QUALITY OF LIFE, INTERPERSONAL RELATIONSHIPS AND COPING STRATEGIES OF THE WOMEN WITH BREAST CANC ER

AND THEIR HUSBANDS

MOHD NASIR B CHE MOHD YUSOFF

FACULTY OF MEDICINE UNIVERSITY OF MALAYA

KUALA LUMPUR

JANUARY 2009

QUALITY OF LIFE, INTERPERSONAL RELATIONSHIPS AND COPING STRATEGIES OF THE WOMEN WITH BREAST CANC ER AND

THEIR HUSBANDS

MOHD NASIR B CHE MOHD YUSOFF

THESIS SUBMITTED IN FULFILMENT OF THE REQUIREMENTS

FOR THE DEGREE OF DOCTOR OF PHILOSOPHY

FACULTY OF MEDICINE UNIVERSITY OF MALAYA

KUALA LUMPUR

JANUARY 2009

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CONFERENCE PRESENTATIONS Yusoff, N., Low, W.Y. and Yip, C.H. Predictors of relationship satisfaction among women with breast cancer. Pre-Summit Scientific Conference. National Summit on Breast Cancer Education. Kuala Lumpur, Malaysia. 30 June – 2 July, 2006. Yusoff, N., Low, W.Y. and Yip, C.H. Perceived husband support and quality of life among women with breast cancer. Ninth International Congress of Behavioral Medicine. Bangkok, Thailand. 29 November – 2 December, 2006. Yusoff, N., Low, W.Y. and Yip, C.H. Depression among women with breast cancer. Seventh Conference of Asian Association of Social Psychology (AASP). Kota Kinabalu, Sabah, Malaysia. 25 – 28 July, 2007. Yusoff, N., Low, W.Y. and Yip, C.H. Husbands’ view of their wives’ body image after breast cancer surgery. Eleventh Biennial Meeting of The Asia Pacific Society for Sexual Medicine 2007 (APSSM 2007). Jeju, South Korea. 6- 10 October, 2007. Yusoff, N., Low, W.Y. and Yip, C.H. Women’s sexual attractiveness after breast cancer surgery: from husband’s perspective. Eleventh Biennial Meeting of The Asia Pacific Society for Sexual Medicine 2007 (APSSM 2007). Jeju, South Korea. 6- 10 October, 2007. Yusoff, N., Low, W.Y. and Yip, C.H. Coping Strategies of the couples with breast cancer. Conference on Behavioral Medicine. Penang, Malaysia. 25 – 27 January, 2008. Yusoff, N., Low, W.Y. and Yip, C.H. Couples’ anxiety after breast cancer surgery. Conference on Behavioral Medicine. Penang, Malaysia. 25 – 27 January, 2008. Yusoff, N., Low, W.Y. and Yip, C.H. Malaysian Women’s and Their Husbands’ Empathy Following Breast Cancer Surgery. 10th International Congress of Behavioral Medicine. Tokyo, Japan. 27 – 30 August, 2008. Yusoff, N., Low, W.Y. and Yip, C.H. Perceived Husband Support Among Malaysian Women After Breast Cancer Surgery. 10th International Congress of Behavioral Medicine. Tokyo, Japan. 27 – 30 August, 2008. Yusoff, N., Low, W.Y. and Yip, C.H. Women’s View On Their Body Image After Breast Cancer Surgery. 40th APACPH Annual Conference. Kuala Lumpur, Malaysia. 7-9 November, 2008.

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PUBLICATIONS

Yusoff, N., Low, W.Y. and Yip, C.H. (2006). Perceived husband support and quality of life among women with breast cancer. International Journal of Behavioral Medicine. 13. (Supplement). p.138 [ABSTRACT]. Yusoff, N., Low, W.Y. and Yip, C.H. (2008). Depression among women with breast cancer. Journal of Asian Social Psychology [IN PRESS] Yusoff, N., Low W.Y.and Yip, C.H. (2008). Predictors of Relationship Satisfaction Among Women with Breast Cancer. In Zailina H. et al. (ed.), Breast Cancer In Malaysia: Issues and Educational Implication. Universiti Putra Malaysia Press [IN PRESS]

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ACKNOWLEDGEMENTS

First and foremost, I am deeply indebted to my main supervisor, Professor Dr Low

Wah Yun (Psychologist), for the invaluable guidance and support she has given me in

facing and enduring the challenges throughout the study. I also wish to express my

gratitude to my co-supervisor, Professor Dr Yip Cheng Har (Breast Surgeon), who has

given much input related to breast cancer. Their motivation, enthusiastic and constructive

comments, during the many discussions we had, are very much appreciated.

My appreciation and gratitude also goes to several Professors, who have given

much advice, critic and guidance, especially for the establishment of the methodology and

scales used in this study. They are Professor Dr Nancy Pistrang (University College

London, United Kingdom), Professor Dr Charles Carver (University of Miami, United

States of America), Professor Dr Penelope Hopwood (Christie Hospital, United Kingdom),

Professor Dr Stephan Franzoi (University Milwaukee, United States of America) and

Professor Dr Janet S. Carpenter (Vanderbilt University, United States of America).

Special acknowledgements are dedicated to University of Malaya (UM), Kuala

Lumpur, Malaysia, for the financial support (Fundamental Grant: FP058/2005C), Science

University of Malaysia (USM) and Ministry of Higher Education, Malaysia, for the Post-

graduate Fellowship.

Last but not least, special thanks to all the women with breast cancer and their

husbands who had willingly taken part in this study (….Al-fatihah to the patients who had

passed away before this study was completed), all the nurses at the Clinical Oncology

Clinics for helping me to recruit the respondents, my family and friends, for their constant

encouragement and support.

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ABSTRACT

Psychosocial morbidity such as the quality of life impairment; change in the pattern

of interpersonal relationship and coping behavior are consequences of breast cancer on

women’s life and their significant other, i.e. husband. The first objective of this study was

to examine the effects of the treatment phases (prior-to, during and post-chemotherapy) on

the quality of life (QOL), interpersonal relationship (IR) and coping strategies (C) of

women with breast cancer and their husbands, as well as to examine the patterns and levels

of QOL, IR and C among these couples, following breast cancer surgery. Secondly, it was

done to observe the effects of the medical factors (types of surgery and breast cancer

stages) and bio/socio-demographic factors (menopausal status and ethnicity) on the QOL,

IR and C of the women with breast cancer and their husbands. Thirdly, it was done to

determine factors predictive of women’s global health status, sexual attractiveness,

relationship satisfaction and coping strategy post-chemotherapy. This study was carried

out prospectively with three times evaluation: Phase one/ prior-chemotherapy following

breast cancer surgery (seven weeks after diagnosis or three weeks after surgery), Phase

two/ during chemotherapy (14 weeks after diagnosis or 10 weeks after surgery) and Phase

three/ post-chemotherapy (23 weeks after diagnosis or 19 weeks after surgery). One

hundred and fifty seven women with breast cancer (mean age: 48.29±8.85sd) and 157

husbands (52.21±9.01sd) participated in this study. Majority of the women had undergone

mastectomy (79.4%, n=127). Over half of the women were diagnosed with stage two of

breast cancer (56.9%, n=91). Various standardized self-administrated scales were used:

Quality of life evaluation [European Organization for Research and Treatment of Cancer

Quality of Life Questionnaire (EORTC-QLQ C30), Breast Module (QLQ BR-23), Hospital

Anxiety and Depression Scale (HADS), Blatt Menopausal Index (BMI)], Sexuality

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evaluation [Body Image Scale (BIS) and Sexual Attractiveness: Body Esteem Scale (SA-

BES)], interpersonal relationship evaluation [Inventory of Socially Supportive Behaviour

(ISSB), Level of Disclosure, Helpfulness of Disclosure, Criticism, Withdrawal, Empathy:

Revised Barrett-Lennard Relationship Inventory (E-RBLRI), Dyadic Satisfaction: Dyadic

Adjustment Scale (DS-DAS)] and coping strategy evaluation [Brief COPE]. Husbands

answered similar scales for HADS, DS-DAS and Brief COPE and some scales were

modified for this purpose. All scales were translated and validated locally to cater for the

multicultural ethnicity of the Malaysian population. Medical and bio/socio-demographic

data were also gathered. Results showed that couples’ psychological aspect (anxiety and

depression), relationship satisfaction and most of the coping strategies (Active Coping,

Planning, Positive Reframing, Acceptance, Using Emotional Support, Using Instrumental

Support, Denial, Venting, Self-blame, Emotion-focused Strategies and Problem-focused

Strategies) exhibited significant effects of time, where women obtained higher scores in all

aspects than their husbands. Nevertheless, the types of surgery and breast cancer stages

did not affect couples’ psychological aspect, relationship satisfaction and their coping

strategies, the fact which contradicts with the menopausal status and ethnicity. The

significant effect of time was also observed for the main domains of quality of life i.e.

Global Health Status, Physical Functioning, Role Functioning, Emotional Functioning and

Social Functioning, sexuality (body image and attractiveness), as well as their

interpersonal relationship aspects (Perceived Husband Support, Level of Disclosure,

Empathy, Criticism and Withdrawal). The regression model indicated that women’s

depression was predictive of their global health status. Women’s sexual attractiveness was

predicted by their body image and anxiety; as well as their husbands’ view on their sexual

attractiveness and body image. Meanwhile, women’s relationship satisfaction was

predicted by their depression, perceived husband’s support, empathy, helpfulness of

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disclosure, husbands’ relationship satisfaction and husbands’ perceived providing support.

Women’s age and their perceived husband’s support are predictive of their problem-

focused strategy. In conclusions, the treatment phases of chemotherapy, following breast

cancer surgery, were revealed to have significant impacts on the quality of life,

interpersonal relationship and coping strategies of women with breast cancer and their

husbands, with the similar patterns over the time. Bio/socio-demographic factors such as

menopausal status and ethnicity are important determinants in these psychosocial aspects

of breast cancer. Healthcare organizations should implement broaden breast health-related

programmes targeting the family of women with breast cancer.

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ABSTRAK

Psikososial morbiditi seperti kemerosotan kualiti kehidupan, perubahan corak

dalam hubungan interpersonal dan tingkahlaku menangani krisis, adalah merupakan urutan

daripada kanser payudara, bukan saja terhadap pengidapnya (wanita) tetapi juga orang

yang hampir dengan mereka i.e. suami. Objektif utama penyelidikan ini adalah untuk

mengkaji kesan fasa-fasa rawatan (sebelum, semasa dan selepas kemoterapi) terhadap

kualiti kehidupan, hubungan interpersonal dan strategi menangani krisis dikalangan wanita

yang mengidap kanser payudara dan suami mereka; selain daripada untuk mengkaji corak

dan tahap psikososial morbiditi ini selepas pembedahan kanser payudara. Keduanya,

untuk meninjau kesan faktor perubatan (jenis pembedahan dan tahap kanser payudara) dan

bio/sosio-demografi (status menopaus dan etnik) terhadap kualiti kehidupan, hubungan

interpersonal dan strategi menangani krisis di kalangan wanita yang mengidap kanser

payudara dan suami mereka. Ketiganya, untuk menentukan faktor peramal terhadap kualiti

kehidupan, tarikan seksual, kepuasan hubungan dan strategi menangani krisis dikalangan

pesakit selepas rawatan kemoterapi. Kajian ini dijalankan secara prospektif dengan tiga

kali penilaian/ peninjauan dilakukan: Fasa Pertama/ sebelum kemoterapi selepas

pembedahan kanser payudara (tujuh minggu selepas diagnosis atau tiga minggu selepas

pembedahan), Fasa Ke-dua/ semasa kemoterapi (14 minggu selepas diagnosis atau 10

minggu selepas pembedahan) dan Fasa Ke-tiga/ selepas rawatan kemoterapi (23 minggu

selepas diagnosis atau 19 minggu selepas pembedahan). Satu ratus dan lima puluh tujuh

wanita pengidap kanser payudara (purata umur: 48.29±8.85sd) and 157 suami mereka

(52.21±9.01sd) terlibat dalam penyelidikan ini. Majoriti wanita adalah mereka yang

menjalani pembedahan mastektomi (79.4%, n=127). Kebanyakan wanita didiagnosis

dengan kanser payudara pada tahap dua (56.9%, n=91). Pelbagai skala yang standard

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digunakan: Penilaian Kualiti Kehidupan [European Organization for Research and

Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ C30), Breast Module

(QLQ BR-23), Hospital Anxiety and Depression Scale (HADS), Blatt Menopausal Index

(BMI)], Penilaian Seksualiti [Body Image Scale (BIS) and Sexual Attractiveness: Body

Esteem Scale (SA-BES)], Penilaian Hubungan Interpersonal [Inventory of Socially

Supportive Behaviour (ISSB), Level of Disclosure, Helpfulness of Disclosure, Criticism,

Withdrawal, Empathy: Revised Barrett-Lennard Relationship Inventory (E-RBLRI),

Dyadic Satisfaction: Dyadic Adjustment Scale (DS-DAS)] and Penilaian Strategi

Menangani Krisis [Brief COPE]. Suami menjawab skala yang sama dengan pesakit iaitu

HADS, DS-DAS dan Brief COPE selain daripada menjawab skala-skala yang

dimodifikasi. Semua skala diterjemahkan dan divalidasi pada populasi setempat (validated

locally) untuk menjangkaui variasi etnik di Malaysia. Data-data perubatan dan bio/sosio-

demografi juga dikumpul. Keputusan kajian menunjukkan terdapatnya kesan masa yang

signifikan terhadap aspek psikologi (kekhuatiran dan kemurungan), kepuasan hubungan

dan kebanyakan aspek strategi menangani krisis (Active Coping, Planning, Positive

Reframing, Acceptance, Using Emotional Support, Using Instrumental Support, Denial,

Venting, Self-blame, Emotion-focused Strategy and Problem-focused Strategy) pada

pesakit dan suami mereka, yang mana pesakit menunjukkan skor yang lebih tinggi

berbanding suami mereka pada semua aspek. Jenis pembedahan dan tahap kanser

payudara tidak menunjukkan kesan yang signifikan terhadap aspek psikologi, kepuasan

hubungan dan strategi menangani krisis pada pesakit dan suami mereka, yang mana

bertentangan dengan keputusan kajian bagi faktor status menopaus dan etnik. Keputusan

yang signifikan juga didapati pada domain-domain utama kualiti kehidupan i.e. status

kesihatan global, fungsi fizikal, fungsi peranan, fungsi emosi, fungsi sosial, seksualiti (imej

badan dan penarikan); juga aspek hubungan interpersonal (sokongan suami, tahap

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keakraban, keupayaan memahami, kritik dan pengunduran diri). Keputusan model regrasi

menunjukkan kemurungan pesakit adalah peramal kepada status kesihatan global mereka.

Penarikan seksual pesakit pula diramal oleh faktor kekhuatiran dan imej badan; termasuk

juga diramal oleh pandangan suami mereka terhadap imej badan dan penarikan seksual

isteri mereka. Dalam pada itu, kepuasan pesakit dalam hubungannya dengan suami adalah

diramal oleh kemurungan mereka, sokongan suami, keupayaan pemahaman suami, tahap

keakraban dengan suami; dan juga kepuasan suami mereka terhadap hubungan dengan

isteri dan sokongan terhadap isteri. Faktor umur pesakit dan sokongan suami pula didapati

meramal strategi pesakit dalam menangani krisis. Kesimpulannya, fasa-fasa rawatan

selepas pembedahan kanser payudara menunjukkan kesan yang signifikan terhadap kualiti

kehidupan, hubungan interpersonal dan strategi menangani krisis pada wanita pengidap

kanser payudara dan suami mereka, dengan corak yang sama merentasi masa. Faktor

bio/sosio-demografi seperti status menopaus dan etnik adalah penentu penting dalam aspek

psikososial kanser payudara. Organisasi kesihatan perlu melaksanakan program-program

kesihatan berkaitan dengan payudara dengan skop yang lebih luas, meliputi ahli keluarga

pesakit.

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CHAPTER ONE

BREAST CANCER: AN INTRODUCTION

In this chapter, it is essential to have a good understanding of the nature of breast,

the treatment for breast cancer and its epidemiology. These components are described as

an introduction of the study. In the final section, the theories and concepts, surrounding

the breast cancer studies, are elaborated as the background of this research.

1.0 Understanding the Nature of Breast and Cancer Cell

Breast is a symbol of many for women; womanliness, sexual attractiveness and

motherhood. Located in the superficial fascia, the breast is composed of tubuloalveolar

gland. Fifteen to twenty ducts are formed at puberty, and 10 to 15 lobes develop into

separate glands which are embedded within the breast fatty stroma. The suspensory

ligaments of cooper allow the breast to attach on the skin, while the retromammary bursa

separates the breast from the fascia of the pectoralis major muscle. The cooper’s ligament,

from fibrosepta (in the stroma), supports the breast parenchyma. The breast is also found

to have 15 to 20 lactiferous ducts, which extended from the lobules, consisting of glandular

nipple epithelium to the openings which are located on the nipple. A dilation of the duct,

which is the lactiferous sinus, is located near the opening duct, in the subalveolar tissue.

The subcutaneous fat and adipose tissue play a role in giving a smooth contour to the

breast, and also contribute to the mass of the non-lactating breast as a whole. The

lymphatic vessels are placed across the stroma of the gland. These lymphatic vessels also

bring lymph to the collecting ducts. The lymphatic channels end at the internal mammary

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(or parasternal) lymph nodes. Meanwhile, the pectoralis major muscle is located near the

ribs and intercostal muscles. The other important parts of a woman’s breasts are the

parietal pleura that latch on the endothoracic fascia, and the visceral pleura which cover the

surface of the lungs, as shown in Figure 1.0 (Romrell and Bland, 1991).

Figure 1.0: The Anatomy of Breast (Source: Romrell and Bland, 1991; as cited in Bland and Copeland, 1991:18)

(Permission: Copyright Elsevier – see Appendix E)

An intricate combination of hormones in the body causes the change in structure,

size, form and function of the breast tissue. The ratio, which permits breast epithelial cells

to produce and secrete milk for nourishment and sustenance of infants, is also influenced

by this complex hormone combination. The growth of the lobuloalveolar segments seems

3

to be influenced or stimulated by progesterone. At the same time, the secretion activity is

inhibited by blocking the terminal differentiation, which is later induced by prolactin

(Davis et al., 1972, as cited by Minton, 1988). The prolactin hormone is stimulated by

cortisol on breast differentiation. Myoepithelial cells, which are located in the basement

membrane of the alveolus along the intralobular ducts, interact with oxytocin. The

oxytocin receptors are said to increase in the breast and uterus at parturition, and

apparently act by the phosphorylation of myosin, which then produces the contraction of

myoepithelial cells (Bremel and Shaw, 1978 as cited by Minton, 1988). Intermittent

release of oxytocin causes better contraction than the continuous release, and this mirrors

the intermittent suckling of the nipple which provides a stimulus to the secretion of milk.

Prolactin is the hormone, which is secreted due to the suckling of infants. It is the

most important hormone, and when combined with the receptor on the milk secreting cells,

the production of milk is stimulated. Mammary growth and differentiation is also

stimulated by prolactin. The production of the milk protein casein and casein mRNA are

increased by prolactin, which also increases the rate in which fatty acids are produced. In

addition, it also causes the synthesis of the breast tissues. The shift in the synthesis to

medium chain fatty acids, which is a characteristic of the lactating breast tissue, is also

stimulated by prolactin (Guyette et al., 1979; Strong et al., 1972; Teyssot and Houdebine,

1980; Wang et al., 1972 as cited by Minton, 1988). The hormone binds the mammary cell

surface prolactin membrane receptors. The level of serum prolactin and the period of an

early lactation have a correlation to the changes in the number of prolactin receptors on the

mammary cells (Bohnet et al., 1977; McNeilly and Friesen, 1977 as cited by Minton,

1988). Secretary signal for the cellular milk production is promoted by prolactin which is

internalized in the cell (Nolin and Witorsch, 1976 as cited by Minton, 1988; Nolin, 1978;

Shiu, 1980 as cited by Minton, 1988).

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The modulation of the lactigenous hormones is influenced by the estrogen,

progesterone and adrenocortical hormones. The promotion of the prolactin secretion by

the anterior pituitary gland is caused by estrogen, which also stimulates mammary growth

and development. However, estrogen inhibits the secretion of milk (McManus and Welsch,

1980 as cited by Minton, 1988). The rapid growth of the mammary epithelium (especially

in the ductile portions of the gland) is caused by estrogen. Nearly all related studies

conducted have shown that there is a relationship between estrogen and intact pituitary

function for a satisfactory mammary growth (Edwards et al., 1979 as cited by Minton,

1988; Leclerg and Heuson, 1979 as cited by Minton, 1988).

A full lobuloalveolar development of the gland is produced by the synergy of

progesterone with estrogen and prolactin. An accumulation of the enzymes, which is

necessary for the differentiation of breast cells for lactation, is prevented by progesterone.

The combination of progesterone and estrogen causes the lobuloalveolar development

during pregnancy, which also causes an increase in the amount of lactose in the breast

(Folley and Malpress, 1948 as cited by Minton, 1988; Kuhn, 1977; Cowie, 1978 as cited

by Minton, 1988; Topper and Freeman, 1980 as cited by Minton, 1988).

Glucocorticoid is important to initiate or sustain lactation; whereas, insulin is

important in the synthesis of breast lipids as it regulates the transportation of glucose to the

acinar cells. However, insulin does not seem to play an important role in the development

of the breast (Robinson et al., 1978 as cited by Minton, 1988). The thyroid hormone

seems to have a permissive role rather than regulatory, and it is involved in the mammary

growth and lactation (Lyons, 1958 as cited by Minton, 1988).

Literally, breast cancer is a malignant (cancerous) growth which begins in the

tissues of the breast. The growth of the cell is uncontrolled, and it lacks the structural and

organizational integrity of its normal counterpart. Cancer cells are developed through the

5

process of “clonal selection,” where an initial mutation in the genome of the cell may

cause an advantage in survival, and more rigorous growth especially when the progeny of

that cell undergoes a second mutation, which also results in a survival advantage. The

growth of the cancer cell is related to the process of carcinogenesis, in which two types of

gene (the promoting and inhibiting growth genes) are damaged, so that the clones of these

cells will lose their normal control mechanism of growth and multiply out of control

(Groenwald et al., 1997 as cited by LeMarbre and Groenwald, 1997).

Normal cells usually go through several stages: metaplasia, dysplasia, carcinoma in

situ and finally invasive cancer (Correa, 1982 as cited by LeMarbre and Groenwald, 1997).

Meanwhile, the telomerase enzyme was observed to take part in the immortality of cancer

cell (Abercrombie, 1975; Greider and Blackburn, 1996 as cited by LeMarbre and

Groenwald, 1997). Cyclin-dependent kinases (cdks) regulate the continuous operation of

the cell cycle engine, while the cancer cells defect the control of the cell cycle and

influence the movement of the cell through a series of regulatory “check-points” in the cell

cycle. Some cancer-suppressor gene codes for proteins are essential for these checkpoints.

