, G., Fink, A., Sonn, G.A., Maliski, S., & Litwin, M.S. (2006).Spirituality influences health related quality of life in men with prostate cancer. Psycho-Oncology, 15, 121–131.

Laubmeier, K.K., Zakowski, S.G., & Bair, J.P. (2004). The role of spirituality in the psyhologicaladjustment to cancer: a test of transactional model of stress and coping. International Journal ofBehavioural Medicine, 11, 48–55.

Lazarus, R.S., & Folkman, S. (1984). Stress, appraisal and coping. NewYork: Springer.Lehto, U., Ojanen, M., & Kellokumpu-Lehtinen, P. (2005). Predictor of quality of life in newly

diagnosed melanoma and breast cancer patients. Annals of Oncology, 16, 805–816.Manning-Walsh, J. (2005). Spiritual struggle: effect on quality of life and life satisfaction in women

with breast cancer. Journal of Holistic Nursing, 23, 120–141.Manuel, J.C., Burwell, S.R., Crawford, S.L., Lawrence, R.H., Farmer, D.F., Hege, A., Philips, K., &

Avis, N.E. (2007). Younger women’s perceptions of coping with breast cancer. Cancer Nursing,30, 85–94.

Martinez, G.P. (2006). Breast cancer as a life process: Psychosocial experiences of Latina and White(non-Latina) long-term breast cancer survivors. Dissertation Abstracts International Section A:Humanities and Social Sciences, 66, 3477.

Osowiecki, D.M., & Compas, B.E. (1999). A prospective study of coping, perceived control, andpsychological adaptation to breast cancer. Cognitive Therapy and Research, 23, 169–180.

Pandey, M., Thomas, B.C., Ramdas, K., & Ratheesan, K. (2006). Early effect of surgery on HRQoLin women with operable breast cancer. Japanese Journal of Clinical Oncology, 36, 468–472.

Ransom, S., Jacobsen, P., Schmidt, J., & Andrykowski, M. (2005). Relationship of problem-focusedcoping strategies to changes in quality of life following treatment for early stage breast cancer.Journal of Pain and Symptom Management, 30, 243–253.

Reid-Arndt, S.A. (2006). The potential for neuropsychology to inform functional outcomes researchwith breast cancer survivors. Neurorehabilitation, 21, 51–64.

Sammarco, A. (2001). Perceived social support, uncertainty, and quality of life of younger breastcancer survivors. Cancer Nursing, 24, 212–219.

Schleinitz, M.D., De Palo, D., Bulme, J., & Stein, M. (2006). Can differences in breast cancer utilitiesexplain disparities in breast cancer care?. Journal of General Internal Medicine, 21, 1253–1260.

Schou, I., Ekeberg, O., Sandvik, L., Hjermstad, M.J., & Ruland, C.M. (2005a). Multiple predictorsof health-related quality of life in early stage breast cancer. Data from a year follow-up studycompared with the general population. Quality of Life Research: An International Journal ofQuality of Life Aspects of Treatment, Care & Rehabilitation, 14, 1813–1823.

Schou, I., Ekeberg, O., & Ruland, C.M. (2005b). The mediating role of appraisal and coping in therelationship between optimism-pessimism and quality of life. Psycho-Oncology, 14, 718–727.

Segrin, C., Badger, T.A., Meek, P., Lopez, A.M., Bonham, E., & Sieger, A. (2005). Dyadicinterdependence on affect and quality-of-life trajectories among women with breast cancer andtheir partners. Journal of Social and Personal Relationships, 22, 673–689.

Stanley, M.A., Beck, J.G., & Zebb, B.J. (1998). Psychometric properties of the MSPSS in olderadults. Aging and Mental Health, 2, 186–193.

Stanton, A.L., Danoff-Burg, S., Cameron, L.L., Bishop, M., Collins, C.A., Kirk, S.B., Sworavski,L.A., & Twillman, R. (2000). Emotionannly expressive coping predicts psychological andphysical adjustment to breast cancer. Journal of Consulting and Clinical Psychology, 68, 875–882.

Taleghani, F., Yekta, Z.P., & Nasrabadi, A.N. (2006). Coping with breast cancer in newly diagnosedIranian women. Journal of Advanced Nursing, 54, 265–272.

Ucman, P. (1990). Ulkemizde calisan kadinlarda stressle basa cikma ve psikolojik rahatsizliklar.(Coping with stress and psychological distress in women). Turk Psikoloji Dergisi, 7, 58–75.

Uzun, O., Aslan, F.E., Selimen, D., & Koc, M. (2004). Quality of life in women with breast cancer inTurkey. Journal of Nursing Scholarship, 36, 207–213.

Wagner, C.D., Bigatti, S.M., & Storniolo, A.M. (2006). Quality of life of husbands of women withbreast cancer. Psycho-Oncology, 15, 109–120.

Ware, J.E. (2000). SF 36 health survey update. Spine, 25, 3130–3139.


Dow

nloa

ded

by [

Uni

vers

ity o

f A

lber

ta]

at 1

4:28

26

Oct

ober

201

4

Ware, J.E., Kosinski, M., & Keller, S.K. (1994). Physical and mental health summary scales––a user’smanual. Boston, MA: The Health Institute.

Ware, J.E., Snow, K.K., Kosinski, M., & Gandek, B. (1993). SF-36 Health survey manual andinterpretation guide. Boston, Mass: New England Medical Centre.

Winefield, H., Coventry, B.J., Pradhan, M., Harvey, E., & Lambert, V. (2003). A comporision ofwomen with breast cancer who do not seek support from the internet. Australian Journal ofPsychology, 55, 30–34.

Wonghongkul, T., Dechaprom, N., Phumivichuvate, L., & Losawatkul, S. (2006). Uncertainityappraisal coping and quality of life in breast cancer survivors. Cancer Nursing, 29, 250–257.

Zimet, G.D., Dahlem, N.W., Zimet, S.G., & Farley, G.K. (1988). The multidimensional scale ofperceived social support. Journal of Personality Assessment, 52, 30–41.

Zimet, G.D., Powell, S.S., Farley, G.K., Werkman, S., & Berkoff, K.A. (1990). Psychometricproperties of the multidimensional scale of perceived social support. Journal of PersonalityAssessment, 55, 610–617.


Dow

nloa

ded

by [

Uni

vers

ity o

f A

lber

ta]

at 1

4:28

26

Oct

ober

201

4

Documents

Coping and social support and health related quality of life in women with breast cancer in Turkey