The risk for developing cancer increases with the absence of this protein (Ruddon, 1981 as

cited by LeMarbre and Groenwald, 1997).

The defection of cell death programming (apoptosis), which is due to the lack of

normal biological blocks located at the end of chromosomes, is related to the cancer. The

number (in times), in which a chromosome replicates, can be limited. The division of the

cell continues and expands in cancer, which can cause an overbalance in the cell loss and is

beyond normal boundaries. Cancer also seems to have a loss of contact inhibition, which

is the natural process of disintegration of damaged cells by other cells (LeMarbre and

Groenwald, 1997).

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The decrease of the growth factor, in a cancer cell, is also another difference which

can be seen. Cancer cells can divide without anchorage. In the shortage of nutrients and

growth factors, the enlargement of the cells and the synthesis of protein (in preparing to

copy Deoxyribonucleic acid or DNA, as well as resting and quiescent of the cells) become

abnormal. They are not in the correct manner, specifically in the contribution of

Retinoblastoma Protein (pRb) and the variety of myriad of changes found in the surface of

the cancer cell (Nicolson, 1976 and Nicolson and Poste, 1976 as cited by LeMarbre and

Groenwald, 1997). The level of Cyclic Adenosine Monophosphate (cAMP) is also low in

cancer cells as compared to the normal cells, and this is also another important difference

(Pastan et al., 1975 as cited by LeMarbre and Groenwald, 1997). Cancer cells also tend to

be less differentiated than the normal ones, and they exhibit a variety of abnormal mitotic

figures (LeMarbre and Groenwald, 1997).

1.1 Breast Cancer Treatments: Surgery and Adjuvant Therapy

1.1.1 Breast Cancer Surgery

Surgery plays an important role in cancer treatment, and it serves as the first line of

defence against cancer proliferation. Thus, most patients with breast cancer undergo

surgical procedure to remove the cancer cells from their breasts. However, at present,

breast surgery is done with the aim to preserve as much of the healthy breast tissues (and

the surrounding area) as possible. Currently, there are two major operations of breast

cancer which are being practiced in the hospital. These operations are known as Modified

Radical Mastectomy and Breast Conserving Surgery. The terms used to distinguish the

two surgeries are based on the breast area which is involved in the operation.

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The first operation, i.e. the Modified Radical Mastectomy (MRM), involves the

removal of the entire breast and axillary lymph nodes en bloc, except for the pectoralis

major muscle (Figure 1.1). This procedure is recommended because the breast tumor is

too large, thus, conservation of the breast is impossible. It is also recommended when the

tumour is multicentric or if good cosmetic results cannot be attained (Donegan and Spratt,

1995; Lynn, 2004).

Figure 1.1: Women with breast cancer following surgical procedure of Modified Radical Mastectomy

On the other hand, Breast Conserving Surgery is an alternative to mastectomy.

Many terms have been used for this operation; these include segmental mastectomy, wide

local excision, partial mastectomy, lumpectomy, quadrantectomy, tumorectomy and

tylectomy. This surgery is carried out so that the breast is left cosmetically acceptable

8

while the tumour is removed (Figure 1.2). Women with small localized tumors are eligible

to undergo this procedure (Donegan and Spratt, 1995; Lynn, 2004).

Figure 1.2: Women with breast cancer following surgical procedure of Breast Conserving Surgery

1.1.2 Adjuvant Therapy: Chemotherapy

Three types of adjuvant therapy are available following breast cancer surgery; these

are chemotherapy, radiotherapy and hormonal therapy (Cancer Chemotherapy Protocal,

Ministry of Health, Malaysia, 2004). Most patients are usually given chemotherapy after

surgery, followed by radiotherapy and hormonal therapy. Chemotherapy is given so that

the chance of cure can be increased, and to remove any cancer cells which may have

spread to the other areas.

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Adjuvant therapy is the administration of cytotoxic chemotherapy or the use of

ablative endocrine therapy after primary surgery of the breast to kill or clinically inhibit

occult micrometastases (Osborne and Ravdin, 2000). This therapy is systemic, where the

drugs used inhibit the growth of cancer cell, by killing or stopping the cells from dividing

in the bloodstream. According to Geddie (2004), this treatment causes side-effects which

can be observed in the blood, mouth, intestinal tract, nose, nails, vagina and hair.

The standard chemotherapy for most malignancies is the administration of a

combination of clinically effective anticancer drugs. This method has been recognized as a

mechanism which can prevent recurrence and survival of the cancer cells. The treatment

was first used for leukaemia and lymphoma, but it is now used for other types of

malignancies to maximize the killing of tumour cells without excessive toxicity.

Furthermore, combination of drugs will avoid the selection of resistant cell lines in

heterogeneous tumour populations (Geddie, 2004).

According to the Cancer Chemotherapy Protocal, Ministry of Health, Malaysia

(2004), the combinations of chemotherapeutic drugs for the treatment of breast cancer is as

stated below:

(a) CMF

Cyclophospamide (750 mg/m2-day 1) + Methotrexate (50 mg/m2-day 1) +

Flourouracil (600 mg/m2-day 1); Recycle Day 22 x 6 cycles

(b) FAC

Flourouracil (500 to 600 mg/m2-day 1) + Doxorubicin (Adriamycin is a

tradename of doxorubicin; 50 mg/m2-day 1) + Cyclophospamide (500 to 600

mg/m2-day 1); Recycle Day 22 x 6 cycles

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(c) FEC

Flourouracil (600 mg/m2-day 1) + Epirubicin (60 mg/m2-day 1) +

Cyclophospamide (600 mg/m2-day 1); Recycle day 22 x 6 cycles

Cyclophosphamide, methotrexate, 5-fluorouracil, doxorubicin, epirubicin,

paclitaxel and docetaxel are among the common chemotherapy regimens used in an

adjuvant setting. The chemotherapy drug, such as Cyclophosphamide, acts by killing

tumour cells and chemically interacting with deoxyribonucleic acid (DNA) (Seeger and

Woodcock, 1995). This can cause cross-linking of DNA strands, which will then prevent

DNA synthesis and cell-division (Dow, 2004). Common toxicities related to this drug

include nausea and vomiting, alopecia, urotoxicity and myelosuppression (Geddie, 2004).

Another regimen such as doxorubicin may intercalate in the DNA helix and

activate the DNA cleavage through topoisomerase II. Similarly, it may also produce free

radicals which act in response with oxygen to generate toxic superoxides. The production

of free radicals is perhaps the apparatus of cardiotoxicity, which is unique to anthracyclines.

This regimen also attaches directly to the DNA base pairs and hinders DNA and

Ribonucliec acid (RNA) synthesis (Seeger and Woodcock, 1995). Patients can experience

cardiotoxicity, nausea and vomiting, myelosuppression, alopecia and stomatitis, as side-

effects of the treatment (Geddie, 2004).

As for the regimen of Mitoxantrone, killing the proliferin and resting cells are the

important acts (Seeger and Woodcock, 1995). These researchers further added that the

mechanism of the regimen of 5-Florouracil is incorporated into ribonucleic acid (RNA),

deoxyribonucleic acid (DNA), and the inhabitation of thymidylate synthesis (1995).

According to Dow (2004), the regimen of chemotherapy can produce several side-effects,

such as neutropenia and thrombocytopenia, photosensitivity, darkening of skin, veins and

11

nails, alopecia, as well as moderate nausea and vomiting. The regimen, such as Taxol,

usually interferes with cell division by increasing the steadiness of microtubules, which is

needed for the mitosis process (Seeger and Woodcock, 1995).

Methotrexate responds to the human cell by blocking the enzyme dihydrofolate

reductase (DHFR), which hinders the conversion of folic acid into tetrahydrofolic acid.

Due to this reason, the depletion of critical folates is observed. Methotrexate also responds

to the human cell by inhibiting the precursors of DNA and RNA, as well as the cellular

proteins. Methotrexate usually results in stomatitis, diarrhoea and nausea, and vomiting

(Geddie, 2004). Forming a cleavable complex, with topoisomerase II and DNA, is a

common reaction by Epirubicin, which results in some side-effects such as nausea and

vomiting (which are very frequent), as well as stomatitis, alopecia, cardiotoxicity and

diarrhoea (Geddie, 2004). As for Docetaxel, this regimen performs by hampering mitotic

spindle apparatus through increased formation and establishment of microtubules. The use

of this regimen in the treatment of chemotherapy has caused patients to frequently report

severe hypersensitivity reaction including flushing, hypotension and dyspnea (Geddie,

2004).

12

Figure 1.3: Women with breast cancer receiving Adjuvant Chemotherapy

1.2 The Epidemiology of Breast Cancer

Breast cancer is a disease which is rapidly rising worldwide. It is the second most

common cancer diagnosed worldwide after lung cancer, with 1.15 million cases in 2002,

and the most prevalent cancer in the world with 4.4 million survivors, up to 5 years

following diagnosis (Parkin et al., 2005). In industrial countries such as the United States

of America, Cancer Facts and Figures, American Cancer Society (2004) estimated that

there are 203, 500 new cases of breast cancer annually. Hewitt et al. (1999) pointed out

that about 1.5 % of the American females are survivors of breast cancer. According to a

report from the National Women’s Health Information Centre, United State of America

(NWHIC), one in eight women in the United State of America will develop breast cancer

during their lifetime. In the same vein, it was estimated that there were 40, 580 deaths of

breast cancer among the survivors in the US in 2004, this cancer type was ranked as the

13

second killer in that country. Out of the figure, 90 % were female survivors (Cancer Facts

and Figures, American Cancer Society, 2004).

According to Parkin et al. (2005), female cancer deaths represent 14% of the 144

000 annual deaths reported. Overall, this figure ranks breast cancer as the fifth cause of

death from cancer, although it is still the leading cause of mortality in women. The

existence of the present day screening programs has resulted in the increased number of

survivors of breast cancer in the western countries, which was 89% at five years, as

indicated by the United State Surveillance Epidemiology and End Results (US-SEER)

Program in 1995-2000 (Reis et al., 2004).

Meanwhile, the incidence rate of breast cancer is high in most of the developed

areas, with the highest age-standardized incidence in North America (99.4 per 100 000

population). According to the annual report on cancer status worldwide, more than half of

the breast cancer cases are reported in industrialized countries. Among others, it is

estimated about 361 000 cases in Europe, representing 27.3% from all cancer in women;

whereas, North America is estimated to have 230 000 cases, representing 31.3% from all

cancers in women (Jemal et al., 2004). According to Parkin et al. (2005), several

European regions such as the southern and eastern, as well as South America, showed

more modest ratios ranging from 40 to 60 per 100 000 population, as compared to the other

regions of Europe, Northern America, Australia and New Zealand. Among the regions

worldwide, Northern Europe shows the highest mortality rate of breast cancer. In the data

documented from 1993-1997, breast cancer was observed to occur in 89.5 American

women per 100 000 population; whereas, in other industrial countries, the incidence was

lower with 74.4 women per 100 000 population in United Kingdom (Surveillance and Risk

Assessment Division, CCDP, Health Canada).

14

In the Asian region, western Asia and Japan revealed a more modest rate with Age

Standardized Rate (ASR), which is more than 30 per 100 000 population, as compared to

Northern America, Western and Northern Europe, Australia and New Zealand, i.e. with

ASR more than 80 per 100 000 population. However, the Age Standardized Rate (ASR) is

lower (less than 30 per 100 000 population) in most of the south eastern and south central

Asia, and China (Parkin et al., 2005). On the contrary, the disease is still the most

common cancer in these geographical regions. The above difference is likely because of

the presence of the screening programs, which detect early invasive cancers, some of

which would have otherwise been diagnosed later or not at all (International Agency for

Research on Cancer- IARC, 2002).

In the data documented between 1993-1997, which compared the incidence rates in

the United States of America (89.5 women per 100 000 population with breast cancer) and

United Kingdom (74.4 women per 100 000 population with breast cancer), it could be said

that the incidence of breast cancer was lower in several countries in Asia, such as

Singapore (43.5 women per 100 000 population with breast cancer), China (36.2 women

per 100 000 population with breast cancer), India (28.9 women per 100 000 population

with breast cancer) and Japan (28.0 women per 100 000 population with breast cancer)

(Surveillance and Risk Assessment Division, CCDP, Health Canada).

In South East Asian countries such as Thailand and Indonesia, breast cancer was

observed as the second most frequent among the population (Trihartini, 2001; Deerasamee

et al., 2001). Meanwhile, Singapore indicated breast cancer as the number one cancer

which killed their women population (Chia et al., 2001). The latest available data in

Thailand showed that the Age Standardized Rate (ASR) was 16.3 per 100 000 population,

as observed in the 1993 census (Deerasamee et al., 2001). Nevertheless, further details and

15

latest documentation could not be reported due to the lack of registration for breast cancer

cases in most of the South East Asian regions.

As compared to the previous incidence of breast cancer, the rates are likely to

increase immensely in most countries (Parkin et al., 2000). In China, for instance, it has

recorded an increase in the incidence rate (i.e. about 3% to 4% annually), as compared to

the overall increase of about 0.5% annually worldwide. Based on the figure for China, the

increase is not much less elsewhere in Eastern Asia. Assuming a 3% growth in East Asia,

this would be about 1.5 million cases of breast cancer in total worldwide in 2010 (Parkin et

al., 2005).

Based on the data gathered by Lim and Halimah (2003), cancer of the breast ranks

as the number one cancer in Malaysia, followed by other types of cancer with age

standardized incidence rate (ASR) of 46.2 per 100, 000 population. It was estimated that

31.0% of 3738 female breast cancer cases were reported in 2003. Comparing the three

main races in Malaysia, in terms of the ASR per 100, 000 population, the rate is highest

among the Chinese population (59.7 per 100 000 population), as compared to Indian (55.8

per 100, 000 population) and Malay (33.9 per 100, 000 population). This illustrates that 1

in 16 Chinese women, 1 in 16 Indian women and 1 in 28 Malay women will develop breast

cancer at one stage in their lives (Lim and Halimah, 2003). In all these races, breast cancer

is the most common cancer in women among other cancers. This also means that the

incidence pattern is the same among these three races, where cancer of the breast is the

number one cancer assaulting females, followed by other cancers. Lim and Halimah

(2003), in their report in the National Cancer Registry Malaysia in 2003, stated that cancer

of the breast was the number one cancer attacking female aged above 15 years old, with

the most susceptible group 50-59 years old, and with the rates declining with age.

16

Based on the observation done between 1998 and 2001, among 774 cases of the

newly diagnosed breast cancer patients in the Kuala Lumpur General Hospital (KLGH),

Malaysia, the peak age group for the three major ethnics distribution in Malaysia (Malay,

Chinese and Indian) ranged from 40 to 49 years old, with the mean tumour size (at

presentation) of 5.4 cm in diameter (ranged from one to two centimetres). The advanced

stage and larger tumours were found to be highest in the Malay ethnic group (Hisham and

Yip, 2004). Malay women also exhibited poorer survival rate, with 45.9% five years

survival (in relation to the high percentage of Malay women who came consulting at later

stages as compared to other races), followed by Indians with 57.1% and Chinese 63.2%

(Yip et al., 2006). Another study, carried out at University of Malaya Medical Centre

(UMMC), Kuala Lumpur, Malaysia, indicated that out of 125 new cases of breast cancer

involved in the study, 85.6% was infiltrating ductal carcinoma, and 52.3% showed axillary

involvement, in which axillary dissection was performed (Yip and Looi, 1996).

Meanwhile, 166 patients (who were followed for a period of 18 and 34 months) revealed

the mortality rate of 20.7% and the recurrence rate of 10.3%, respectively (Yip and Looi,

1996).

1.3 Related Theories and Concepts Surrounding the Breast Cancer Studies Psychosocial aspects of breast cancer has also been widely studied by many

researchers (e.g. Ahn et al., 2007; Andritsch et al., 2007; Northouse et al., 2001), and its

detrimental effects on well-being can not be neglected (Bulatine et al., 2007; Engel et al.,

2003; Vacek et al., 2003; Yeo et al., 2004). Since many years ago until the present day,

the issues of quality of life, interpersonal relationship and coping behaviour in relation

17

breast cancer have always been essential, relevant and in need of greatest attention from

the researchers to scrutinize them.

Previous works have also demonstrated the importance of social support and

interpersonal relationships in adaptation to serious illness (Burman and Margolin, 1992;

Coyne and Bolger, 1990; Gove et al., 1983; Porter et al., 2005), and these may also play a

role in the survival of patients (e.g. Weihs et al., 2008). Based on the above facts and the

root idea from the earlier researches in counselling and therapeutic relationships (e.g.

Rogers, 1957), the present study continued to look at the processes in relationships, which

affect an individual’s well-being, within the context of breast cancer; more specifically

during the first phase of the treatment after surgery, i.e. chemotherapy. Thus, one of the

main focuses of the study was based on the previous works (Pistrang and Barker, 1995;

Pistrang and Barker, 1998; Pistrang et al., 1999), i.e. examining the aspect of interpersonal

relationships within the context of breast cancer. This research took on the same views of

the previous studies in terms of two aspects. Firstly, the relationship with a patient’s

partner may play an important role in illness adaptation. Secondly, the close relationship

can be beneficial as well as detrimental for the well-being of a patient. Nevertheless, this

study further took into account the marital relationship process, and its association to other

dimensions, such as quality of life and coping behaviour.

Indeed, issues in marriage, especially during cancer treatment, have not been

thoroughly explored by previous studies. Treatment episodes for cancer patients, such as

chemotherapy, can be a very terrible episode in their life. Chemotherapy involves the use

of drugs or chemicals to treat cancer, which is normally given in the form of liquid injected

into a patient’s vein in the arm, or in the form of oral tablets. Most of the patients given

chemotherapy drugs are treated as outpatients. This study examined those who were

having adjuvant chemotherapy; in specific, those who had the tumour removed during

18

surgery, but chemotherapy was added as an assurance policy to reduce the chance of it

returning in other parts of the body in the future. It has been stated that drugs used in

chemotherapy can produce several side-effects like hot flashes (Crandall et al., 2004; Stein

et al., 2000), hair loss (Genre et al., 1997), cognitive dysfunction (e.g. Jenkins et al., 2006),

and fatigue, etc. (Andrykowski et al., 2005). Apart from these side-effects, breast cancer

patients, who are treated with chemotherapy, also experience medical menopause (e.g.

McInnes and Knof, 2001) which leads to sexual health interruption.

Besides the insufficient exploration for the specific condition, i.e. chemotherapy,

several things remain questionable in relation to breast cancer issues, and these lead to

inconclusive findings. For instance, several studies on the quality of life among breast

cancer survivors did not include spouse or partner’s perspective (spouses’ or partners’

evaluation on the psychosocial impact of breast cancer towards their wives) intensively as

one variable which could affect the psychosocial aspect of the married subjects (e.g.

Pistrang and Barker, 1995; Wimberly et al., 2005). Consequently, it is important to

include men in the study of breast cancer, as “women’s perception of their husbands’

responses on the illness situation” alone is obviously not enough to tell the whole story of

breast cancer, particularly about the issues related to interpersonal relationships.

In addition, there is still a scarcity in the research which uses the European

Organization of Research and Treatment of Cancer Quality of Life Questionnaire (EORTC

QLQ-C30) and the Breast Module (QLQ-BR 23), a specific instrument used for measuring

the quality of life among breast cancer survivors; in a wider perspective, to deeply observe

the association with other dimensions, such as the interpersonal relationship process and

coping behaviour, mainly among the Asian population like Malaysia.

Focusing on the issues of quality of life, interpersonal relationships and coping

strategy, Hewitt et al. (2004) identified several phases of care related to the psychosocial

19

needs of women with breast cancer. These include diagnosis, treatment, post-treatment

and recurrence phase.

Diagnosis phase involves the determination of the level of cancer, and the

prognosis in which tumour is categorized in term of its size, histology, hormone receptor

status and nodal involvement. This phase also includes the issue of decision making

concerning the type of surgery which needs to be undertaken (mastectomy, mastectomy

with reconstruction or lumpectomy), and determining where to obtain the best treatment

from (which hospital and specialist to go to). Many women experienced the feeling of

acute fear and disbelief, in which they never thought that they would be at risk of having

breast cancer. Women are also found to be ignorant about breast cancer and its treatment.

For this, advice from others (e.g. family) can usually help them considerably (Clauson et

al., 2002, cited in Hewitt et al., 2004).

During the treatment phase, the issue of care or support from a patient’s family is

essential. After their surgery, women suffering from breast cancer are found to be in need

of assistance, particularly in dealing with household tasks and nursing care, such as the

management of surgical drains and dressings. In the treatment phase, women themselves

have to be prepared, for instance what to expect from the treatment, because this can help

in their mental health and assist them in the recovery process (Wickman, 1995, cited in

Hewitt et al., 2004). Moreover, breast cancer patients have to be accustomed to the

treatment to relieve the psychological disturbance. In this phase, Hewitt et al. (2004)

explain that these patients will have a “love and hate” feeling toward the treatment. On

one hand, they “love” the treatment because it helps them with the cancer, but they will

also “hate” it because of the side-effects.

20

After the treatment or post-treatment phase, most patients will feel a mixture of

elation, fear and uncertainty (Rowland and Massie, 1998, cited in Hewitt et al., 2004). At

this stage, patients are also found to be distant from the intensive health care system.

Thus, in the present study, three core concepts and theories related to breast cancer

were applied - the quality of life, interpersonal relationship and coping behaviour. These

are further explained as follows:

1.3.1 Quality of Life

The quality of life of an individual with cancer is a multidimensional concept

which is constructed and developed by at least four areas: psychological functioning,

physical functioning, social functioning, as well as symptoms and side effects (Figure 1.4.)

Meanwhile, World Health Organization (1993) defines the quality of life as “an

individual’s perception of their position in life in the context of the culture and value

systems, in which they live and in relation to their goals, expectations, standards and

concerns”. In the present study, the concept of quality of life (within the context of

married subjects) was captured using the specific quality of life instrument, namely the

European Organization of Research and Treatment of Cancer Quality of Life

Questionnaire (EORTC QLQ-C30). The evaluation of the breast cancer patients’ quality

of life, has actually been done previously (e.g. Arora et al., 2001; Lu et al., 2007; Schou et

al., 2005). Psychosocial distress, as an important component in the quality of life, is

suggested as a “reaction to the disease and consequence of the disease on employment,

health insurance and social functioning including family relationships” (Kornblith, 1998,

as quoted by Hewitt et al., 2004; McEvoy and McCorkle, 1990, as quoted by Hewitt et al.,

2004:37). The concept of psychosocial distress is also defined by the National

21

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22

Comprehensive Cancer Network (1999), as quoted by Hewit et al., (2004) as a “multi-

factorial unpleasant emotional experience of a psychological (cognitive, behavioural,

emotional), social, and/or spiritual nature that may interfere with the ability to cope

effectively with cancer, its physical symptoms, and its treatment. Distress extends along a

continuum, ranging from common normal feelings of vulnerability, sadness and fears to

problems that can become disabling, such as depressions, anxiety, panic, social isolation

and existential and spiritual crisis”.

Sexuality is another aspect which can not be neglected, in relation to the study on

the quality of life among married subjects with breast cancer. The World Health

Organization (1975) defines human sexuality as the “ integration of somatic, emotional,

intellectual and social aspects in ways that are positively enriching and that enhance

personality and love”. The sexuality aspect of the breast cancer subjects had also been

intensively studied in the past, but in a different condition and perspective (e.g. Abt et al.,

1978; Wiederman, 2000; Wimberly et al., 2005; Wolberg et al., 2000), which is not

comprehensive compared to this study.

Thus, all definitions of the quality of life (QOL) as described above were addressed

in this study to illuminate the various dimensions of the QOL among breast cancer patients

and their husbands.

1.3.2 Interpersonal Relationship

Interpersonal relationships play an important role in a victim’s adaptation to

chronic diseases. As stated in the Oxford dictionary, ‘interpersonal relationship’ is termed

as a relationship which is reciprocally shared by persons. In relation to interpersonal

relationship, the concept of ‘informal helping’, proposed by Barker and Lemle (1984), is

23

used to describe the relationship interaction that happens interpersonally. In specific,

Barker and Lemle (1984) describe this concept as an interaction in which one partner tries

to help the other with an external problem; whereas, internal problem is considered more

as a conflict. For this, Barker and Lemle (1984) also define external problems as “those in

which one individual’s problem originates outside the relationship”. For instance, one

partner feels that she is not assertive as she would like to be in working environment, or if

she faced with a stressful situation (such as the death of a family member). Meanwhile,

internal problems are related to the “concern for the other partner or the relationship as a

whole”. For example, when one partner feels that the other is too far-away. In addition,

Barker and Lemle (1984) suggested that the interactions, pertaining to internal problems,

are better considered as conflicts rather than helping. However, in this study, the term

‘interpersonal relationship’ included the two concepts, the external and internal problems.

These concepts were also brought forth by Pistrang and Barker (1995) to replace a more

precise but unwieldy term, ‘help-intended communication’ (Goodman and Dooley, 1976),

which refers to a dyadic communication where one party is experiencing emotional distress

and the other is attempting to alleviate that feeling of distress. This concept has been

intensively used in breast cancer studies and other diseases as well (Pistrang and Barker,

1995; Pistrang and Barker, 1998; Pistrang et al., 1999).

The concept of help-seeking is seen to have a relation with the concept of social

support (Pierce et al., 1997, cited in Penner et al., 2000; Pierce et al., 1996 cited in Penner

et al., 2000). According to Bretherton et al. (1996), as quoted by Penner et al., (2000),

social support is a mode of communication which occurs during ordinary and

extraordinary life events. Supportive relationships between intimates, acquaintances, work

associates, friends and relatives may affect physical and emotional well-being (Albrecht et

al., 1994, as quoted by Penner et al., 2000). An early definition of support, which was

24

based on the perception of acceptance and caring, was brought up by Cobb (1976), as

quoted by Penner et al., (2000), who suggested “an individual’s perception of being

esteemed and valued, of belonging to a network of communication and mutual obligation”.

On the other hand, Tolsdorf (1976), and Eyres and MacElveen-Hoehn (1983), as quoted by

Penner et al., (2000) viewed support as “an action or behaviour that facilitates coping,

mastery or control”. Later, the definition of ‘support’ was expanded to include the

processes of exchange between the people. Currently, researchers view social support as

“an interactional process of helping, comforting, caring for, aiding and responding to the

needs of others” (Albrecht and Adelman, 1987; Albrecht et al., 1992; Burleson et al., 1994;

Cutrona, 1996; Cutrona and Russell, 1990; Duck and Silver, 1990; Sarason et al., 1990, as

quoted by Penner et al., 2000:71). While it is structured as a communication process,

social support is interpreted as both verbal and non-verbal behaviour which influences

interaction and views on one’s self, situation, other individuals and relationship. In

addition, social support is viewed as a method to manage personal and situational

uncertainties, and it raises the perception of personal control (Albrecht and Adelman, 1987;

Ford et al., 1996, as quoted by Penner et al., 2000).

According to Nadler (1991), as quoted by Penner et al., (2000), the consideration

for seeking help is influenced by several factors. First is the personal characteristic, where

some individuals are interested in looking for help from others, while some are not

interested. Second is the need for specific help, in which an individual only needs help in

some aspects that he/she is comfortable with, while this individual is more interested in

doing something for himself/herself in the other aspects. Third is the relationship with the

potential helper. In the context of cancer or chronic diseases, a good interpersonal

relationship is usually rated by looking at the quality of care received by the patients.

Based on a related work by Williamson et al. (2000), several factors have been identified

25

to have influences on the quality of care received by individuals. These factors include the

pre-illness relationship quality, the amount of care provided and caregiver resentment.

The quality of the pre-illness relationship is the main and most important factor in

the issue of care quality. The decision to take on or continue care-giving responsibilities

may be influenced by the interpersonal relationship aspect between the caregiver and the

care recipient. Williamson et al. (2000) pointed out that caregivers (with a positive and

less stressful perception towards care giving duties) are those with high levels of affection

towards care recipients. In addition, stronger attachment and greater relationship closeness

is related to lower the caregiver’s burdens. Beside these, there is also evidence which

shows that the role of the caregiver is still assumed although he/she has a poor relationship

with the care recipient. This explains that duty, obligation and fear of the societal

sanctions stimulate care provisions. On top of these, the interaction between the caregiver

and care recipient can be dramatic. For example, if the caregiver is financially dependent

on the care recipient, this may result in negative interaction such as abusive behaviour.

This can lead to unresolved family conflicts and poor conflict resolution skills. Therefore,

studies have revealed that the history of troubled relationships has connections with

inadequate care. In line with this, Williamson et al. (2000) suggest that the individual

differences, between the caregivers and care recipients, are most probably contributed by

the aspect of interpersonal relationship and the interaction between both parties.

The second factor which influences the quality of care, received by the care

recipient, is the amount of care provided. In this aspect, caregiver distress has been

indicated to affect the amount of care given.

The third important factor, in relation to the quality of care, is the caregiver

resentment. Sometimes, providing care encourages anger, hostility and resentment. Based

on the work by Williamson et al. (2000), behavioural problems and violence toward some

26

care recipients has been noted. For instance, caregivers who have highly expressed

emotion (e.g. those in whom hostility and criticisms are frequently expressed) are found to

cause a high incidence of relapse in psychiatric patients. Moreover, it has also been found

that caregivers, who have the characteristics of being critical, angry and threatening in their

interaction with care recipients, are the people who are very frustrated and emotionally

upset; as characterized by the criticisms in their management (e.g. yelling, criticizing and

threatening). Furthermore, the ability of a caregiver in coping with stress can be

compromised by anger. This scenario reflects that anger, hostility and perhaps resentment

in caregivers affects their ability to cope with or manage difficult situations in care giving,

leading to a poor quality of care and maltreatment.

Nonetheless, in this study, the definition of interpersonal relationship is broadened

into the combination of relationship satisfaction, social support (with specific reference to

the husband’s support) and verbal or non-verbal communications (disclosure, empathy,

holding back, withdrawal and criticism).

1.3.3 Coping Strategy

Another important concept, related to breast cancer, is how survivors or victims

and their spouses or partners cope with the crisis of cancer. John and MacAuthur (1998)

view ‘coping’ as “the specific efforts, both behavioural and psychological that people

employ to master, tolerate, reduce or minimize the stressful events”. Meanwhile, Folkman

and Lazarus (1984) proposed two perspectives of coping, namely problem-focused

strategies and emotion-focused strategies. The emotion-focused form of coping is a

strategy which “consists of cognitive process directed at lessening emotional distress and

includes strategies such as avoidance, minimization, distancing, selective attention,

27

positive comparisons and wresting positive value from negative events”. On the contrary,

the problem-focused form of coping implies an objective and analytic process which

focuses primarily on the environment (characterized by the directed inward strategies), and

it is “often directed at defining the problem, generating alternative solutions, weighting the

alternatives in term of their costs and benefits, choosing among them and acting”. Within

this concept, specific types of coping observed can be beneficial or detrimental in adjusting

to illnesses (Ben-Zur et al., 2001).

Filipp (1999), as quoted by Ferring and Filipp, (2000) brought forth coping as “all

attempts to gradually transform an objective reality comprised of bad news (losses, threats

or trauma) into a subjective reality in which victims can continue to live in relative peace”.

On the other hand, Ferring and Filipp (2000), as quoted by Harvey and Miller, (2000)

proposed a heuristic model for the conceptualization of coping with loss and trauma. Their

model integrates three fundamental processes as a core of the model: attentive processes,

comparative processes and interpretive processes. Attentive process is described as a

factor “that contributes to the construction of an individual’s perspective reality, in term of

selectively attending to bad news and, thus, defending positive illusions”, whereas

comparative process is described as a factor “that helps to shape perspective reality

towards a reality that victims of life crisis gradually tolerate and accept”. The third core,

i.e., the interpretive process is a factor “that helps to construe an interpretative reality

mainly through attempts to ascribe subjective meaning to what currently makes up one’s

perspective reality”. An individual’s internal model of the self, internal model of the

world and his or her individual motivational system influences these attentive, comparative

and interpretative processes. In other words, one’s perception and actions are guided by

the internal models of the self and the world. This conceptualization of coping is

illustrated in Figure 1.5 below.

28

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29

The quality of life of patients with breast cancer is a multidimensional concept

which has at least four items: psychological functioning, physical functioning, social

functioning, and symptoms and side-effects. Meanwhile, the quality of their interpersonal

relationship is mainly determined by the concept of ‘help seeking’ which is contributed by

both internal and external factors. In relation to the above, coping behaviour is proposed to

be constructed by three fundamental processes: attentive processes, comparative processes

and interpretive processes.

Based on the above discussions, the introduction of the study was given to serve as

the background of this research. In the subsequent chapters, several related literature

reviews encompassing breast cancer studies will be provided to support the hypotheses

postulated (presented in Chapter Four).

30

CHAPTER TWO

LITERATURE REVIEW: PART ONE

QUALITY OF LIFE, INTERPERSONAL RELATIONSHIP AND COP ING

STRATEGIES IN BREAST CANCER: FROM THE PERSPECTIVES OF WOMEN

AND THEIR SPOUSES

In this study, previous studies related to the issues of quality of life, interpersonal

relationship and coping strategies among women with breast cancer and their spouses, are

reviewed. These studies are highlighted (in two separate sections) to illustrate the

significant issues pertaining to breast cancer in women and their spouses. These sections

are: 1. Quality of Life, Interpersonal Relationship and Coping Strategies in Breast Cancer:

From the Perspective of Women with Breast Cancer; 2. Quality of Life, Interpersonal

Relationship and Coping Strategies in Breast Cancer: Spouse or partner-related

Perspective. Before the two central sections are presented, the reviews on the socio-

demographic and medical aspects surrounding breast cancer studies are explicated.

2.0 The Importance of Socio-demographic and Medical Aspects Surrounding

Breast Cancer Studies

Socio-demographic variables (e.g. age) and medical aspect (e.g. type of surgery)

have both direct and indirect associations with psychosocial adjustment in breast cancer

patients (Vos et al., 2004). However, some researchers do not see the importance of socio-

demographic (Northouse and Swain, 1987) and medical aspect (e.g. Andritsch et al., 2007;

Bloom et al., 1998; Northouse and Swain, 1987) in cancer issues.

31

The importance of the types of surgery in affecting patients’ quality of life has been

documented. Cohen et al. (2000) reported that women who had undergone breast

conservation surgery exhibited significantly greater levels of psychological distress and

marginally worse quality of life than women who had undergone mastectomy. In addition,

Cohen et al. (2000) also suggested that the effects of different surgical treatments for

breast cancer on the quality of life became evident only after a period of several years.

This is parallel to the findings by Monteiro-Grillo et al. (2005) who discovered that the

quality of life was negatively affected by mastectomy. This result is almost similar to one

by Rabin et al. (2008) who pointed out that physical and psychological well-being could be

affected by the surgical treatment such as mastectomy. In addition, the change in the

social behaviour pattern such as avoiding going to the beach and using low-cut cloths, etc.,

is also caused by mastectomy (Monteiro-Grillo et al., 2005). However, there are studies

which did not find the association between the types of breast cancer surgery and the

patients’ quality of life. For example, Bleiker et al. (2000) did not find the influence of the

types of surgery on distress. Similarly, the type of breast cancer surgery was also not

associated with the fear of cancer recurrences (deHaes et al., 1986). This is also in lieu to

the findings by Ganz et al. (1992b) and Chang et al. (2007a), who revealed that patients

who had undergone mastectomy and breast conserving surgery experienced a similar level

of quality in life.

The types of breast cancer surgery can also influence an individual’s coping and

adjustment to chronic diseases. For instance, Omne-Ponten et al. (1992) indicated that

lumpectomy group had a better social adjustment than mastectomy women. As explicated

by Gottschalk and Hoigaard-Martin (1986), women who had undergone mastectomy

scored higher in denial strategy. However, many researchers tend to conclude that the

types of breast cancer surgery are not important in patient’s coping and adjustment. This is

32

proved by Buddeberg et al. (1990) who concluded that the process of coping, at six months

after a primary treatment, was not influenced by the type of surgery. The similarity in the

coping strategy was also observed between women with mastectomy and breast conserving

surgery (Jackish et al., 1997). This is emphasized by Omne-Ponten et al. (1994) who

indicated that psychosocial adjustment did not differ between women who had mastectomy

and those who had breast conserving surgery. In addition to these, marital adjustment was

also found to be unaffected by the types of surgery (Onen-Sertoz et al., 2004).

Nevertheless, the types of breast cancer surgery can cause a significant effect to the

sexual life of breast cancer patients. Bukovic et al. (2005), for instance, demonstrated that

the patients’ sexual life was grossly reduced after the treatment of breast cancer for

mastectomy and lumpectomy women. However, according to Engel et al. (2004), women

with breast conserving treatment had a better sexual functioning than those with

mastectomy. This finding is similar to the ones yielded by Margolis et al. (1990) who

found that the mastectomy group reported to be less sexually desirable and less attractive

than those in the breast conserving treatment group. In the same study, those in the

mastectomy group also scored lower for the quality of sex life as compared to the

lumpectomy group, as evaluated at six and 12 months following the surgery (Pozo et al.,

1992). This is supported by Beckjord and Campas (2007) who stated that the treatment of

mastectomy was associated with sexual disruption. Parallel to Steinberg et al. (1985),

women with mastectomy expressed less openly their sexual feelings after breast cancer

surgery than those who had undergone lumpectomy. Meanwhile, among women who had

undergone lumpectomy, they were observed to have more positive sexual drive (Wapnir et

al., 1999). In addition to this observation, the lumpectomy group also exhibited a greater

sense of sexual desirability than others, as evaluated at 21 months after their treatment

(Wellisch et al., 1989). According to Schou et al. (2005), breast conserving surgery is a

33

predictive method for better physical functioning. Nevertheless, there are several studies

which yielded contradictory results. Among others, Monteiro-Grillo et al. (2005) revealed

that sexuality was not affected by both procedures, neither mastectomy nor breast

conserving surgery. Non-difference in terms of sexual disturbances was also observed

between the mastectomy group and lumpectomy group at 13 months after surgery (Omne-

Ponten et al., 1992). In another study, sex satisfaction was another area which was found

to be unaffected by the types of surgery (Onen-Sertoz et al., 2004).

The types of breast cancer surgery can have a drastic effect to the women’s

perception on their body image. Bukovic et al. (2005) discovered that women who had

undergone mastectomy usually had a feeling of body image change, as opposed to the

lumpectomy group. In lieu to deHaes et al. (1986), women with mastectomy perceived

themselves as having severely impaired body image, in contrast with women with breast

conserving treatment. In addition, women with mastectomy were observed to have more

problems with clothing and body image as compared to the group of breast conserving

surgery (Ganz et al., 1992). This is in line with the finding by Hartl et al. (2003) who

stated that breast cancer patients who were treated with mastectomy reported less

favourable body image than the breast conserving treatment group. In another study,

women from mastectomy group were also reported to be more ashamed with their body

image than those with breast conserving cancer treatment (Margolis et al., 1990). Schou et

al. (2005) suggested that the treatment of breast conserving surgery is a predictive for

better body image. Yeo et al. (2004) added that women with breast conservative surgery

exhibited better responses to their sexual image than those who had mastectomy operation.

Stages of breast cancer can be an important determinant for breast cancer patients’

quality of life. This was what Lu et al. (2007) intended to prove. Much earlier than that,

breast cancer stage had been suggested as an indicative of patients’ quality of life (Pandey

34

et al., 2005; Weitzner et al., 1997). In addition, nodal status was also proposed as an

indicative of patients’ quality of life (Pandey et al., 2005). According to Gotay (1984),

information seeking was common among the early stage group. Nevertheless, many

researchers tend to conclude that breast cancer stages are not critical in psychosocial aspect

of breast cancer. This was proven by Buddeberg et al. (1990) who stated that the process

of coping, at six months after primary treatment, was not influenced by the stage of lymph-

nodes. Similarly, Bleiker et al. (2000) claimed that breast cancer stages do not influence

the level of distress. In another study, it was also observed that the stages of disease were

not predictive of patients’ overall quality of life (Greimel et al., 2002).

Meanwhile, in the aspect of religion, Andrykowski et al. (1996) observed that

breast cancer patients had deeper religious satisfaction. Related findings in breast cancer

reported that when compared to white women, black women were found to rely on their

religion as a coping mechanism (Bourjolly, 1998). Nevertheless, non-Hispanic white

women had less “religious” elements in their coping strategy than the African-American

and Hispanic women (Culver et al., 2002). For elderly women, who were newly

diagnosed with breast cancer, religious and spiritual faith provides them with an important

tool to address their illness (Feher and Maly, 1999). Gotay (1984) revealed that religious

faith had always been cited by the advanced stage cancer patients as their pillar of strength.

In lieu to Northouse (1989), focusing on religion was observed as one of the factors which

contributed to patients’ coping with breast cancer. Therefore, religion has also been seen

as an indicative of patients’ quality of life (Pandey et al., 2005). This is in agreement with

the statement by Stanton et al. (2002) who believed that coping through the element of

“religion” would be effective for hopeful women with breast cancer.

There have been numerous reports on age and its association to psychosocial aspect

due to breast cancer. For example, Cimprich et al. (2002) reported that there is a link

35

between the years of survival and the patients’ age when breast cancer is diagnosed. In

their study, younger women were found to usually exhibit less social functioning as

compared to older women who usually demonstrated worse physical functioning from

breast cancer (Cimprich et al., 2002). Adding to this finding, Compas et al. (1999) found

that younger women also tended to engage in less adaptive ways of coping (1999). In the

same vein, the symptoms of anxiety and depression were related to women’s age when

mediated by the emotional ventilation of coping (Compas et al., 1999). On the contrary, a

positive relationship between age and quality of life was observed among married women

who received segmental mastectomy (Ganz et al., 1992a). According to Ahn et al. (2007)

and Awadalla et al. (2007), age is an important element in predicting the quality of life of

cancer patients. Coping style was observed to be different between the elderly and middle

age survivors (Halstead and Fernsler, 1994). Other researchers suggested that older

survivors had a better adaptation (Kornblith et al., 2007) and might have a better physical

and psychosocial dimension, following breast cancer diagnosis as compared to younger

women (Kroenke et al., 2004). Kurtz et al. (1993) also suggested that physical functioning

was associated with age. In lieu to Vacek et al. (2003), the decline in the quality of well-

being was related to the increase in age. However, it was reported that women aged less

than 50 years had been observed to suffer more anxiety (Hopwood et al., 2007). Being

younger was also associated with more disruptions in quality of life (Hopwood et al.,

2007; Janz et al., 2007) and greater distress (Costanzo et al., 2007; Kenefick, 2006). In

relation to this, Northouse (1994) stated that older women experienced less distress as

compared to younger ones. Being older might also be associated with less cancer-related

fatigue (Pater et al., 1997). In line with the earlier statement, Okano et al. (2001)

suggested that the age of the breast cancer patients significantly correlated with the

element of hopelessness/ helplessness in their coping strategy. Adding to the age-related

36

factor, it was observed that concern about their family was more likely to be reported by

younger women (below 50 years old) (Wang et al., 1999). Furthermore, younger women

were also found to indicate more concerns over finances and work than older women

(Wang et al., 1999). According to Walker (1997), younger patients expressed greater fear

about cancer recurrence. Besides the significant effect of age on the psychosocial aspect in

breast cancer, some other studies did not observe it. For example, there are studies which

reported that age did not influence the quality of life (Greimel et al., 2002; Weitzner et al.,

1997). This is parallel to Compas et al. (1999) who observed that younger women and

older women did not differ in their adjustment over the subsequent course of their

treatment and initial recovery.

In relation to sexuality issue and aging in breast cancer, Hopwood et al. (2007)

revealed that women below 50 years old had more problem with their body image after

breast cancer surgery; whereas, older women were less concerned about their self-esteem

than younger women (Wang et al., 1999). Avis et al. (2005) reported that hot flushes,

difficulty with bladder control and pain with sexual intercourse experienced by breast

cancer patients were observed to increase with age. Ganz (1995) also suggested that the

decline in sexual activity was related to age. Adding to this, Ganz et al. (1995) pointed out

that older women reported more sexual problems than younger women. According to

Speer (2005), age was found to be a contributing factor in the development of sexual

dysfunction. Thus, older women were observed to have more concerns about vaginal

lubrication and pain. On the other hand, Beckjord and Campas (2007) suggested that

being younger was associated with more disruptions in sexual health. This is supported by

another study which yielded that sexual- and partner-related concerns were stronger among

younger women than older ones (Spencer et al., 1999).

37

Occupational status and its relation to psychosocial aspect in breast cancer have

also emerged in literature. According to Fasching et al. (2007), 12 % of women suffering

from gynaecological and breast malignancies reported that they were less satisfied with

their occupation. Bloom (1982) suggested that being employed had a significant influence

on adjustment to cancer. In line with this finding, employment status was also associated

with the quality of life of the women with breast cancer (Uzun et al., 2004). This is

supported by another finding which indicates that better employment is associated with

higher quality of life (Awadalla et al., 2007). Related to this fact, the Regional Survey

Report (2005) revealed that the impact of better employment (i.e. relationship at the work

place, rate of pay, balance between work and life, as well as the interest and enjoyment in

the job) was shown to have a significant contribution to one’s quality of life.

Ethnicity may also have a significant effect on breast cancer patients. In a related

study, it was reported that black women relied highly on religion as a coping mechanism

than white women (Bourjolly, 1998). Ethnic differences are also another significant

predictor for the quality of life; for this, Ashing-Giwa et al. (2007) reported that Latinas

were found to have the lowest quality of life score as compared to other races (African,

Asian and European-Americans). Another study on breast cancer patients showed that

white women had less difficulty in social functioning as compared to black women

(Bourjolly et al., 1999). In a similar study, Culver et al. (2002) discovered that African-

American women had lower venting strategy than Hispanic women. Culver et al. (2002)

also demonstrated that non-Hispanic white women used more humour strategy as

compared to Hispanic women who used more of self-distraction in their coping towards

breast cancer. Another significant example was pointed out by Gopal et al. (2005) who

stated that Malaysian women ranked sexual attractiveness as one of the most important

38

information needed, following the diagnosis of breast cancer, as compared to the women in

United Kingdom.

Im et al. (2002) suggested that culture is an important milieu which influences an

individual’s health or illness experience. The differences between ethnic groups could also

be observed in another study which reported that Hispanic women had stronger concerns

and more life disruption associated with breast cancer than other races (Spencer et al.,

1999). Being concerned over finance and work was also more likely to be reported by

non-white rather than white women (Wang et al., 1999). They further reported that more

white than non-white patients expressed concerns about the future life, following the

diagnosis of breast cancer (Wang et al., 1999). White women were also more likely to

complain about the negative effects of breast cancer on their sex lives than other races

(Wyatt et al., 1998). This is similar to Gotay et al. (2002) who observed differences in

several areas of the patients’ quality of life across the different ethnic groups.

Educational status is also important (e.g. Lu et al., 2007). For instance, Uzun et al.

(2004) stated that the educational status of women with breast cancer was associated with

their quality of life. This is parallel to the finding by Drageset and Lindstrom (2005) who

pointed out that instrumental-oriented coping strategy was associated with the educational

level of the women with breast cancer. Inoue et al. (2003) reported that breast cancer

patients who had high educational level exhibited the adjustment which was characterized

by low fighting spirit. Meanwhile, Kenefick (2006) found that the higher one’s education,

the higher distress experienced by that particular individual. This finding, nevertheless,

contradicts with the result gathered by Awadalla et al. (2007) which revealed that the

higher one’s education, the higher her quality of life will be. Nonetheless, some

researchers concluded that patients’ educational level was not crucial in affecting their

quality of life, as had been suggested that it was more influenced by the comorbidity

39

(Vacek et al., 2003), cancer stages and the life experience with cancer (Weitzner et al.,

1997).

There are several important aspects in socio-demographic and medical issues that

arise in cancer studies. Among others, Baider and Kaplan De-Nour (1988) suggested that

gender could influence the adjustment to chronic disease. Financial difficulty was also

brought forth (Ahn et al., 2007; Kadmon et al., 2008), and was associated to patients’

overall quality of life (Andritsch et al., 2007, Baider et al., 2003). According to Bloom

(1982), higher social status also had a significant influence on adjustment. In lieu to Butler

et al. (2006), cancer patients with good adjustment had statistically lower annual healthcare

expenditure as compared to those patients who had poor to fair adjustment. The travelling

distance to reach the treatment was also suggested as an indicative of patients’ quality of

life (Pandey et al., 2005). In the medical aspect, the severity of surgery was observed to

predict patients’ overall quality of life (Greimel et al., 2002). Interestingly, Awadalla et al.

(2007) indicated that the longer the duration of cancer, the better one’s quality of life. Ahn

et al. (2007) pointed out that recuperation time since surgery was also important in

predicting patients’ quality of life.

Meanwhile, the socio-demographic and medical aspects of the husbands, whose

wives have breast cancer, are equally important. Looking at the effect(s) imposed by the

types of surgery on breast cancer mainly on marital and sexuality issues, it was observed

that husbands of the breast cancer patients who had undergone mastectomy exhibited

greater changes in the perception of their wives’ body and sexual images as compared to

lumpectomy group (Yeo et al., 2004). However, women with lumpectomy reported that

their husbands’ interest in sexuality increased as evaluated at 14 months after breast cancer

surgery (Steiberg et al., 1985); this suggested that husbands’ desires for sexual intimacy

increased once their wives had recovered from the breast cancer surgery. According to

40

Omne-Ponten et al. (1993), husbands from the mastectomy group reported more positive

in marital relation, whereas husbands from breast conservative surgery group reported

marginally better in psychosocial adjustment. In terms of their adjustment to breast cancer,

husbands from breast conservative surgery group were reported marginally better in

psychosocial adjustment (Omne-Ponten et al., 1993). Baider and Kaplan De-Nour (1988),

in their study among various types of cancer patients (i.e. cancer of the breast, colon and

testicular), suggested that gender of the spouses (male or female) played an important role

in adjustment. However, some studies do not observe any differences on any of the

adjustment of the patients’ husbands, either from the mastectomy or lumpectomy groups.

Yeo et al. (2004) stated that husbands, whose wives had mastectomy, experienced more

emotional and symptomatic distress. In addition, husbands of the patients with

mastectomy also reported to be more depressed at four month following the surgery

(Omne-Ponten et al., 1993).

Age and culture of the spouse or partner of the women with breast cancer also

emerged as an important issue in breast cancer. In terms of age, younger husbands of the

breast cancer patients were found to exhibit the greatest number of life stresses and more

problems with domestic roles, as compared to those who were older (Northouse, 1994). In

explaining this finding, Smith et al. (2000) pointed out that the varying social support and

personal control between the older and younger husbands might have possibly contributed

to their wives’ health status. Similarly, older age was also related to greater adjustment

among husbands of the women with breast cancer (Bernard and Guarnaccia, 2003).

According to Kadmon et al. (2004), spousal responses to their wives’ illness can be

influenced by culture. Qualitative observation, conducted among the ethnic groups of

Asian-American and European–American, indicated that interpersonal relationship with

husbands was demanded differently from the different ethnic groups, whereby European

41

women were found to be capable of being dependent to their husband and family, as

compared to the Asian-American women who were expected to be self-sacrificing and

nurturing (Kagawa-Singer and Wellisch, 2003). In the same study, Kagawa-Singer and

Wellisch (2003) also found that European-American women had a goal of intimacy over

harmony, and they valued verbal communication rather than non-verbal communication as

compared to Asian-American women.

As for the educational level of the patients’ spouses, the study by Pandey et al.

(2005) indicated that it could be an important predictor to the quality of their wives’ life

with breast cancer. This supports the fact that spouse’s educational level may help them to

understand and cope with the illness in a much better way, and thus leads to a higher

quality of life, not only for themselves but also for their wives. Meanwhile, religion is

important for husbands in coping with their wives’ breast cancer (Northouse, 1989a).

Socio-demographic aspects such as being younger, ethnicity, lower educational

level, religion, financial difficulty, etc. seem to be crucial factors which predispose the

individuals with cancer in the risk of psychosocial morbidity. Similarly, several medical

factors, such as having mastectomy procedure and critical cancer stage, also seem to be

important predictors to the patient’s psychosocial being, following breast cancer diagnosis.

On the other hand, the contradictory results surrounding this issue could not simply be

neglected.

In the next section, the central review of the chapter, further discussion on the

issues of quality of life, interpersonal relationship and coping strategies surrounding breast

cancer, from the perspectives of women with breast cancer and their spouses, will be

presented.

42

2.1 Quality of Life, Interpersonal Relationship and Coping Strategies in Breast

Cancer: From the Perspectives of Women with Breast Cancer

The issues of quality of life, interpersonal relationship and coping strategies are

focused in this section. Besides reviewing each issue independently, the association

between these issues, i.e. women’s quality of life and its association with their coping

strategies, is also explicated in a separate section.

2.1.1 Quality of Life of the Women with Breast Cancer Female diseases (e.g. breast cancer and endometriosis) always place women in high

risk of life’s quality impairment (e.g. Aranda et al., 2005; Hartl et al., 2003; Low et al.,

1993a, Low et al., 1993b). In breast cancer studies, numerous results have proven that this

disease significantly affects women’s quality of life (e.g. Ahn et al., 2007; Amir and

Ramati, 2002; Aranda et al., 2005; Avis et al., 2005; Cappiello et al., 2007). In

comparison to other types of cancer such as rectal cancer, breast cancer has been found to

be affecting one’s well-being the most (Engel et al., 2003). A long-term study among

survivors who had completed treatment for breast cancer indicated that there was a decline

in the global quality of life (Ganz et al., 1996), as well as poorer physical health and

functioning (Andrykowski et al., 1996). The patients’ overall quality of life was found to

be worse when evaluated at nine months, following the breast cancer surgery (Bulotiene et

al., 2007). Several other long-term studies observed that minor impairment of the life’s

quality occurred at four years after diagnosis of breast cancer (e.g. Hartl et al., 2003).

Evaluation at four to 42 months post-diagnosis indicated that the global quality of life of

the women with breast cancer was significantly lower than the non-patient sample (Avis et

43

al., 2005). Nevertheless, Bardwell et al. (2004) found that the health-related quality of life

of the women, who were previously treated for an early stage of breast cancer, was

comparable to the norm of women in the general population and the norm of women with

breast cancer. In a prospective study of breast cancer, Vacek et al. (2003) discovered that

breast cancer survivors, who had completed treatment, reported a decline in their quality of

life over time. This situation was also observed in other studies focussing on other types of

cancer (Griemel et al., 2002; Stommel et al., 2004). On the contrary, breast cancer patients

exhibited an increase in the perceived health status, from one week to a year post-surgery

(Hoskins, 1997), and an improvement in their overall quality of life (de Haes et al., 1986;

Shimozuma et al., 1999). According to Metcalfe et al. (2005), the quality of life of the

women, who had previously undergone a bilateral prophylactic mastectomy, could be

predicted by psychological distress and vulnerability. The variance of breast cancer

patients’ functional well-being was counted as much as 46% from their social and spiritual

well-being (Levine and Targ, 2002). A qualitative finding on breast cancer has supported

the other researchers’ findings by emerging the issues, such as concerns over the overall

health and physical well-being (Ashing-Giwa et al., 2004).

In relation to the issue of quality of life among breast cancer patients, psychological

disruption has often been reported (e.g. Ashing-Giwa et al., 2007; Bower, 2008; Benedict

et al., 1994; Cappiello et al., 2007; Chantler et al., 2005; Kissane et al., 1998).

Meanwhile, the symptom of worrying was the most severe one reported (Kenne-

Sarenmalm et al., 2007). Chantler et al. (2005) stated that the fear of recurrence of

disease, and death was common among breast cancer patients, at six and eight months

following diagnosis. This psychological disturbance in breast cancer patients’ quality of

life has been noted to worsen as compared to other types of cancer patients such as rectal

cancer (Engel et al., 2003). In the same vein, psychological disturbance is another problem

44

among long-term breast cancer survivors (e.g. Hartl et al., 2003; Weitzner et al., 1997).

As indicated by Andritsch (2007), depression explained 25% of the variance of the global

quality of life of the breast cancer patients. According to Ganz et al. (1996), breast cancer

survivors appeared to attain the maximum recovery from their psychological trauma of

cancer treatment by one year following surgery. Breast cancer survivors also had the

element of “deeper spirituality” at two years after completing a primary treatment

(Andrykowski et al., 1996). In line with the earlier finding, a prospective study in breast

cancer showed that negative feelings, such as the burden of depression and anxiety

persisted over time (Longman et al., 1999). For this, emotional functioning was

specifically indicated as the most affected, during and after a cancer treatment (Greimel et

al., 2002). At the time of breast cancer diagnosis, women’s emotional functioning was

found to be lower as compared to healthy women, but it seemed to improve over time

(Schou et al., 2005). According to Andritsch et al. (2007) and Baider et al. (2003),

psychological distress among the breast cancer patients could be caused by the number of

stressful life events in the previous years, financial problems and feeling uncomfortable

with the body. Bleiker et al. (2000) stressed that the best predictive of high-level distress,

at two years after diagnosis of breast cancer, includes intrusive thoughts about the disease,

trait-anxiety, health complaints and problems with sleeping. The spirituality element was

observed as an important predictor for lower mood disturbance among women who had

been treated with breast cancer (Romero et al., 2006). Furthermore, psychological

disruption was also reported to have a link with the level of catastrophizing (Bishop and

Warr, 2003), cancer-related concerns and fear of recurrence (Costanzo et al., 2007).

In the issue of quality of life in breast cancer, fatigue was observed as a common

problem among women with breast cancer (e.g. Ahn et al., 2007; Aranda et al., 2005;

Bower, 2008; Kenefick, 2006). Several long-term studies in breast cancer suggested that

45

fatigue could even persist even after a treatment was ended (Dow et al., 1996; Servaes et

al., 2002). Breast cancer patients also suffered more serious fatigue as compared to other

patients with rectal cancer (Engel et al., 2003). At four to 42 months after diagnosis,

women with breast cancer reported having acne and pain (Avis et al., 2005). Acne and

pain were also reported by the long-term survivors of breast cancer (Dow et al., 1996).

Hot flashes and arthralgia (arthralgia literally means joint pain; the term "arthralgia" is

usually used when the condition is non-inflammatory, while the term "arthritis" is usually

employed when the condition is inflammatory) were reported by Harbeck and Haidinger

(2007). A four-year’s prospective study observed the symptom of sleeplessness among the

survivors (Engel et al., 2003). In this study, cancer patient complained of having insomnia

(insomnia is a sleeping disorder, characterized by a persistent difficulty of falling asleep or

staying asleep despite the opportunity) and nausea (Ahn et al., 2007; Kurtz et al., 1993).

Lower cognitive functioning is another possible effect from breast cancer (Ahn et al.,

2007; Bower, 2008; Schou et al., 2005). According to Kenne-Sarenmalm et al. (2007),

breast cancer patients who experienced multiple symptoms reported higher level of

distress.

Other important aspects, in relation to the issues of life quality among women with

breast cancer, are the impairment of roles and social functioning (e.g. Ahn et al., 2007;

Aranda et al., 2005; Ashing-Giwa et al., 2007; Chwalczyrska et al., 2004; Ferrel et al.,

1997). A prospective observation in breast cancer showed that women’s role performance

(such as vocational and domestic) could improve over the time (Hoskins, 1995b).

Meanwhile, another prospective study in breast cancer reported that the social functioning

problem could persist up to a year (Schou et al., 2005). Similarly, Northouse et al. (1998)

indicated that the role problem at diagnosis were likely to remain highly distressed at 60

46

days and a year follow-up. In addition, patients’ role functioning could be used to predict

emotional adjustment (Hoskins, 1995a).

Other studies have uncovered yet another important aspect which significantly

contributes to the breast cancer patients’ quality of life, i.e. body image (e.g. Ashing-Giwa

et al., 2004; Shimmozuma et al., 1999). However, body image could also be a minor issue

when evaluated at more than four years after diagnosis (Hartl et al., 2003). In specific, it

was stated that women, who had poorer body image at one month after breast cancer

surgery, indicated a lower level in terms of their quality of life at one year post-diagnosis

(Shimozuma et al., 1999). Other qualitative studies also revealed the issue pertaining to

body image as one of the important concerns in breast cancer (Ashing-Giwa et al., 2004).

Sexual health is another important concern that cannot be neglected in discussing

life quality of women with breast cancer. Many findings have reported deterioration in

sexual well-being among breast cancer survivors (e.g. Avis et al., 2004; Beckjord and

Campas, 2007; Bukovic et al., 2004; Conde et al., 2005). The emergence of the issue

related to sexual health deterioration was also reported by patients with gynaecological and

breast malignancies (Fasching et al., 2007). Changes in sexual behaviours and level of

sexual arousal were also reported by women with breast cancer and gynaecologic cancer

(Anderson and Jochimsen, 1985). Women with female cancer (i.e. gynaecological and

breast cancer) also reported feeling of less sexual attractiveness (Karesen and Langmark,

2000). Several researchers, on the contrary, had toned down this issue (e.g. Ganz et al.,

1995; Mannor and Zohar, 2006). Sexual problems also arose as the greatest social concern

among long-term breast cancer survivors (Broeckel et al., 2002; Dow et al., 1996). In the

meantime, other prospective studies on breast cancer indicated that sexual health problems

(such as sexual discomfort, feeling unattractive and self-confidence in relation to sexuality)

have not improved over time (Engel et al., 2004; Hatcher et al., 2001; Hawighorst-

47

Knapstein et al., 2004). Moreover, qualitative findings revealed several other sexual

issues, such as the loss of sexual sensations, altered sexual self and loss of womanhood

(Wilmoth, 2001). There are in lieu with Kenne-Sarenmalm et al. (2007) who suggested

that the problem related to sexual interest had been indicated as the most frequent

symptom. Several findings have also suggested the association between sexual problem

and psychological aspect (e.g. Fobair et al., 2006; Wimberly et al., 2005). In the same

vein, Speer et al. (2005) observed the link between lower sexual desire and depression.

Meanwhile, Fobair et al. (2006) suggested that greater sexual problems were associated

with vaginal dryness and poorer mental health. This result is parallel to the finding by

Harbeck and Haidinger (2007) who pointed out that one of the most significant sexual

problems which occurred due to breast cancer was vaginal dryness. This contradicts with

the result of a study by Wimberly et al. (2005) who discovered that emotional distress was

relevant to the frequency of sex and positive sexual experience after the treatment.

Women’s self-esteem, following breast cancer surgery, is significantly accounted for by

sexuality factor (Feather and Wainstock, 1989), and can generate higher level of mood

disorders (Reich et al., 2007).

Menopausal issue, in breast cancer, has also been explored previously by many

researchers (e.g. Crandall et al., 2004; Schultz et al., 2005). Menopausal symptoms such

as hot flashes and sweats were observed to have significant impacts on the overall quality

of life among women who received the treatment for breast cancer (e.g. Gupta et al.,

2006). Crandall et al. (2004) observed that during breast cancer treatment, pre-menopausal

women had more menopausal symptoms as compared to those who were not in the

therapy. Other important results yielded in the same study revealed that the post-

menopausal women (with or without therapy) experienced more menopausal symptoms as

compared to the pre-menopausal group (Crandall et al., 2004).

48

Generally, most findings indicated that the impairment on the overall quality of life

among women with breast cancer (at varying degree) might improve over time. Thus, it

could be stated that the quality of life, in relation to the psychological aspect, functional

status, cancer symptomatology and sexuality, were important predictors of women’s well-

being.

2.1.2 Coping and Adjustment of the Women with Breast Cancer

As stated in the earlier section, breast cancer has a significant psychosocial impact

on women, specifically in relation to their coping and adjustment towards cancer. Women

usually go through several processes in coping and adjusting toward cancer. Among

others, Lewis and Deal (1995) observed that women’s lives revolved around four major

actions in coping with breast cancer. In more details, these women were found to manage

everyday illness, surviving, healing and preparing for death (Lewis and Deal, 1995). In the

mean time, Link et al. (2005) proposed that cancer patients went through several stages of

coping processes. They reacted to the cancer diagnosis, followed by identification and

evaluation of potential strategies. Then, patients chose their strategies, based on the

influence of others and their own goals before deciding on the coping strategy, which were

contributed by both internal and external factors.

Women who experience breast cancer engage with various styles in their coping

and adjustment. It is reported that avoidance behaviour and active style are among the

most frequent strategies used by women with breast cancer (Hosaka et al., 1995), whereas

other researchers have noted the element of “minimization” (Orr and Meyer, 1990),

repressive style (Watson et al., 1984) and humour (Johnson, 2002), as other useful

strategies. Li and Lambert (2007) indicated planning, positive reframing and self-

49

distraction to be the most commonly used coping strategies among women with breast

cancer. Women with breast cancer also exhibited the component of helplessness in their

mental adjustment toward the disease, within six months after completing medical

treatment (Koopman et al., 2001). In dealing with pain, Gaston-Johansson et al. (1999)

indicated that women with breast cancer employed various strategies like positive coping

statements, diverting attention, praying and hoping, as well as increasing activity level, in

controlling pain. Some women with breast cancer were also observed to cope with the

pain by self-isolation, passive acceptance, seeking social support, positive reappraisal,

distancing and wishful thinking, which were rather similar to the strategies employed by

healthy women and women with benign in the breast (Anagnostopoulus et al., 2004). The

element of self-blame was associated with poorer scores on adjustment scale (Houldin et

al., 1996). A study on female cancer (cervical, breast, gynaecologic cancers) demonstrated

the component of firm action, information seeking and religious faith in their coping

strategies (Gotay, 1984).

Nevertheless, there is also a positive view, in relation to women’s coping and

adjustment in breast cancer. Many researchers concluded that breast cancer patients (as

well as other cancer patients) were well adjustment (e.g. Andrykowski et al., 1996; Baider

and Kaplan De-Nour, 1988; Carlson et al., 2001b). For this, it is important to note that

breast cancer patients with better adjustment exhibited low coping avoidance (Hack and

Degner, 1999), lower levels of helplessness, made fewer changes to their social behaviour,

were more anxiously pre-occupied with the illness, and exercised more information-

seeking behaviour (Lavery and Clarke, 1996). In addition, greater coping strategy among

women with breast cancer was characterized by fighting spirit, whereas lower coping

strategy was related to hopelessness/ helplessness, anxious-preoccupation and fatalism

(Schnoll et al., 1998). On the other hand, women who made attributions about their cancer

50

origins usually had a lower adjustment, according to Lavery and Clarke (1996). Positive

adjustment, among women with breast cancer, has been reported to be predicted by their

active acceptance (Stanton et al., 2002). In addition, greater adaptation among women

with breast cancer, mainly among women with high hopes, is associated with their oriented

coping strategy approach (Stanton et al., 2002). This positive coping and adaptation were

reported to predict longer survival, specifically among post-menopausal women (Coates et

al., 2000). Classen et al. (1996) suggested that breast cancer patients with better

adjustment also exhibited their fighting spirit and emotional expressiveness.

Physical, psychological and social factors can influence the way an individual

copes and adjusts in cancer. As indicated by Taylor et al. (1984), adjustment is associated

with cognitive control. Other findings on breast cancer have reported that the patients’

coping strategy could be associated with the disability, where active and passive coping

were related to greater or lesser of one’s ability (Bishop and Warr, 2003). The adjustment

of women with breast cancer also indicated a mild association with behavioural control

(Taylor et al., 1984) and positive association with invulnerability (Timko and Jonoff-

Bulman, 1985). However, Barez et al. (2007) proved that patients with better adaptation

exhibited higher perceived control. Breast cancer patients’ coping strategies (emotion-

focused coping strategy and problem-focused strategy) had been positively associated with

the control over the course of cancer (Cousson-gelie et al., 2005). The personality traits

and the form or degree of problem existed could influence the coping behaviour

(Herschbach et al., 1985). Another study indicated that adjustment had been strongly

related to the aspect of self-efficacy (Manne et al., 2006). Meanwhile, the characteristics

of fighting spirit and hopelessness in mental adjustment seemed to be associated with

optimism and pessimism (Schou et al., 2005).

51

Certain coping characteristics can be observed among the long-term survivors.

Among others, a study on the long-term survivors of breast cancer suggested that the

strategy of planful problem solving might provide benefit for survival (Wonghongkul et

al., 2000), even though the correlation between survival and coping style was not

suggested (Soler-Vila et al., 2003). Escape-avoidance strategy was also identified as a

type of coping strategy among the five-year’s post-diagnosis survivors of breast cancer

(Wongkonghul et al., 2000). Another study indicated the decrease of maladjustment at six

years, following breast cancer surgery (Omne-Ponten et al., 1994). Optimistic and

confrontive elements were often used by breast cancer survivors who had survived for five

years (Halstead and Fernsler, 1994). Survivors of more than three years of breast disease

were found to indicate the element of intrusive thought in their psychological adjustment

(Matsuoka et al., 2002). On the contrary, poor long-term psychological adjustment was

observed among women with passive acceptance and resignation (Hack and Degner,

2004).

Certain coping and adjusting characteristics were also observed in the short-term

prospective studies of breast cancer. For instance, some researchers found the

characteristics of denial (Carver et al., 1993; Dean and Surtees, 1989) and emotion-focused

engagement (Epping-Jordan et al., 1999) in the coping strategies employed by women with

breast cancer at short-term follow up. Other most common coping elements such as

acceptance, positive reframing and the use of religion, have also been noted in a 12 months

follow-up study on breast cancer (Carver et al., 1993). Nevertheless, Carver et al. (1993)

also indicated on other coping strategy, i.e. behavioural disengagement, which is least

common. The elements of helplessness/ despair and fear, in the coping mechanism, were

also observed with slight increase at follow-up; whereas, fatalism and denial were

decreased at follow-up (Neises et al., 1995). Another coping strategy, such as

52

hopelessness, was suggested as the strongest predictor for women’s adjustment (Northouse

et al., 2001). Regression, which was characterized by high level of defensiveness and low

anxiety, was found to increase among women with breast cancer at four weeks post-

diagnosis (Zachariae et al. 2004). Other findings of breast cancer studies reported that

women admitted the important role of information and attitude which helped them to cope

and adapt with breast cancer (Northouse, 1989a).

Some qualitative studies have pointed out important issues in coping and

adjustment in breast cancer. For example, researchers frequently discovered the religious

and spirituality elements in women’s coping strategy (e.g. Henderson et al., 2003; Gall and

Cornblat, 2002; Lackey et al., 2001; Lopez et al., 2005; Taleghani et al., 2006; Tam-

Ashing et al., 2003). In another qualitative study, women with breast disease used more

defence mechanisms, denial, intellectuality and reaction formation (Ollonen et al., 2005).

In addition, Ollonen et al. (2005) added that these patients also used less coping

mechanisms, concentration, intellectuality, logical analysis, empathy, ambiguity tolerance,

regression-ego, sublimation and substitution.

Women with breast cancer may use positive or negative coping and adjustment in

adaptation toward the disease. This psychosocial aspect of coping and adjustment may

persist over time and play an important role in survival.

2.1.3 The Association between Women’s Quality of Life and their Coping/

Adjustment in Breast Cancer

Women’s quality of life and their coping or adjustment toward breast cancer has

emerged as an important issue in cancer psychosocial studies. The link, between women’s

quality of life and their coping/adjustment in breast cancer context, has actually been

53

proven by many researchers (e.g. Kenne-Sarenmalm et al., 2007; Okano et al., 2001; Wolf

et al., 1995; Zabalegui, 1999).

A growing body of literature has demonstrated the importance of psychological

aspect in a patient’s coping and adjustment, mainly in confronting a chronic disease. The

cross-sectional data of breast cancer has revealed the association between psychological

problem and certain elements in coping strategies, such as behavioural escape avoidance,

distancing (Zabalegui, 1999), engagement (Fletcher et al., 2006) and self-blame (Li and

Lambert, 2007). Woods and Lewis (1995), in a related study among chronic disease

patients, reported that introspective coping behaviour might be observed in dealing with

psychological interruption. Similar to the findings of the earlier study, Matsushita et al.

(2007) also observed that one of the important determinants of depression and anger,

among gynaecologic patients undergoing surgery, was emotion-oriented coping style.

These findings seem to suggest that the psychological attribution was seen to have a link

with the characteristics of depression and problem solving in coping strategies (Wolf et al.,

1995). A cross-sectional finding, reported by Watson et al. (1991), indicated there were

elements of emotional control, fatalism and helplessness in the coping strategy of breast

cancer patients who were suffering from psychological morbidity. In addition to this, a

distress symptom problem could also be detected among those who exhibited the

characteristics of hopelessness in their adjustment towards breast cancer (Northouse et al.,

1995). Friedman et al. (2007) found that women, who had the characteristic of “self-

blaming”, experienced more mood disturbance and poorer quality of life than those who

did not blame themselves. According to Okano et al. (2001), breast cancer patients who

showed the characteristics of helplessness and hopelessness in their mental adjustment,

usually possessed a history of major depression. A study conducted among breast cancer

patients, with family history of cancer, revealed the association of cancer specific distress

54

and passive coping style (Kim et al., 2003). The result of this particular study obviously

supports the earlier finding which associates the passive coping styles and negative

emotion (Hosaka et al., 1995). Other studies on cancer also supported the link between the

psychological well-being and coping strategy, where patients who experienced depression

and anxiety exhibited the element of being withdrawn in their coping strategy (Georgoff,

1991). However, negative association between women’s anxiety and their instrumental

coping strategy was found in another study; this anxiety was found to have no association

with emotion-focused coping (Drageset and Lindstrom, 2003). Similarly, Chen and Ma

(2004) also proved contradicting findings when they discovered that breast cancer patients

with less distress symptoms tended to use problem-focused approach in their coping

strategy. A related cancer study pointed out the link between patients’ poor adjustment

and depression (Butler et al., 2006). Supported by another cancer study which looked at

the patients’ response toward cancer diagnosis, Burgess et al. (1998) found the

characteristics of hopelessness-helplessness among patients suffering from anxiety and

depression. The psychological aspect, related to internal causal attribution, was also

observed among breast cancer patients with high emotion-focus coping and problem-focus

coping (Cousson-Gelie et al., 2005). However, other researchers indicated that the

emotional approach coping (such as avoidance) was not observed among distressed women

with breast cancer (Ben-Zur et al., 2001), and thus, this strategy was suggested to have a

minimal association (Baider and Kaplan De-Nour, 1997). Therefore, the link between the

psychological aspect and other elements of coping strategies such as denial, fatalism

(Classen et al., 1996) and ventilation (Ben-Zur et al., 2001) can not be established.

Another element of coping strategy, i.e. “live balancing” had been indicated by Lewis and

Deal (1995) to might not be increasing the mood of the breast cancer patients. The

55

element of spirituality, in adjusting to breast cancer, was also observed by other

researchers (e.g. Cotton et al., 1999; Manning-Walsh, 2005; Okano et al., 2001).

The coping and adjustment strategies of an individual are also contributed by their

quality of life. For instance, studies on cancer yielded that the quality of life of patients

was very much influenced by the coping strategies such as problem-oriented coping (e.g.

Cerny and Heusser, 1999), although this claim was toned down by other findings in breast

cancer (e.g. Oh et al., 2004). This finding is supported by the result gathered in a study by

Cotton et al. (1999) who reported a negative correlation between the quality of life and the

use of helplessness/hopelessness style by women with breast cancer. Establishing the link

between coping strategies and the quality of life in cancer research, other researchers

reported the association between positive life event and lower levels of breast cancer

specific-avoidance among breast cancer patients (Kim et al., 2004), although other

researchers did not find coping as a moderator between life events and breast cancer

(Edwards et al., 1990). In a related study on chronic disease, the relationship between the

optimum family functioning and introspective coping behaviour was found (Woods and

Lewis, 1995). Furthermore, social provision had also been noted to be related with the

instrumental coping, albeit a weak one (Drageset and Lindstrom, 2003). Another related

finding pointed out that the social constraint, as a factor, leads to poorer adjustment

(Cardova et al., 2001). Meanwhile, women who use passive and avoidance styles in their

coping were observed to have high level of disability (Passik and Mc Donald, 1998). The

long-term breast cancer survivors, with high anxiety and depression, reported to have

problems with coping and adjusting (Alder and Bitzer, 2003). This is proven and

supported by the fact that the use of planful problem solving, among breast cancer

survivors, might be beneficial in regulating stress (Wongkonghul et al., 2000).

56

Women’s coping/ adjustment and its association with psychological well-being as

observed prospectively has also been given much attention by many researchers (e.g.

Epping-Jordan et al., 1999; Glinder and Compas, 1999; Northouse, 1989b). For this,

breast cancer patients who used certain coping strategies (e.g. acceptance and use of

humour) prospectively predicted their lower distress level, whereas, those who made use of

denial and disengagement were found to predict more distress (Carver et al., 1993). In the

same way, changes in anxiety and depression were predicted by low dispositional

optimism and partially mediated by the use of emotion-focused disengagement coping,

which were observed at diagnosis and six months follow-up post-diagnosis (Epping-Jordan

et al., 1999). Other prospective studies in breast cancer also showed the comparable

results, where women’s distress at six months and a year after diagnosis were significantly

predicted by the element of self-blame in their coping strategy (Glinder and Compas,

1999). The strategy in coping such as cognitive avoidance, among women with breast

cancer, is related to patients with greater distress (Lebel et al., 2003). As such, Longman

et al. (1999) suggested that women with breast cancer, who were followed up after the

treatment up to five months, indicated that their psychological adjustment was influenced

by the level of depression and anxiety. Mc Caul et al. (1998) suggested that thinking and

worrying about breast cancer could have a positive impact to the self-protective behaviour

such as frequency of breast screening. In the same vien, breast cancer patients, who were

followed up a month after surgery, revealed that their emotional aspect was vital for them

in coping with the illness (Northouse, 1989b). Similarly, positive reappraisal coping was

found to predict positive mood, at three and 12 months, after the primary medical

treatment of women who had been diagnosed with the early stage breast cancer (Sears et

al., 2003). Other prospective studies suggested certain coping strategies, such as

avoidance-oriented coping which predicted greater fear (Stanton et al., 2002) and distress

57

(Mc Caul et al., 1999) among women with breast cancer. Wade et al. (2005) suggested

that the denial strategy was observed as a strong predictor for patients’ fear about their

future health over time. The element of spirituality in mental adjustment, which predicts

the distress change over time, was also reported in another prospective study of breast

cancer (Andritsch et al., 2004).

The link between the adjustment/ coping strategies and other aspects of women’s

life quality in facing breast cancer (as observed prospectively) was also exhibited. Sears et

al. (2003) noted that the patients’ perceived health was associated with certain coping

strategies such as positive reappraisal coping, when evaluated at three and 12 months after

the completion of the primary medical treatment. The link was also detected for the

subjective state of health and most of the adjustment dimensions among breast cancer

patients who were followed up once they first learned about the illness up to six months

later (Kulik and Kronfeld, 2005). Thus, Lampic et al. (2002) suggested that there was a

link between certain aspects in the quality of life (i.e. life value) and the psychological

adaptation on the women’s perspective before and after breast cancer diagnosis. For this,

Stanton and Snider (1993) also proved the cognitive-avoidance coping as a predictor of

low vigour. On the contrary, breast cancer patients who used expressive coping reported

improvement in quality of life (Stanton et al., 2000). A one-year follow-up study

conducted among breast cancer patients revealed the severity in the aspect of illness which

predicted women’s adjustment (Northouse et al., 2001). Women’s role functioning had

also been indicated as an important predictor for the emotional adjustment (Hoskins,

1995a). For this, Carver et al. (1998) observed the vulnerability to poorer psychosocial

adjustment among women who were greatly concerned about their body image after breast

cancer surgery.

58

Generally, greater adjustment and coping strategies among women with breast

cancer, were strongly related with their quality of life. It was observed that coping

strategies such as planful strategy, acceptance, use of humour and problem-oriented

approach were related to the better quality of life of the women with breast cancer.

Meanwhile, strategies such as helplessness, hopelessness, element of withdraw and self-

blame may not be benefiting to their quality of life. Thus, it can be suggested that the

impairment in the quality of life, mainly in the area of women’s psychological state,

significantly contributes to the ways of coping and adjustment used by the women with

breast cancer.

2.2 Quality of Life, Interpersonal Relationship and Coping Strategies in Breast

Cancer: Spouse- or Partner-related Perspective

The issues of quality of life, interpersonal relationship and coping strategies related

to spouses or partners of the women with breast cancer, are highlighted in this literature

review. Apart from reviewing each issue independently, the association between these

issues (i.e. the association between the husbands’ quality of life and their coping strategies,

the association between the husbands’ quality of life and their interpersonal relationship,

the association between the husbands’ interpersonal relationship and their

coping/adjustment) are also presented in separate sections.

59

2.2.1 Interpersonal Relationship Issue in Breast Cancer: Spouse- or Partner-

related Perspective

The occurrence of breast cancer presents a new dimension in the life of patients and

their spouses or partners, mainly in relation to their marital satisfaction, communication

and interpersonal support. Thus, the emergence of this chronic disease has also made them

vulnerable, and in need of honest communication, strong relationship and familial support

in confronting the crisis of cancer. As such, breast cancer could be wrongly attributed as a

factor which can affect the marital relationship, which is contrast to other’s findings

(Dorval et al., 1999; Taylor-Brown et al., 2000). In fact, several studies conducted on

breast cancer have shown that women with breast cancer admitted the significant role of

their spouse in facing breast cancer (e.g. Bultz et al., 2000). Furthermore, the importance

of family environment (spouse or partner of the patient as a unit in family) was highlighted

by Torminga et al. (1998) for the patients’ survival from breast cancer. According to

Barker and Lemle (1984), spouse usually responds to sickness partner in three ways.

Firstly, by expressing sympathy, cheer and comfort, affection or reassurance; secondly,

giving advice or problem solving; and thirdly, passive listening.

Northouse et al. (1988), in their prospective study of breast cancer, suggested that

a reciprocal interaction did exist between women and their husbands, where couples

reported almost the same level of adjustment difficulties at three and 30 days, as well as at

the same time receiving the similar amount of social support. In Dorval et al. (2005),

mutual action could be seen as spouse was getting advice from their wives with breast

cancer, and at the same time, patients received more affection from their spouses. This is

in lieu with the finding by Weihs et al. (2008) who suggested the importance of marital

confiding as a protection against the breast cancer progression. Similar to the finding by

60

Andrykowski et al (1996), it was also stated that breast cancer could enhance women’s

interpersonal relationship. In other prospective observations of breast cancer, nearly half

of the couples reported that breast cancer had brought them closer (Dorval et al., 2005;

Sheppard and Ely, 2008), after having been in troubled relationships before cancer was

diagnosed (Holmberg et al., 2001). This is parallel to the report on breast cancer patients,

where they rated the improvement in the close relationship with others as a common theme

as compared to myocardial infarction patients who rated healthy lifestyle change as a

common theme (Petrie et al., 1999). On the other hand, based on the examples gathered

from women with cervical cancer and their spouses who survived for up to two years, the

patients reported that their relationship and intimacy had been disrupted (de Groot et al.,

2005). Interestingly, another study on various chronic diseases indicated that breast cancer

affected partners’ marital life the most, as compared to other chronic diseases (Lewis et al.,

1989) even though the effects on them were much lesser than the effects of the disease on

the patients themselves (Daneker et al., 2001). However, based on several studies on other

diseases (such as multiple sclerosis), it was found that the partners’ rating on the level of

satisfaction, with regards to their relationship with patients, was lower as compared to the

patients themselves (Woollett and Edelmann, 1988). Furthermore, Litcman et al. (1987)

found that both breast cancer patients and their husbands, who were satisfied with their

marital life, viewed the marriage as a mutual interaction and appraised their spouse in a

romanticized mode. Nevertheless, other studies suggested that the marital problem (prior

to the diagnosis of cancer) could cause strains and difficulties in future relationship (e.g.

Manne, 1998) and the existence of the chronic illness might worsen any pre-existing

marital problems (Stern and Pascale, 1979).

Apart from the marital relationship issue among partners in breast cancer, another

aspect which cannot be neglected is sexuality, the factor which has been stated as one of

61

the greatest concerns in this form of female cancer. As stated in the earlier section, women

with breast cancer were found to value the important role of their partners in their

interpersonal relationship, especially in the sexual aspect after breast cancer (e.g. Fobair et

al., 2006; Holmberg et al., 2001; Wood and Earp, 1978). Similarly, Fobair et al. (2006)

suggested the fact that patients being married and their partners’ difficulty to understand

their feelings contributed to greater sexual problem within seven months of diagnosis with

breast cancer. Hence, breast cancer patients who had experienced changes in their

relationship were more likely to report negative impacts on sexuality (Meyerowitz et al.,

1999). Sexual dysfunction, in relation to the non-communication area of sexual

relationship, was also identified (Onen-Sertoz et al., 2004).

Long-term survivors of breast cancer were observed to go through the sexual

adaptation in marital relationship (Wood and Earp, 1978), which might be contributed by

the decrease in their sexual satisfaction after the cancer treatment (Bukovic et al., 2005).

Based on the example from other female cancer studies, such as cervical and endometrial

cancer, it was found that the sexual relationship of these women indeed deteriorated, and

there was a disruption of sexual desire (Lalos et al., 1995). Other findings showed that the

relationship distress, among breast cancer patients, could affect their arousal, orgasm,

lubrication and satisfaction (Speer et al., 2005) which could further lead to sexual

dysfunction. A one-year observation, after breast cancer surgery, revealed that greater

marital satisfaction was predicted by their partners’ initiation of sex (Wimberly et al.,

2005). The issue pertaining to body image (such as the problem of nakedness in front of

the husband) after breast cancer surgery was also reported (Urbanek et al., 1992).

In the context of the patients’ interpersonal relationship, communication between

the couple is another important aspect which needs to be considered. Good

communication, characterized by openly communicating (Atchley and Miller, 1983;

62

MacKinnon et al., 1984; Parron and Troll, 1978; Roberts, 1979), is understood as a sharing

in companionship, value and activities together (Hodgson et al., 2003). For this, various

studies on breast cancer reported ineffective communication as a primary relational

concern (e.g. Litchman et al., 1987; Neuling and Winefield, 1988; Zahlis and Shands,

1991). In addition, there is evidence which suggests that communication style between

couples affects marital satisfaction in breast cancer (e.g. Hodgson et al., 2003). According

to Litchman et al. (1987), strained communication could be a common problem among

breast cancer patients, particularly when the patients felt that their fear was discounted by

their spouses. Thus, the partners’ ability to communicate their concerns over their

spouses’ breast cancer was the same to their spouses themselves (Walker, 1997).

However, another study on female cancer found that partners faced difficulty in

communicating with cancer patients (Lalos et al., 1995). This situation might not be

comparable to other breast cancer studies, where it seemed that only some partners were

involved in problematic communication (Hilton and Koop, 1994) which might potentially

affect their interpersonal relationship. As revised by Holmberg et al. (2001),

communication in couple could be less open due to the effort to protect each other. In lieu

to this, Pistrang and Barker (1995) identified high empathy and low withdrawal as two

positive characteristics in the communication between women with breast cancer and their

partners. Based on the example from gastrointestinal cancer, patients and their spouses

reported a low level of holding back, but moderately high levels of disclosure. However,

the level of disclosure was different between the patients and their spouses, in which

spouses indicated lower levels of disclosure than the patients (Porter et al. 2005). In

addition, poorer relationship functioning was associated with low levels of disclosure and

high levels of holding back among patients and their spouses (Porter et al., 2005). In the

same vein, Vess et al. (1985) suggested that the effectiveness of roles, the amount of role

63

strain and conflicts, as well as the level of cohesion and conflicts in the family, were

strongly influenced by the communication patterns of the patients’ spouses. A quantitative

observation in a small group showed that women with breast cancer might communicate

non-verbally with their partners (Im et al., 2002), the phenomenon which might be due to

the women’s perception of feeling conscious in front of their partners.

In order to influence one’s appraisal of threat posed by the disease, instrumental

and emotional support is crucial. The need of strong familial environment, for those who

are suffering from the disease, is essential (e.g. Northouse, 1988). For instance, Dirksen

(2000) suggested that social support was a significant predictor for women’s

resourcefulness. Based on the example taken from outside the field of breast cancer,

instrumental support was an important predictor for coronary atherosclerosis (Seeman and

Syme, 1997). Addressing the interpersonal support in the context of breast cancer,

emotional support from family (spouse as a unit in family) was therefore ranked as the

highest support required as compared to from other sources, such as friends and providers

(Arora et al., 2007). Many health seeking studies also pointed out that partners or spouses

were one of the helpers who were the most frequently being used or approached by the

help-recipients (e.g. Pistrang and Barker, 1992; Barker et al., 1990). According to Barker

and Lemle (1984), more support and understanding tend to be experienced by the helpers

as they are satisfied with their relationship and become more helpful by their disclosure.

In the study by Sandgren et al. (2004), it was observed that 60% of the breast cancer

patients chose their spouse as a source of emotional support. In addition, spouses

described how to be supportive to their wives whenever they faced significant challenges

in breast cancer, where they shared vivid accounts of personal emotional reactions,

changes in daily work life and household responsibilities and dealing with work-related

demands (Fitch and Allard, 2007). Partners or spouses may go through “balancing,” which

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is an action that interprets their support to their spouses with breast cancer. These actions

include managing everyday illness, surviving, healing and preparing for death (Lewis and

Deal, 1995). In managing women’s everyday illness, certain types of action which can be

interpreted as “support” is observed; these are such as talking about the treatment and the

disease, checking in, interpreting symptoms, not dwelling on it, dealing with feelings, as

well as dealing with the unknowns and uncertainties. Another behaviour which has been

identified as related to certain supportive actions is talking about the kids and being in

control. Meanwhile, certain support such as ‘making progress and moving on’ was

associated with the ongoing healing process. Similarly, talking about dying (in a proper

way) may be a good support in preparing for death. Lewis and Deal (1995) commented

that such behaviour can facilitate behavioural function, but it may not encourage high

marital quality. According to Sabo et al. (1986), partners regarded themselves as

‘protective guardians,’ where they placed a high priority on their wives and kept their own

feelings at bay during their wives’ hospitalization. As indicated by Thompson and Shubin

(1993), over protectiveness on patient might occur when there was a discrepancy between

the patient’s and caregiver in evaluating the patient’s functioning, caregiver’s protective

behaviour (i.e. hampering the patient because of the fear for the patient’s security) and

caregiver’s negative approach toward the patient. At the same time, patients could also

have highly critical spouses (Manne and Zautra, 1989). Other findings in breast cancer

observed that partners seemed not to know what to expect, being unsure how to assist and

feeling helpless (Hilton et al., 2000). Furthermore, the qualitative observation in the study

by Hilton et al. (2000) also revealed that spouses did not want to share their fears and

emotions with their wives who were suffering with breast cancer; nevertheless, they

attempted to be positive, up holding their normal routines and activities. The same

researchers also added that partners were encouraged by their spouses to be positive

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(Hilton et al., 2000). According to Arora et al. (2007), the perceived helpfulness of

information and decision making provided by the family significantly decreased overtime.

Addressing social support with special focus on interpersonal support, similar level of

spouses’ support was received by women with breast cancer and their husbands (Walker,

1977). However, breast cancer patients and their spouses reported the differences in

support and reciprocity than their spouses (Makabe and Nomizu, 2006). Douglass (1977)

observed that patients perceived more interpersonal support than their spouses. Related

studies showed that partners or spouses gave satisfactory support to women with breast

cancer (Bukovic and Fajdic, 2005; Carlson et al., 2001b; Chantler et al., 2005). Baider et

al. (2004) suggested that the refusal of partners to participate in their study was associated

with the women’s negative perception of their family support, as compared to other breast

cancer studies.

In sum, patients’ quality of life is highly contributed by their partner or spouse’s

role and response in communication and support which leads them to achieve higher

quality in their relationship.

2.2.2 Quality of Life Issue in Breast Cancer: Spouse- or Partner-related Perspective

With regard to the issue on the quality of life among the spouse or partner of the

patient in cancer study, it has been suggested that breast cancer has significant

repercussions throughout the family system, with the spouse or partner of the patient being

potentially one of the most vulnerable. Family distress and burden (spouse as a unit in

family) were acknowledged by women as the greatest social concerns in breast cancer

(Dow et al., 1996). In lieu to this issue, most studies in breast cancer showed that partner

or spouse of the patient experienced psychological morbidity throughout their spouse’s

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cancer crisis (e.g. Fitch and Allard, 2007; Omne-ponten et al., 1993; Wagner et al., 2006).

As reviewed by Petrie et al. (2001), the spouses of the women with breast cancer

demanded for the various psychosocial needs such as emotional, spiritual, practical and

physical.

Psychological implications such as frustration, resentment and guilt, among spouse

or partner might be caused by the restrictions in his activities, which were due to patient’s

illness situation (Burish and Lyles, 1983), feeling of not doing enough to assist the patient

(Bilodeau and Hackett, 1971), lesser focus on the patient’s needs (due to too much focus

on own needs), respond to the patient’s dependency or demands and dealing with

irritability and firmness with the patients (Bilodeau and Hackett, 1971; Vess et al., 1988).

Meanwhile, according to Fitch and Allard (2007), several other reasons could be the

challenges which the spouses faced in obtaining better quality of life, such as personal

emotional reactions, changes in their daily work life and responsibilities, worries about

children and relationship with the patients. Another related study indicated that carers who

perceived the cancer as more serious were much more likely to have psychological

problem (Compas et al., 1994). However, a report by Lutzky and Knight (1994)

hypothesized that male caregivers could fail to recognize and report distress when they

were less likely to be attentive on their emotions, even though the argument was not fully

supported by their finding.

In addition to the findings discussed above, Lalos (1997) observed the

psychological crisis, among the spouses of the cancer patients, at the initial phase of the

treatment. Moreover, Makabe and Nomizu (2006) reported that the psychological state of

the partner, due to breast cancer, was not different from that of the women. Another

prospective finding also suggested that partners of breast cancer women experienced

consistent psychological distress overtime with minor changes which were similar to the

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patients (Baider et al., 2004). Similarly, Hoskin (1995) reported the improvement of the

psychological well-being of the partner over the time was similar to that of the patient. In

contrast, Sandren et al. (2004) found differences in emotional well-being between the

women and their confidant, at four months follow-up after the breast cancer diagnosis.

However, according to Ben Zur et al. (2001), although partners experienced psychological

disruption with their spouse’s breast cancer, the disruption was less than that experienced

by the women themselves. A study, conducted outside the breast cancer (patients with

end-stage renal disease), indicated that the spouses’ depression was associated with the

patients’ depression (Daneker et al., 2001). A similar situation was also observed for the

spouses and patients’ anxiety, whereby their anxiety was found to be correlated to each

other (Segrin et al., 2007). Another study on breast cancer, among the principle caregivers

of the women with cancer, indicated that the depression of the caregivers was linked

negatively to the women’s functional status (Grunseld et al., 2004). Nevertheless, Bultz et

al. (2000) suggested that lesser mood disturbance was observed among patients whose

partners had received the psycho-educational intervention program. A study on genetic

testing exposed the association between the patients’ perception of their spouses’ anxiety,

at the time of genetic testing and their psychological morbidity two years later (Wylie et

al., 2003). Furthermore, a prospective observation in breast cancer indicated that the

partners’ role in the vocational, domestic and social environment improved over time,

which was similar to the patients’ role (Hoskin, 1995). Another related study was

conducted among confidants of breast cancer patients; it revealed that these confidants

rated the similar level of most aspects of life quality as the patients did, at four months

post-diagnosis (Sandren et al., 2004).

Findings from a chronic disease study (i.e. breast cancer, diabetes or fibrocystic

breast disease) reported that the level of depression among the patients’ partners could be

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predicted by the number of their spouse’s illness demand (Lewis et al., 1989). The study

by Lethborg et al. (2003) noted the impact of breast cancer on the spouses’ role

functioning, as they had to assume the new role of the caregiver during the treatment of the

patients; although it could not be proven by another study which made a comparison

between the partners of the women with breast cancer to the partners of the healthy

subjects (Wagner et al., 2006). Northouse et al. (1998) suggested that the spouses’ distress

(at 60 days and a year following the diagnosis) was likely associated with their distress and

the role problem at diagnosis.

Based on the reviews given above, it could be suggested that both patient and

spouse are not exceptional from facing the challenges of the crisis due to cancer, mainly

from the psychological aspect, social and role. Therefore, the disruption in the quality of

life of the spouse or husband does not differ much as compared to the patient.

2.2.3 Coping and Adjustment in Breast Cancer: Spouse- or Partner-related

Perspective

Several researchers suggested that psychosocial adjustment to cancer is a family

affair (e.g. Ben-Zur et al., 2001; Northouse and Muhammad, 2000). In specific, family

(spouse as a unit in family) can be a source for the patients in adjusting their life toward

cancer (e.g. Ben-Zur et al., 2001; Dorval et al., 2005; Northouse and Muhammad, 2000).

In a study on breast cancer by Wilson and Morse (1991), identifying the threat, engaging in

the fight and becoming a veteran were identified as basic processes in the husbands’

coping with their wives’ breast cancer. In relation to these coping processes, Wilson and

Morse (1991) proposed the basic concept of “buffering” as a core process which involved

the actions of filtering and trying to eliminate the daily stressors to protect their wives,

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such as being constantly attentive in supervising their spouses’ reactions to the treatment,

and their communications with and responses to others, taking cognitive action by

construing and appraising situations they perceived their wives to be in and choosing

proper action to employ in order to buffer them from the situation. Meanwhile, Lewis and

Deal (1995) suggested the concept of “balancing” as a part of the adjustment which was

implemented by partners in breast cancer. The balancing process consists of four major

processes, which are managing everyday illness, surviving, healing and preparing for

death. The coping strategies, which are related to managing everyday illness, include

talking about the treatment and the disease, educating themselves, checking in, interpreting

the symptoms, not dwelling on the ill situation, as well as dealing with the feelings, the

unknowns and uncertainties. Several strategies have been observed to be related with

surviving; these include learning to live with the illness, struggling with the relational

parts, talking about the kids and being in control. Meanwhile, making progress and

moving on, maintaining optimism and trying to keep stress to the minimum level, have

been identified as associated with the healing strategies. The final process, i.e., preparing

for death is noted by the researchers to relate to ‘talking about dying and talking about the

husband’s life afterward.’

In breast cancer, there is evidence which have shown that not only do cancer

patients go a process of psychological adjustment, their spouses also go through such a

process (e.g. Baider et al., 2004; Ben-Zur et al., 2001; Holmberg et al., 2001). The

psychosocial adjustment, among spouses of breast cancer patients, was suggested to persist

overtime (Northouse, 1989b), but with the different pattern overtime (Oberst and Scot,

1988). However, there was a suggestion which indicated the adjustment pattern between

the partners and the patients was similar (Gotay, 1985), with a slight difference, where

spouses were noted to have an element of directed action in their adjustment, as compared

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to the patients (Gotay, 1984). A prospective observation by Northouse et al. (1998) also

suggested that there was a strong correspondence between the breast cancer patients’ and

their spouses’ adjustment overtime. Adding to this, a one-year post-diagnosis observation

conducted among breast cancer patients exhibited a significant direct effect on each other’s

(husbands’ and wives’) adjustment (Northouse et al. 2001). Based on the example from

colon cancer, it was concluded that the adjustment between patients and their spouses was

observed to correlate overtime (Northouse et al., 2000).

In the breast cancer conflict, spouse or partner (as a unit in dyad coping) has been

noted to contribute significantly to the women’s ability to adjust (Ben-Zur et al., 2001),

suggesting the importance of a mutual interaction between the women with breast cancer

and their spouses (Northouse et al., 1995). Giving a more specific explanation, Dalton et

al. (2007) reported that the husbands’ adjustment was accounted for as much as 54% by

their avoidant coping and wives’ adjustment. The significance of the spouses, in coping

and adjusting to their partners’ cancer, has also been proven by the other types of cancer

studies (Baider and Kaplan De-Nour, 1988; Gotay, 1985; Pitceathly and Maguire, 2003).

In these studies, it was also suggested that the patients’ partners (who made strong causal

attributions toward the spouses’ disease) potentially affected their ability to adapt and

adjust (Gotay, 1985).

On the other hand, Baider and Kaplan De Nour (1988) found that spouses had

many adjustment problems, as compared to the patients. However, Baider et al. (1989), in

the study among chronic disease patients (i.e. colon cancer), revealed that the male partners

of the patients were found to be far worse in adjusting as compared to the female partners

of the patients, indicating the influence of gender in the psychosocial adjustment.

Regardless of their gender, caregivers (whose partners were admitted to the intensive care

unit) were found to incorporate strategies such as seeking for information, seeking for

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support, reliance on their cultural belief and practices, turning to their religious belief,

maintaining hope and acceptance of illness, in their coping with the disease (Chan and

Twinn, 2007). Oberst and James (1985) identified eleven specific problems, related to the

coping and adjustment in chronic diseases, such as adaptation toward life-style disruption,

physical care, symptoms, uncertainty, emotions, roles/relationships, identity, stigma,

information, health care system, and finances. In another study, spouses were observed to

engage with escaping and avoiding strategies in coping with their partners’ surgical

treatment (Keitel et al., 1990). Meanwhile, protective buffering and active engagement

were the significant strategies which were found to decrease among the spouses over time,

according to Hinnen et al. (2007).

Spouse’s mental and emotional coping and adjustment have also been documented.

Findings on the responses shown by the significant other of the breast cancer patients

indicated that they expressed the need to cope with the dread of losing their partners

(Lethborg et al., 2003). For this, Ben-Zur et al. (2003) explained that the emotion-focused

coping strategy employed by both breast cancer patients and their spouses was correlated

to each other.

Besides coping and adjusting psychologically in breast cancer, partners or spouses

also adjusted and coped towards their role and the social problems. As such, spouses

indicated that coping with their work-related demands was a significant challenge in facing

their wives’ breast cancer (Fitch and Allard, 2007). However, Northouse and Swain

(1987) reported that the role adjustment of spouses was lesser compared to breast cancer

patients. Based on the example derived from the colon cancer study, Northouse et al.

(2000) reported that the patients’ role adjustment could be predicted by their spouses’ role

problem. They further added that the spouses’ role problem, however, was predicted by

their own role problem at one week post-diagnosis (Northouse et al., 2000). Other studies

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on cancer also showed that the adjustment among carers was related to their appraisals on

the patients’ illness (e.g. Given et al., 1993; Kurt et al., 1995). In addition to this, Carey et

al. (1991) pointed out that the care-giving burden was one of the predictors for the negative

appraisal of care-giving.

Spouse or partner of the cancer patient plays an important role in the patient’s

adjusting and coping toward cancer crisis. Based on the findings of the previous studies

reviewed, it can be observed that the patient’s ability to adjust is generally contributed by

the spouse’s coping and adjustment, suggesting the similarity of coping and adjustment

between the patients and their husbands.

2.2.4 The Association between the Quality of Life and the Interpersonal

Relationship in Breast Cancer: Spouse- or Partner-related Perspective

The interpersonal relations between individuals can have a critical consequence for

one’s health (e.g. Awadalla et al., 2007; Bulotiene et al., 2007; Huang and Mathers, 2006).

Pistrang and Barker (1995), in their study on breast cancer, reported that women’s

perceived satisfactory relationship with their husbands was associated with their

psychological well-being. The finding derived from a chronic disease study exhibited the

relationship between the patients’ perceived partners’ response to their pain and their

depressive symptom (Stroud and Turner, 2006). Individuals with spinal cord injury, who

experienced pain, reported the element of solicitousness in their relationship (Giardino and

Jensen, 2003). A related cross-sectional finding also indicated an association between the

patients’ and their husbands’ distress with the interdependence elements in the relationship

of the couple in breast cancer (Walker, 1997). Giving a more specific explanation,

Pistrang and Barker (1995) proposed that women’s well-being was highly affected by the

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quality of the helping relationship with the partner, as compared to the satisfaction with the

general relationship. Parallel to the findings of other studies on cancer, it was found that

depressed patients tended to feel that they did not really invest much time and attention on

their relationship; whereas, the feeling of depression was higher among the spouses when

they felt that they did not receive much advantage in their relationship (Ybema et al.,

2001). In lieu to Hinnen et al. (2007), breast cancer patients, who rated low marital

satisfaction and tended not to express their feelings and concerns, usually experienced

more stress with their cancer situation. Interestingly, higher cohesion, expression and

conflict in relationship were unexpectedly associated with less distressed among breast

cancer patients and less mood disturbance among spouses, indicating that patients might

benefit by involving themselves with the difficulties and conflicts openly (Giese-Davis et

al., 2000). In addition to this, Hannum et al. (1991) also agreed that the patients’

psychological distress could best be predicted from their partners rating of the relationship

with the patients. However, the above scenario did not correspond to the finding by

Hodgson et al. (2003) who did not yield any correlation between the disengaged

statements and depressive symptoms, as reported by breast cancer couples.

Psychologists clearly state the effects of spouses’ depression on marital adjustment

(e.g. Lewis et al., 1989), which may lead to the breakdown in a relationship. For this,

Manne et al. (2007) found that the partner’s distress and the patient’s buffering (buffering

is defined as a protective act such as hiding worries, denying/ concerns and yielding to

one’s partner in an effort to avoid disagreement and reduce one’s partner’s upset and

burden) were moderated by the partner’s relationship satisfaction. In line with this, the

quality of marriage was negatively perceived by the depressed breast cancer patients and

their partners who faced the demands of the illness (Lewis et al., 1993). Parallel to the

findings by Weihs et al. (1999), breast cancer patients who reported dissatisfaction in their

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marriage were at a greater risk for distress increment in the future, as compared to those

who were feeling satisfied with their marriage. Wimberly et al. (2005) found that the

perception on the partner’s emotional involvement in cancer significantly predicted their

satisfaction with the marriage, at pre-surgical and post-operatively. In the same study, the

result gathered revealed a correlation between the perception of the partners’ emotional

involvement (during the cancer episode) and the patients’ marital satisfaction at the

subsequent time point. Researchers in breast cancer studies agreed that the quality of

marital relationship reversely correlated to the women’s negative mood (Lewis and

Hammond, 1992). For the same reason, Cutrona (1996) suggested that the problem in a

close relationship could be caused by the lack in sense of security and self-efficacy, as well

as the lack of concern, reassurance, understanding and willingness to help in the

relationship. Also related to the issue of spouses in the quality of life and interpersonal

relationship, Avis et al. (2005) pointed out the impact of the sexual and relationship on the

breast cancer patients’ quality of life. In relation to this, it was observed that the patients’

psychological distress was explained by family relation factor, which was characterized by

the level of intrusion and cohesion; however, the spouses’ distress was explained by the

intrusion, and not the cohesion (Baider et al., 1998). In addition, the link between the

women’s perceived positive sexual relationship from the partner (e.g. partner sex initiation,

partner positive response of the first sexual experience after the treatment and the

frequency of sex) and their psychological well-being was also found by Wimberly et al.

(2005).

Wortman and Dunkel-Schetter (1979) noted that the communication problems

among cancer patients might occur when their spouses were unable or afraid to express

their feelings of helplessness and anger. Hence, it was concluded that the spouses, who

could communicate openly with their wife, could help reduce their stress (Mireskandari et

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al., 2007). This is in line with the result gathered by Manne et al. (2006) in their study

which revealed that the existence of a mutual constructive element in the communication

of a couple would lead them to experience less distress. Walker (1997) suggested that the

amount of communication would increase when the fear of breast cancer recurrence

increased. Based on the example from a gastrointestinal cancer study, the high levels of

holding back and low levels of disclosure were associated with the psychological burden of

both the patients and their spouses (Porter et al., 2005). Supported by the finding of

another study, Manne et al. (2004) believe that there is a link between the partner’s

responses to the patient’s self-disclosure and distress symptoms. They further added that

patients complained of less distress when their partners reacted with mutual self-

disclosure, humour, and were less likely to suggest solutions (Manne et al., 2004).

Similarly, taking an instance from a case of prostate cancer (regardless of gender and

nature of disease), a stronger negative relation was observed between the intrusive thought

and the mental health among the patients who felt socially constrained in talking about

their cancer as compared to the patients who felt unconstrained (Lepore and Helgeson,

1998). In addition, the level of constraints from their family and friends was positively

associated with level of avoidance in thinking and talking about cancer, which in turn was

associated with poorer mental health (Lepore and Helgeson, 1998).

The importance of family member(s), in providing support to the women with

breast cancer, was found to be related to their outlook toward life (Bloom and Spiegel,

1984). In the same line, Pieterse et al. (2007) emphasized that seeking for support and its

benefit could help in reducing distress. In relation to this, other cancer researchers

suggested that mutual support between couples could have a positive impact on their

psychological well-being (Douglass, 1997). Nevertheless, this finding is slightly different

from the one gathered by Chantler et al. (2005), where spouses or partners were found to

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be more helpful in providing tangible support (transportation, household task), but not in

sharing their emotions. A qualitative study conducted showed that some partners of the

women with breast cancer experienced an emotional difficulty due to the tangible support

they had been giving to their spouse, such as “taking over” and “helping task” at home

(Hilton et al., 2000). Parallel to this finding, Baider et al. (2003) indicated that highly

distressed couples reported a lower level of perceived family support. Bloom et al. (2001)

supported this finding by stating that better mental well-being was related to greater

emotional support. Meanwhile, other related studies found the positive association

between the supports rendered to the patients and their psychological well-being (Hoskin

1995; Wylie et al., 2003). According to Samms (1999), in his qualitative study on breast

cancer, partners could misinterpret their own personal emotions which then interrupted

their ability to provide support to their spouse. The positive association between the

support from the patients’ family members (e.g. husband) and obtaining a better life

quality of women with breast cancer was pointed out by Manning-Walsh (2005). The

effect of the spouses’ support on the women’s level of depression had also been noted by

other types of cancer studies (Ohara-Hirano et al., 2004). A prospective observation in

breast cancer reported that women’s lower distress (at post-surgery) was predicted by their

spouses’ instrumental support, at pre-surgical of breast cancer (Alferi et al., 2001). In lieu

with the finding by Manne et al. (2005), partners’ unsupportive behaviour was suggested

to have a link with the women’s distress with breast cancer. Meanwhile, researchers also

suggested that the support from the patients’ partners could be influenced by their male

gender role (Samms, 1999). A study conducted outside the breast cancer field, indicated

that the spouse might react negatively to an ill partner, due to a greater restriction on their

activities, as functional difficulties increased (Manne et al., 1999a). Another related study,

among caregivers of the patients with other types of cancer, reported that the caregivers’

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mental health was characterized by optimism, and thus, it influenced their reaction to care-

giving (Given et al., 1993).

The quality of the marital relationship, such as communication and interpersonal

support, was not only demanded by cancer patients but their spouses or partners as well.

The quality of a couple’s relationship is observed to be related with the quality of life, both

from the patients and their spouses.

2.2.5 The Association between the Interpersonal Relationship and Coping/

Adjustment in Breast Cancer: Spouse- or Partner-related Perspective

In the interpersonal relationship and coping/adjustment issue, numerous studies in

and outside breast cancer suggested that the link between interpersonal relationship aspect

and coping behaviour did exist (e.g. Holmberg et al., 2001; Hoskin, 1995; Lewis and

Hammond, 1993). The feeling of satisfaction in a relationship has been proven to be

related with the success in the marital adjustment (Litchman et al., 1987). For this, Hinnen

et al. (2007) stressed that coping with an active engagement seemed to make women

satisfied with their relationship. Similarly, a study outside the cancer field, suggested that

the spouse’s attitude had a noteworthy effect on the patient’s adjustment (Manne and

Zautra, 1989). They further added that patients involved in more adaptive coping manners

when they perceived the important role of their spouses in their situation (Manne and

Zautra, 1989). Enhancing marital relationship via the strategy of “live balancing,” such as

managing their wives’ everyday illness, surviving, healing and preparing for death, was

proposed by Lewis and Deal (1995). Morgan et al. (2005), in their qualitative observation,

identified six main categories of coping which reflected the marital quality of the African-

American couples with breast cancer, which included walking, praying, seeking, trusting,

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adjusting, and being together. In another study, patients indicated that the nature of their

relationship in the family (whether husband and wives or daughter and mother) might

affect the adjustment or coping in breast cancer (Bernard and Guarnaccia, 2003). As stated

in the earlier section, a high level of family cohesiveness (spouse as a unit in family) had a

positive effect on the patients’ adjustment toward breast cancer (Friedman et al., 1988).

An unexpected finding by Kulik and Kronfeld (2005) revealed that the sexual relation was

relatively low, while patients adjusted relatively well in the family and domestic

environment. According to Lewis et al. (1989), the type of coping behaviour used by the

family (spouse as a unit in family) could be predicted by the marital adjustment. They

further reported that discussion held in the patients’ families could influence spouses’

coping behaviour (Lewis et al., 1989). Similarly, women with a strong intimate

relationship were found to exhibite successful adjustment in breast cancer (Wilmoth,

2001). Based on the example gathered from a study on colon cancer, Northouse et al.

(2000) reported that the marital satisfaction could be used to predict the role problem faced

by the patients’ spouses.

Addressing the aspect of sexuality in the interpersonal relationship and

coping/adjustment issue in breast cancer, Onen-Sertoz et al. (2004) discovered the element

of avoidance in women’s coping with their sexual relationship. Another finding by

Wilmoth (2001), found the new sexual self in women’s adjustment with breast cancer.

Although social support was not proven to link with survival (Goodwin et al.,

2001; Kissane et al., 2007), it had been identified as an important resource which could

influence the way an individual adjusted and adapted to an illness (DiMatteo and Hays,

1981; Helgeson et al., 2000; Northouse et al., 1988; Valentiner et al., 1994). In the issue

related to partner in breast cancer, the link between the partners’ support and coping

behaviour had also been noted in other breast cancer studies, done cross-sectionally and

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longitudinally (e.g. Feldman and Broussard, 2005; Hoskin, 1995; Northouse, 1988;

Northouse, 1989; Manne et al., 2005). Supporting the interpersonal relationship and

coping issues, studies conducted among women with breast disease revealed a significant

link between the women’s perceived other’s support and their coping strategies (Drageset

and Lindstrom, 2003). In the same vein, Edgar et al. (2000) speculated that support

supplements an individual with the capacity to cope with “problem solving” and avoids the

strategies of escaping and avoiding. In lieu to this speculation, Ell et al. (1988) stressed

the importance of social resources (than illness-related factors) in improving mental health.

It was also noted that the positive coping patterns (such as acceptance), among women

with breast cancer, might positively be associated with the aspect of “special care”

(Catania et al., 1988), reflecting the importance of the “care” element in the relationship

quality which might affect coping and adjustment in cancer patients. Manne et al. (1999b)

suggested that spouses’ support of the patients could be beneficial for coping. From the

social perception, i.e. the sense of having a supportive and understanding person to talk to

in times of trouble, Ross and Mirowsky (1989) reported that those individuals who feel in

control of their lives are more likely to endeavour in overcoming the crisis. Some

investigators proposed that the support given by others could lead to the adaptive coping

behaviour in dealing more effectively with stressors (Lazarus and Folkman, 1984;

Valentiner et al., 1994). A study carried out outside the cancer field exhibited that the

patients engaged in a more adaptive coping strategy when they perceived that their spouses

were supportive (Manne and Zautra, 1989). Similarly, Manne et al. (1999b) suggested that

the spouses’ criticism and support could be mediated by the patients’ avoidant and

positively-focused coping. Thus, support could also be used to predict emotional

adjustment (Hoskin, 1995). As indicated by Northouse (1989), emotional support is

important for couples to cope with breast cancer. In addition, Manne (2005) reported that

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the avoidant coping of the patients’ spouses could be predicted by their unsupportive

behaviour.

Addressing the communication aspect in the interpersonal relationship issues, its

association to the couples’ adjustment and coping in cancer, have been identified in

numerous studies (e.g. Ress and Bath, 2000; Walker, 1997). As pointed by Ress and Bath

(2000), the informational coping styles of partners could influence the couples’

communication regarding breast cancer. This is parallel to the finding by Walker (1997)

who suggested that the couples’ adjustment was predicted by the amount of

communication about the illness. Lerman et al. (1993) observed that breast cancer

patients, with communication problem, usually used less assertive coping styles. In the

meantime, Manne et al. (2006) reported that couples, with an early stage breast cancer and

who had elements of demand-withdraw (“withdrawal” is classified as one type of coping

approach in this study) in their communication, were reported to rate low in their

relationship satisfaction (Manne et al., 2006). This fact was also proven by other breast

cancer studies (Litchman et al., 1987; Stanton et al., 2000) and other studies on other types

of cancer (Vess et al., 1985). According to Stanton et al. (2000), breast cancer patients,

who perceived their social contexts as highly receptive, usually had the characteristic of

“expressiveness” in their coping strategy. As such, strained communication could occur

when breast cancer patients felt that their feeling was discounted by those close to them

(Litchman et al., 1987). Similarly, cohesion and conflict in the family could be influenced

by the spouses’ communication (Vess et al., 1985). In relation to this fact, other finding in

breast cancer indicated a significant association between the poor communication in family

(spouse as a unit in family) and the adjustment elements such as helplessness/ hopelessness

among women (Inoue et al., 2003). The ability of the patients in adjusting themselves to

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breast cancer was also related to certain characteristics in women’s communication, such

as avoiding to talk about the threat and refusing to accept further implications (Orr, 1986).

In sum, the interpersonal relationship quality, such as marital relationship,

interpersonal support and the aspect of communication, could have a positive effect to the

coping and adjustment of the patients and their spouses in dealing with breast cancer. It

was observed that coping elements such as active engagement, adaptive approach and

“being together” (between husbands and wives) in dealing with the crisis of cancer can

have a positive effect on patients and their spouses’ adjustment towards the disease. In

addition, cohesiveness in family (spouse as a unit in family) may benefit for the marital

relationship of the cancer patients. Nonetheless, other coping elements such as avoidance,

less assertive, demand-withdraw, hopelessness and helplessness may not be benefiting to

their marital relationship.

2.2.6 The Association between Quality of Life and Coping/ Adjustment in Breast

Cancer: Spouse- or Partner-related Perspective

Numerous studies on breast cancer have proven the crucial link between the quality

of life and the aspect of psychosocial adjustment towards cancer. In the spouse’s

psychosocial issue, studies which were done cross-sectionally and longitudinally indicated

a significant association between the spouses’ coping/ adjustment and their psychological

aspects in facing their wives’ breast cancer (e.g. Feldman and Broussard, 2005; Northouse,

1989a; Northouse, 1989b; Northouse et al., 1995). As pointed out by Feldman and

Broussard (2005), in the study among partners and patients with newly diagnosed breast

cancer, partners’ patterns of coping and adjustment were predisposed by their depression.

This is parallel to the finding gathered by Northouse et al. (1995), who suggested that the

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husbands’ level of adjustment toward their wives’ breast cancer was mostly accounted by

the symptoms of distress. In addition to Northouse (1989), the emotional aspect was also

regarded as important for them to cope with breast cancer. Even though Ptacek et al.

(1994) discovered the largely independent of coping strategies between the breast cancer

patients and their husbands, a couple was believed to live under great psychological

distress when trying to deal actively with the threatening situation. Dyad coping, as

modelled by Ben-Zur et al. (2001), proposed that dyad emotion-focused coping strategy

(i.e., coping scores from both patients and their spouses) was highly related to the distress

and adjustment of the breast cancer patients. This is almost similar to the finding in a

study conducted by Romero et al. (2007) who observed that breast cancer patients’

avoidant coping and their mood disturbance were mediated by the discrepancies between

the husbands’ perceptions of their wives’ adjustment and wives’ perception of their own

adjustment. As a support to the above fact, another cross-sectional study among

significant others found that partner’s adaptation to breast cancer could be influenced by

their psychological symptom of feeling fear of losing partner (Lethborg et al., 2003). In

the mean time, Manne et al. (2007) suggested that the coping strategy of “protective

buffering” (defined as hiding worries, denying concerns and yielding to one’s partner in an

effort to avoid disagreement and reduce one’s partner’s upset and burden) would result in a

less psychological distress among breast cancer patients who rated their relationship as

more satisfactory. In addition, Lewis and Deal (1995) proposed a link between the

partners’ coping via “balancing” and their psychological state in facing with their spouses’

breast cancer.

In addressing the issues pertaining to coping and quality of life among the spouses

or partners of breast cancer patients, an association between the significant others’

psychological distress and certain characteristics in the patient’s coping (fatalistic and

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anxious pre-occupation) was found (Boehmer et al., 2005). In their research on breast

cancer, Ben-Zur et al. (2001) observed the influence of the spouses’ coping behaviour

(such as reliance on religion, ventilation and denial) on the patients’ psychological well-

being. This finding is supported by another cancer study, whereby the spouses’ coping

behaviour was indicated as a good predictor of the patients’ psychological distress

(Hannum et al., 1991).

Partners are at risk of high distress and maladjustment in breast cancer (Morse and

Fife, 1998). For instance, male cancer patients, who had the element of avoidance in their

coping strategies, were associated with their spouses’ anxiety and depression, regardless of

the gender of the patients (Ey et al., 1998). According to Mireskandari et al. (2007), a

higher level of distress among partners of the women, who were at high risk of developing

breast or ovarian cancer, was associated with the high monitoring style in their coping. A

longitudinal view among cancer caregivers identified a trait of “optimistic” which

contributed to the caregivers’ coping and reactions to the burdens of cancer (Kurtz et al.,

1995). Similarly, spouses were also observed to express their concerns on what the

upcoming might grasp and portray their endeavour so as to reduce the effects of the disease

(Zahlis and Shands, 1991).

As a conclusion, the level of quality, in the life of both patients and their spouses, is

important to determine or predict their coping and adjustment in dealing with chronic

illness such as breast cancer. The elements of “protective buffering” and Dyad emotion-

approach in coping strategies, contribute to the lower level of cancer patients’

psychological distress. Other elements of coping strategies, such as avoidant (whether

from cancer patients or their spouse) may result in psychological problem of their spouses.

In addition, the characteristic of high monitoring style in spouse’s adjustment may not be

benefiting to reduce their psychological distress.

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Apart from the above reviews on the studies previously done on breast cancer

(from the perspective of women and their spouses), the review was also carried out

specifically on the psychosocial aspect related to the chemotherapy treatment in breast

cancer, which will be explicated in the next chapter.

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CHAPTER THREE

LITERATURE REVIEW: PART TWO

SPECIAL FOCUS ON THE PSYCHOSOCIAL ASPECT OF ADJUVANT

CHEMOTHERAPY TREATMENT FOLLOWING BREAST CANCER

SURGERY

In this chapter, the literature review is carried out in a more specific manner; it

focuses on the psychosocial aspect of adjuvant chemotherapy treatment, following the

breast cancer surgery.

3.0 Introduction

There has been evidence which indicates that more cycles of chemotherapy in

breast cancer treatment lead to longer survival (Stockler et al., 2000); whereas, a four to six

month duration of multi-agent chemotherapy in breast cancer shows an improvement in

survival in both hormone receptor-positive and negative tumours (Abrams, 2001).

Meanwhile, six months of adjuvant Cyclophosphamide, Methotrexate and Fluorouracil

(CMF) chemotherapy is considered worthwhile for relatively modest survival gains (Simes

and Coates, 2001). Although a combination of chemotherapy regimens shows a

significantly worse toxicity, a modest improvement in the overall survival has been

exhibited (Carrick et al., 2005). While there was a randomized trial that showed the

effectiveness of adjuvant chemotherapy to improve the long-term survival for most women

with breast cancer (Early Breast Cancer Trialists’ Collaboration Group, 1998), several

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studies, which focussed on chemotherapy treatment, have never neglected the negative

impacts of this therapy in several domains, including physical and psychosocial (e.g.

Broeckel et al., 2000; Hurny et al., 1996). Based on the above discussions and the

experiences indicated by breast cancer patients, it is undeniable that chemotherapy is

actually a treatment which most patients can not endure; this could clearly be observed in a

study by Love et al. (1989), who found that almost a majority of the breast cancer patients

had thoughts of quitting therapy when the treatment was nearly ended. Some researchers

offered their explanation to this problem, whereby they related it to the negative impacts

imposed by the chemotherapy dose (Fairclough et al., 1999). This is contrary to the

finding by Palmer et al. (1980) who suggested that the percentage of the patients, who had

suffered the severe side-effects of the chemotherapy treatment, was considerable.

Although some women regarded adjuvant chemotherapy as not more than an “insurance

policy” (Cowley et al., 2000), the majority of patients expressed their willingness to go

through the six-month chemotherapy treatment for even a small to modest potential

advantage (Lindley et al., 1998).

Thus, despite the tendency to report that chemotherapy is a negative treatment (due

to its worst side-effects), the survival benefits of this treatment should not counterbalance

the side-effects on the patient’s quality of life.

3.1 The Importance of Medical and Bio/Socio-demographic Aspects Related to

Adjuvant Chemotherapy in Cancer Treatment

Some studies have indicated the importance of properly administered dose and the

duration of chemotherapy in preventing the extent and permanence of the treatment side-

effects, i.e. ovarian damage (e.g. Bines et al., 1996). Another study reported the

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importance of the time interval, between the breast cancer operation and the first treatment

of chemotherapy, in causing mental fatigue (de Jong et al., 2005). Negative impact of

chemotherapy (such as nausea) had also been observed to be influenced by the type of

breast cancer operation, where women who had undergone lumpectomy were found to

have less fatigue, as compared to those who had had mastectomy (de Jong et al., 2004).

However, neuropsychologic evaluation prior to, at short-term and long-term intervals of

adjuvant, chemotherapy treatment for breast carcinoma did not exhibit any statistically

significant correlation with clinical characteristics (Wefel et al., 2004). According to

Penman et al. (1986), women who had received adjuvant therapy following the

mastectomy demonstrated more body image dissatisfaction and feminine self-image

concerns than those women with benign biopsy and cholecystectomy.

Age seems to be another important determinant in causing fatigue on breast cancer

patients who had received adjuvant chemotherapy (de Jong et al., 2005). According to

Fehlauer et al., age could also be an important predictor for the role and social disruption

following cancer therapy (2005). Therefore, chemotherapy can have a drastic effect on the

older group due to the muscle mass, strength and functioning status, which tend to decline

with the increasing age (Kallman et al., 1990; Forrest et al., 2007; Landers et al., 2001;

Newman et al., 2003; Watters et al., 1993). A study conducted among older women

reported that the worse symptom of life’s quality (e.g. fatigue) was associated with

chemotherapy treatment (Given et al., 2001). Pandey et al. (2005) revealed that women,

who were less than 45 years old and currently undergoing active treatment, exhibited

poorer scores on the quality of life. However, one longitudinal study did not report any

negative effect of chemotherapy on older patients (Hurria et al., 2005). Nevertheless,

Newcomb and Carbone (1993) found that older groups were more likely to reject

chemotherapy than the younger ones. Fehlauer et al. (2005) reported that sexual

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functioning declined among older patients who received cancer therapy. Women aged

more than 35 years old are more at risk in developing permanent menopause, following the

treatment of chemotherapy, than younger women who possess a larger number of oocytes.

Younger women were also found to endure more of the higher doses of chemotherapy

before the possibility of malfunction of the ovaries (Surbone and Petrek, 1997). However,

some researchers reported that they did not find any significance of age on the

psychosocial sequel of chemotherapy treatment (Dees et al., 2000; Watters et al., 2003).

Ethnicity also seems to be a crucial indicator in making decisions on whether or not

to receive the treatment of chemotherapy (Richardson et al., 2006). In the meantime, other

socio-demographic factors such as ‘returning to work’ and ‘years of education’ were not

proven to be important factors on the psychosocial sequel of chemotherapy treatment

(Bushunow et al., 1995). Neuropsychologic evaluation, which was done before, at short-

term and long-term intervals of chemotherapy treatment, did not exhibit any statistically

significant correlation with the socio-demographic factors (Wefel et al., 2004).

Other factors, such as the regiment of doses, duration of therapy, treatment interval

and type of operation, seem to be important contributors in determining the psychosocial

consequent to chemotherapy treatment. Meanwhile, socio-demographic factors, such as

age and ethnicity, exhibit a significant association with the psychosocial aspect of cancer

chemotherapy.

3.2 Quality of Life

There are studies which have suggested that the anti-tumour treatment in breast

cancer is generally correlated with the quality of life outcome (e.g. Carlson, 1998;

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Fasching et al., 2007). Until the present day, chemotherapy has been documented to have

a measurable adverse effect on the quality of life (e.g. Galalae et al., 2005; Hopwood et al.,

2007; Hurny et al., 1996; Mills et al., 2005). Groenvold et al. (2007) clearly reported that

patients’ quality of life was impaired during the treatment phase of chemotherapy. This

statement is supported by Stead (2003) who reported that chemotherapy had caused short-

and long-term effects on the breast cancer patients’ quality of life. In the same vein, Mc

Phail and Smith (2000) demonstrated that women, who had received adjuvant systemic

breast cancer treatment, were more likely to experience tiredness, hot flashes and night

sweats. Furthermore, adjuvant chemotherapy has also caused a significant lower quality of

life in health-related aspects versus hormones or radiotherapy treatment alone (Galalae et

al., 2005). A comparison study, between post-chemotherapy breast cancer patients and

non-cancer group, revealed major differences in most areas related to the quality of life

(Broeckel et al., 2000). Bernhard et al. (2004) found that breast cancer patients who

received tamoxifen for five or three years, prior to the cycles of Cyclophosphamide,

Methotrexate and Fluorouracil (CMF) of chemotherapy, reported deterioration in most

quality of life domains at the third month during the treatment. Other researchers also

discovered and revealed that survivors, who had been treated with systemic chemotherapy,

scored significantly lower on the overall quality of life as compared to those who were

only treated with the local therapy (Ahles et al., 2005). Meanwhile, some other researchers

observed a slight deterioration in the physical functioning among women who had received

adjuvant treatment as compared to those who did not receive any (Ganz et al., 1998).

According to Schreier and Williams (2004), other studies on breast cancer therapy have

observed deterioration in the quality of life, even at the beginning of the therapy.

Meyerowitz et al. (1983) stated that nearly half of the breast carcinoma patients

reported long-term disruptions in at least one area in the quality of life, and more than 50%

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described continuing physical problems related to chemotherapy. At the end of the

primary treatment for breast cancer, women showed a decline in physical functioning,

particularly among those who had mastectomy or received chemotherapy (Ganz et al.,

2004). Moreover, it was observed that the levels of physical activities and energy intakes

significantly dropped during the adjuvant chemotherapy from prior-to adjuvant

chemotherapy (Demark-Wahnefried et al., 1997). Another study revealed that the quality

of life of the patients, who received chemotherapy, did not improve longitudinally, as

evaluated at six weeks after further treatment with radiotherapy (Galalae et al., 2005). In a

systematic overview on the effects of chemotherapy in breast cancer patients, Bergh et al.

(2001) suggest that the adjuvant polychemotherapy has an initial detrimental effect;

nevertheless, no evidence for the long-term effects in patients’ quality of life has been

gathered as compared to the untreated patients. Thus, it is likely that chemotherapy

interrupts the gradual improvement of the life quality, which tends to occur after surgery

(among others, Arora et al., 2001; Ganz et al., 1989; Schover et al., 1995). Lee et al.

(2005) gave more evidences on the adverse effects of the treatment; they demonstrated a

significant decrease in the physical functioning and general health of the breast cancer

patients treated with chemotherapy.

Besides the documentation of the negative effects caused by adjuvant

chemotherapy in the treatment of breast cancer, there are several other studies which have

shown contrary results (e.g. Campora et al., 1992; Ganz et al., 2003; Joly et al., 2000).

Among others, Bottomly et al. (2004) reported that the global quality of life of the patients

who had received chemotherapy treatment was maintained. This is supported by Joly et al.

(2000) who brought forward the issue of body image, which was not different between the

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patients who had and had not received adjuvant Cyclophosphamide, Methotrexate and

Fluorouracil (CMF) of chemotherapy of breast cancer.

The improvement in the quality of life over time, for women who had received

adjuvant therapy, was discovered in the study by Schreier and Williams (2004). Ozyilkan

et al. (1998) reported that physical symptoms were improved at post-chemotherapy. In the

work of Bergh et al., adjuvant polychemotherapy was found to have an initial detrimental

effect, but not causing impairment after a long-term period (2001). A two-year follow-up

conducted among breast cancer patients, following a high dose of chemotherapy with

autologous blood stem cell transplantation, indicated that the functional living index scores

were significantly better than the baseline (Conner-Spady et al., 2005). Other researchers

have also pointed out significant improvements in four out of five areas of life quality

(Meyerowitz et al., 1983).

In relation to the impact of chemotherapy treatment, breast cancer patients

exhibited a significant decrease in their social and role functioning (e.g. Lee et al. 2005). It

was noted that survivors, who had been treated with systemic chemotherapy, scored lower

on the social sub-scale as compared to those survivors who were only treated with the local

therapy (Ahles et al., 2005). This finding indicated that breast cancer patients ranked the

effects of the treatment on their work and home responsibilities as fourth and social

activities as fifth (Carelle et al., 2002). Ozyilkan et al. (1998) reported improvement in the

activity level for post-chemotherapy. On the contrary, Wefel et al. (2004) discovered that

the majority of the cancer patients reported a greater difficulty in maintaining their ability

to work at the short-term post-chemotherapy time point. Pressure related to getting back to

work as soon as possible had also been reported (Browall et al., 2006). According to

Berger and Far (1999), women were less active during the day, took more naps and spent

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more time for resting during the third cycle of the chemotherapy course. Meyerowitz et al.

(1983) found that breast cancer patients reported some continuous disruptions in the

general activity level at approximately 21 months, following the adjuvant chemotherapy,

as compared to the baseline assessment (as it was responded at two and half years earlier).

A significant improvement was also observed in the life activity among those patients in

the group involved at post-chemotherapy, as compared to the group of patients during

chemotherapy (Ozyilkan et al., 1998). Breast cancer patients who had been treated with

chemotherapy also demonstrated a significant decrease in the social and role functioning

(Lee et al., 2005). In addition, breast cancer patients, treated with chemotherapy, exhibited

a specific pattern of reduction in their usual activities and an increase in the hours of

resting (Lee et al., 2005). Nonetheless, some researchers did not report any negative

impacts of the chemotherapy treatment on the social and role functioning of the patients

(e.g. Campora et al., 1992; Joly et al., 2000). This is parallel to other findings which

suggested that adjuvant chemotherapy did not delay or prevent patients from returning to

work, for women who were treated for the early-stage breast cancer (Bushunow et al.,

1995). In a qualitative study by Browall et al. (2006), several important themes related to

the patients’ view of life, in confronting breast cancer treatment emerged; these include life

transformation and being in positive mind.

In relation to breast cancer treatments, emotional distress is one of the most

reported (e.g. Hoskin, 1997). According to Shilling et al. (2005), breast cancer patients

treated with adjuvant chemotherapy had a possibility to experience psychological

morbidity. Carlson et al. (2001a) stated that psychological disruption such as patients’

worries about the future, anxiety about the treatment and the general worrying, were

indicated to be the most problematic symptoms among those who had received

chemotherapy. Lauver et al. (2007) identified several primary stressors, at the end of

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treatment, such as the feeling of uncertainty about the treatment, follow-up and symptoms,

as well as the concerns over the physical difficulties in concentrating. Another study on

chemotherapy revealed that about one quarter of the breast cancer patients experienced

severe anxiety (Campora et al., 1992). Similarly, it was reported that 35% of the

participants experienced fear or anxiety at the end of chemotherapy (Beisecker et al.,

1997). Other researchers found higher anxiety scores among breast cancer patients who

received chemotherapy treatment (e.g. Schreier and Williams, 2004); while Berger and

Higginbotham (2000) gathered some evidences which suggested the existence of distress

symptoms, which occurred several days after the third cycles of chemotherapy, among

most women with breast cancer. Schreier and Williams (2004) also reported a higher level

of anxiety at the start of the treatment, and they associated it with the decrease in the

quality of patients’ life.

A long-term evaluation, which was done to measure the late effect of the treatment

on health, revealed that breast cancer survivors had poorer mental health (Ganz et al.,

2003). Among others, Mills et al. (2007) proposed that chemotherapy treatment could lead

to a significant increase in depressed mood, but this was observed to improve six months

afterwards (Wong and Fielding, 2007). Parallel to another study among metastatic breast

cancer patients, who received high dosage of chemotherapy and autologous stem cell

transplantation, anxiety and depression symptoms were found to continuously increase

during the entire follow-up period, which were prior to, during the treatment and up to one

year of post-chemotherapy (Carlson et al., 2001a). Browall et al. (2006) found that

women, who had previously been treated with chemotherapy, had a feeling of “not being

afraid of dying but wanted more time to prepare themselves” Bottomley et al. (2004) also

observed major improvements in the emotional functioning of the breast cancer women

who had received chemotherapy.

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However, psychological status was rated normal by 39 to 45% of the breast cancer

patients who had undergone chemotherapy (Campora et al., 1992). A similar finding was

also observed when a comparison was made between the survivors, who had been treated

with systemic chemotherapy, and those who had undergone the local therapy only; these

patients rated a normal range for the psychological or spiritual domain (Ahles et al., 2005).

In another study by Ganz et al. (2004), women reported to have a good emotional

functioning at the end of the primary treatment for breast cancer, particularly among those

who had mastectomy or received chemotherapy.

Based on above facts, the chemotherapy treatment of breast cancer has shown a

tendency to affect the general health of women, as well as their social and psychological

well-being, although some researchers have found inconsistent results which could

challenge the many adverse effects proven so far.

3.3 Chemotherapy Symptomatology

It has been suggested that the chemotherapy treatment for breast cancer can cause

various symptoms leading to the impairment on the patients’ quality of life. Several

studies on cancer chemotherapy have revealed that there is a significant symptom of hot

flashes among breast cancer patients who have received chemotherapy (Crandall et al.,

2004; Macquart-Moulin et al., 1997; Stein et al., 2000). A long-term observation by

Conner-Spady et al., indicated sleeping disturbances as one of the most common

symptoms (2005). Meanwhile, Lindley et al. (1998) reported the incident of insomnia

among breast cancer patients who had survived two to five years, following the adjuvant

therapy. When compared to healthy women control, breast cancer patients who were

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treated with chemotherapy exhibited sleep disturbances when assessed during

chemotherapy and at four-month post-chemotherapy (Ozyilkan et al., 1998). This finding

is similar to the results gathered by Janz et al. (2007) who found the adverse effect of

breast cancer treatment on the patients’ sleep quality, when evaluated at seven months,

following the surgery. Conner-Spady et al. (2005) suggest that headache is another most

common symptom in the longer term. Similarly, hair loss has been indicated as a frequent

symptom (e.g. Genre et al., 1997). Among others, a study done by Love et al. (1989)

indicated that hair loss was experienced by more than 80% of the patients during

chemotherapy treatment; this was in fact accepted more negatively than the loss of a breast

(Browall et al., 2006). Nausea is another symptom which has also been frequently

reported (e.g. Beisecker, 1997; Genre et al. 1997; Roscoe et al., 2004). Local numbness at

the site of surgery has also been experienced by patients, and this occurs with greatest

frequency (Lindley et al., 1998). Other researchers documented a significant weight gain

in women who had been treated with adjuvant chemotherapy for breast cancer (e.g.

Demark-Wahnefried et al., 1993; McInnes and Knobf, 2001), while Ozyilkan et al. (1998)

proposed that the loss of appetite was seen to improve at post-chemotherapy. Low blood

count was also another most frequently described symptom, which usually occurred

shortly after completing chemotherapy (Beisecker et al., 1997). A long-term follow-up

study, comparing the survivors of breast cancer to the population controls, concluded that

the problem associated to the arm was a significant one (Dorval et al., 1998). This is

supported by the findings of other studies, which observed the adverse effects of

chemotherapy on the arm and breast areas (Hopwood et al., 2007; Jaz et al., 2007).

Another symptom which is associated with long-term chemotherapy treatment is smell

aversion among patients (Berglund et al., 1991). Several previous studies reported pain as

one of the most frequently mentioned symptoms (e.g. Wyatt and Friedman, 1998) which

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gradually declined over time (Bottomley et al., 2004). Joint paint, which is closely related

to the pain symptom, was also reported as one of the most problematic long-term symptom

(Carlson et al., 2001a). Ozyilkan et al. (1998) found physical symptoms as another major

regression which was found to improve at post-chemotherapy. Meanwhile, the symptom

of tiredness had been reported by more than 80% of the breast cancer patients (Love et al.,

1989. Other crucial symptoms (associated to cancer therapy) which can not be neglected is

alopecia (Alopecia also refers to hair loss and is the medical description of the loss of hair

from the head or body, sometimes to the extent of baldness) (Carelle et al., 2002), mood

swings (Young-McCaughan, 1996), lymphoedema (Lymphoedema is the swelling which

develops due to the accumulation of lymph fluid in a part of the body) (Nail, 2001), and

dermatological side-effect (Hackbarth et al., 2008).

Yet another important impact, which can be observed among those who have

received chemotherapy, is cognitive dysfunction (e.g. Jenkins et al., 2006; Schagen et al.,

1999; Shilling et al., 2005; Tchen et al., 2003; van Dam et al., 1998). For instance,

Schagen et al. (1999) noted a higher risk of late cognition impairment which could be

caused by the treatment of chemotherapy, in which the regimen of Cyclophosphamide,

Methotrexate and Fluorouracil (CMF) is used. The study by Wefel et al. (2004)

documented that 61% of the women with breast carcinoma demonstrated a decrement in

one or more domains of cognitive functioning, at the short-term post-chemotherapy time

point. To add to this, problems associated with memory and concentration were also

reported at six months post-surgery (Shilling and Jenkins, 2007). However, Fan et al.

(2005) recommended that the adverse effect of chemotherapy on the cognitive dysfunction

was improved in majority of the patients. Meanwhile, an observation at six-month post-

adjuvant therapy did not report any significant problems in relation to cognitive

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functioning among women who had been treated with chemotherapy, as compared to those

who were not treated (with chemotherapy) (Donovan et al., 2005).

Fatigue is a symptom which has been increasingly realized by many, specifically in

affecting the breast cancer patients’ quality of life, even though such symptom is

sometimes being unrecognized and untreated. Cancer-related fatigue is a clinical

syndrome which is experienced by many patients, before and during adjuvant therapy for

breast cancer (Andrykowski et al., 2005). Some researchers strongly suggested that

adjuvant chemotherapy could cause fatigue in women with breast cancer (Broeckel et al.,

1998; Carelle et al., 2002; Lindley et al., 1998; Tchen et al., 2003). In the same vein,

several researchers pointed out that chemotherapy led to a significant increase in fatigue

(Bottomley et al., 2004; Janz et al., 2007; Mills et al., 2005; Shilling et al., 2005);

however, the condition was found to improve over the time (Fan et al., 2005). de Jong et

al (2005) indicated that the symptom of fatigue seemed to be stable during the treatment of

chemotherapy and an insignificant decline was observed when the treatment was

completed. They further explained that fatigue could affect the daily functioning of the

breast cancer patients (de Jong et al., 2004). On the contrary, Shilling et al. (2005) argued

that fatigue increased following the chemotherapy. It was also observed that fatigue

significantly increased after the last cycle of chemotherapy, before declining (de Jong et

al., 2004). This result is parallel to the findings by Jacobsen et al. (1999) who found that

fatigue would worsen after the treatment was started. Another study revealed the increase

in the problem of fatigue after the third cycle of chemotherapy treatment (Berger and

Higginbotham, 2000). Some researchers suggested that the symptom of fatigue fluctuated

during the course of chemotherapy treatment and did not cease even when the treatment

was ended (Payne, 2002).

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Based on these arguments, both cognitive impairment and fatigue have clearly

been documented as common symptoms which are experienced by breast cancer patients

treated with chemotherapy; whereas, other symptoms such as hair loss, nausea, headache

and sleeping disturbance have been indicated as temporary side-effects which impair

patients’ quality of life.

3.4 Coping and Adjustment

Appropriate coping and adjustment is important in facing chronic diseases,

especially during the treatment period such as in the chemotherapy. A qualitative

observation reported that breast cancer patients tried coping with adjuvant chemotherapy

through normalizing strategies, such as keeping a brave face, maintaining previous patterns

of life, looking for humour and restructuring time (Cowley et al., 2000). When compared

with women who had no history of cancer, former adjuvant chemotherapy patients

exhibited a greater use (higher level) of catastrophizing as a coping strategy (Broeckel et

al., 1998). Another study on chemotherapy treatment indicated that breast cancer patients

made use of certain strategies to get back to their normal life, such as seeing their family

members as usual, sustaining or returning to their normal patterns of life as soon as

possible, minimizing disorderliness, de-emphasizing sick role demands, reframing

negatives, and putting the cancer behind them (Hilton, 1996). In the meantime, Payne

(1990) stated that chemotherapy recipients employed four predominant styles in coping

with the treatment crisis - think positively/fighter, acceptance, fearfulness and

hopelessness. Women, who underwent chemotherapy treatment and had “confrontive”

element in coping style, were found to experience less psychological and physical

symptoms, as compared to the patients who had “avoidant” element in the coping strategy

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used (Shapiro et al., 1997). Another researcher pointed out that behavioural escape-

avoidance and cognitive escape-avoidance as the most important coping mechanisms

which contribute to the psychological distress of the cancer patients receiving

chemotherapy (Zabalegui, 1999). Thus, the coping style with a fighting spirit has been

observed to associate with a greater adherence to the chemotherapy regimen (Ayres et al.,

1994).

In general, breast cancer patients exhibit positive coping strategies in the treatment

situation. Certain coping strategies, such as disengage style, behavioural escape-avoidance

and cognitive escape-avoidance, have been identified to cause negative psychosocial

impacts to patients treated with chemotherapy.

3.5 Sexuality

Women’s sexual dysfunction in breast cancer could be predicted by the treatment

of adjuvant chemotherapy (e.g. Awadalla et al., 2007; Barni and Mondin, 1997; Ganz et

al., 1998; Hopwood et al., 2007). According to several researchers, breast cancer patients

have reported to experience a wide range of sexual difficulties, following the systemic

adjuvant therapy (e.g. Ganz et al., 1998; Lindley et al., 1998). As reviewed by Stead

(2003), chemotherapy has been shown to be associated with both short- and long-term

effects on the sexual functioning in gynaecologic cancer treatment. Furthermore, sexual

problems have also been reported to arise, mainly after chemotherapy (Barni and Mondin,

1997). However, some long-term studies did not relate problems pertaining to sexual

functioning of breast cancer women who had received adjuvant chemotherapy (e.g. Joly et

al., 2000).

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Various long-term studies revealed that breast cancer patients (treated with

chemotherapy) experienced a decline in their sexual interest (Broeckel et al., 2002; Carlson

et al., 2001a; Conner-Spady et al., 2005). As evident from the study carried out among

patients with gynaecological and breast malignancies (who were in adjuvant situation),

Fasching et al. (2007) stated that these women complained of their interrupted sexual life.

In addition, Barni and Mordin (1997) emphasized that the majority of the patients who had

undergone chemotherapy treatment experienced the absence of sexual desire. When

compared to women with no history of cancer, Broeckel et al. (2002) reported that women,

who had previously been treated with adjuvant chemotherapy, experienced the inability to

relax and enjoy sex, as well as exhibited difficulty in becoming aroused and achieving

orgasm. Specifically, Surbone and Petrek (1997) explained that chemotherapy treatment

could also cause a decline in the ovarian function related to follicle destruction or fibrosis

of the ovaries, which might lead to the disruption in the sexual relationship of breast cancer

patients.

Barni and Mondin (1997) reported that most of the breast cancer patients continued

with their sexual activity after the treatment; however, they further stated that there was an

increase in the sexual problems which affected the quality of their sexual life. In terms of

the number of patients affected, Barni and Mondin (1997) indicated that about one third to

nearly half the number of women treated with breast cancer therapy experienced

dyspareunia (a condition which involves painful sexual intercourse due to medical or

psychological causes), frigidity (a term used to refer to the loss of libido in females),

lubrication problems, vaginismus (a condition which affects a woman's ability to engage in

any form of vaginal penetration, including sexual penetration, insertion of tampons, and

the penetration involved in gynaecological examinations) and female orgasmic disorder

(this problem occurs when there is a significant delay or a total absence of orgasm

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associated with the sexual activity). Similarly, Ganz et al. (1998) found that the symptom

of pain during intercourse and vaginal dryness occurred more often in survivors who had

been treated with chemotherapy. Broeckel et al. (2002) carried out a study to compare

breast cancer patients with women without any history of cancer; they discovered that the

severity of vaginal dryness significantly contributed to poorer sexual functioning among

the long-term breast cancer survivors who had been treated with chemotherapy.

Hence, sexuality disturbance is obviously a major issue among breast cancer

women treated with chemotherapy. Women’s sexual interest and libido have been

identified to be the areas which are mostly affected.

3.6 Menopausal Issue

Symptoms, associated with menopause, have also emerged as a significant problem

among women who had gone through the treatment of breast cancer (e.g. Carpenter and

Andrykowski, 1999; Tchen et al., 2003; Young Mc-Caughan, 1996). In addition, Mc Phail

and Smith (2000) demonstrated that chemotherapy recipients were more likely to exhibit

menopausal symptoms such as tiredness, hot flashes and night sweats, as compared to the

control group in their study. In breast cancer treatment, the prevalence of hot flashes was

high, with 17%, 51% and 71% occurring in the pre-, peri-, and post-menopausal women,

respectively (Crandall et al., 2004). At the same time, vaginal dryness and pain during

intercourse were among the symptoms observed to be more severe in post-menopausal

women, as compared to peri-menopausal breast cancer patients who had gone through

cancer therapy (Crandall et al., 2004). Similarly, it was discovered that adjuvant therapy

was associated with a significant worsening of menopause-related symptoms among post-

menopausal women (Biglia et al., 2003). Furthermore, Biglia et al. (2003) explained that

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the incidences of vasomotor and dystrophic symptoms were significantly higher in the pre-

menopausal women. Weight gain was also detected among pre-menopausal women who

had received chemotherapy treatment (Demark-Wahnefried et al., 1993; McInnes and

Knobf, 2001). However, according to Fan et al. (2005), menopausal symptoms could be

improved over time. As such, the impairment of physical function and other functional

domains, among post-menopausal women, during adjuvant chemotherapy, could also be

subsequently recovered (Watters et al., 2003). In comparison to this, the feelings of

concerns and worries about recurrence and the quality of life impairment were found to be

higher among pre-menopausal women who had undergone cancer therapy than older

women (Biglia et al., 2003).

Moreover, it was also found that the majority of breast cancer patients, who had

been treated with chemotherapy, experienced disturbances in their menstrual cycles

(Ketiku and Ajekigbe, 1990; Kumar et al., 2004). The disturbances in the menstrual cycle

(also termed as chemotherapy–induced menopause by the medical specialist) caused the

menopausal symptoms to be more common and severe as compared to the natural

menopause situation (McPhail and Smith, 2000; Young McCaughan, 1996). In addition,

chemotherapy treatment has also been associated with the ovarian damage among pre-

menopausal women with breast cancer; the condition which is suggested as a long-term

consequence of the adjuvant chemotherapy treatment (Bines et al., 1996). A study by

Mehta et al. (1991) on the endocrine profile among breast cancer patient, who received the

regimen of Cyclophosphamide, Methotrexate and Fluorouracil (CMF), exhibited the

suppression of the ovarian function.

Therefore, it can be stated that chemotherapy treatment may cause different effects

on the psychosocial aspect of women, depending on their menopausal status. The

treatment may also result in more common and severe menopausal symptoms.

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3.7 Spouse or Partner Issues Related to Breast Cancer

The psychosocial impact of chemotherapy on partners or spouses of cancer patients

is also vital; however, there is still a lack in terms of the research on the subject matter,

leading to inconclusiveness and a gap surrounding the breast cancer issues related to

partners or spouses. The importance of spouses or partners in breast cancer has not been

explored or studied by many researchers. Among related studies, Carelle et al. (2002)

found out that cancer patients rated the “effect on partner or family members” as the most

important psychosocial outcome from chemotherapy treatment. Based on the limited

studies in the chemotherapy setting, it was indicated that the majority of patients rated the

changes in the relationship with their partner as crucial (Barni and Mondin, 1997), besides

the good relationship with their partner (Campora et al., 1992). At the same time, Kreling

et al. (2006) indicated the importance of family members (partner or spouse as a unit in the

family) in making decisions on further treatment of chemotherapy. In another study

among breast cancer patient treated with chemotherapy, researchers have presented the

themes of relationship issues related to the roles, responsibilities and connectedness

(Bakker et al., 2001). In addition to this, Carlson et al. (2001a) pointed out that the worst

problems, faced by recipients of chemotherapy in breast cancer treatment, were the

patients’ feelings of adversity, not only for themselves but also their families. Relating

their experiences with chemotherapy treatment, women described the lack of support from

the people close to them, as the fact which had been indicated as leading to a feeling of

imbalance in the patients’ relationships (Browall et al., 2006).

In relation to the sexuality issue, associated to spouse or partner following the

breast cancer treatment, it is indicated that roles of the patient’s partner in initiating

intercourse is important for women’s marital satisfaction, well-being and psychosexual

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adjustment (Wimberly et al., 2005). On the same issue, Wimberly et al. (2005) also stated

that the emotional involvement of their partner in the relationship had been largely

associated with women’s psychosocial aspect. Other important finding from Wimberly et

al. (2005), in relation to partners in breast cancer treatment is that, partners’ adverse

reaction to the scar was predictive of their marital satisfaction. It means that the higher the

partners’ negative reaction/feeling on patients’ scar (following surgery), the lower the

feeling of marital satisfaction. The rating on the quality of the first sexual experience after

treatment also predicted less distress among women with breast cancer.

In dealing with their wives’ breast cancer and chemotherapy, Hilton et al. (2000)

observed that men took certain actions, such as focusing on the illness and care, relying on

health care professionals, being informed and contributing to decision making, focusing on

their families to keep life going, helping out, trying to be positive, putting self on hold,

adapting work life and managing finances. For these, Wilson and Morse (1991) have

identified three stages of basic social process, which husbands undergo in coping with their

wives’ chemotherapy: identifying the threat, engaging the fight and becoming veterans. In

relation to this coping process, “buffering” has been identified as a core process which

involves filtering and attempting to eradicate daily stressors to shield their wives. In

addition, buffering also requires men to being constantly alert in monitoring their spouses’

reactions to chemotherapy and their interactions with others, taking cognitive action by

construing and appraising the situations they perceived their wives to be in and deciding

what action(s) to utilize in order to protect them from their circumstances.

Partners or spouse of women with breast cancer, treated with chemotherapy, stand

as a critical determinant in these women’s post-breast cancer relationship. Their role in

their families is definitely essential and can not be totally neglected, especially in

providing support to their wives who have to confront with the adverse effects of the

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chemotherapy treatment. In general, partners react with positive or negative coping

strategies and adjustments in dealing with their spouses’ treatment of breast cancer. In

other words, they also undergo the psychosocial process such as buffering, in order to

adapt with chemotherapy.

In sum, despite the chemotherapy treatment can have a negative effect on

recipient’s quality of life, it survival advantage should not be undermined. It was pointed

out that medical factor (i.e. regiment of doses, duration of therapy, treatment interval and

type of operation) and socio-demographic factor (i.e. age and ethnicity) may contribute to

the psychosocial aspect of the chemotherapy recipients. In terms of chemotherapy side-

effect, it was observed that cognitive impairment, fatigue, hair loss, nausea and sleeping

disturbance were among the common symptoms experienced by the chemotherapy

recipients. Meanwhile, in facing the chemotherapy treatment, breast cancer patients

exhibited the coping strategies such as disengage style, behavioural escape-avoidance and

cognitive escape-avoidance which was indentified to have a negative psychosocial impacts

to this chemotherapy recipient. In sexuality aspect, decreased in sexual interest and libido

have been observed as a major issues. In addition, the side effects of chemotherapy

treatment were also related to the more common and severe menopausal symptoms. In

discussing this issue related to the psychosocial aspect of chemotherapy treatment for

breast cancer, the psychosocial effect on the patient’s spouse is also important. It has been

reported that spouses react to the situation with positive and negative coping strategies and

adjustment in dealing with their spouses’ treatment of breast cancer.

Based on the introduction of the study in Chapter One and the reviews which

included numerous findings on breast cancer in the literature review, the hypotheses of the

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study (postulated with a justification through the development of the conceptual

framework of the study) will be presented in the next chapter.

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CHAPTER FOUR

A CONCEPTUAL MODEL OF QUALITY OF LIFE, INTERPERSONA L

RELATIONSHIP AND COPING STRATEGIES OF WOMEN WITH BR EAST

CANCER AND THEIR HUSBANDS

The justification of the conceptual framework of the current study is described in

detail in this chapter. This conceptual framework was constructed using the main

components of women’s quality of life, elements of interpersonal relationship and coping

strategies. In addition, the framework was further strengthened by incorporating the

various factors related to husbands (as one of the main components), as well as the

bio/socio-demographic and medical factors.

4.0 Rationale of the study

The significant importance of the main aim of the study, which examined the inter-

relationship between the quality of life, interpersonal relationship and the coping strategies

among women with breast cancer and their husbands, had been described in the previous

chapters. Specifically, this study was framed based on several rationales. Firstly, breast

cancer is an important disease where the psychosocial impact of the disease is not only

experienced by the patients, but also by their family members, the fact which subsequently

affect the patients’ overall quality of life. Thus, the framework had also included the

spouse of the breast cancer patients as an important part of the study.

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Secondly, it is important to examine the psychosocial impact of breast cancer, with

special attention on chemotherapy. There is a uniqueness in the effect of the chemotherapy

treatment on the patients’ psychosocial aspect, as it has been suggested that the treatment

can cause the fluctuating patterns of impairment on women’s quality of life (Berger and

Hingginbotham, 2000; Payne, 2002), which also affects women’s interpersonal

relationship and their coping behaviour. In addition, this study broadened the knowledge

in the area on the quality of life among patients suffering from breast cancer, where the

link between psychosocial aspects, such as the interpersonal relationship and coping

strategies was explored in the proposed conceptual framework.

Thirdly, there is a need for a more local data pertaining to the psychosocial impact

of breast cancer, as there has been a scarcity of research in this area, particularly among

Malaysian women. In addition, there are enormous possibilities in the differences

surrounding the issues on breast cancer between the Asian and Western populations. For

instance, Kagawa-Singer and Wellisch (2003) found that Asian-American women

sacrificed more and placed their priorities in taking care of their husbands and family than

in themselves. On the other hand, the European American women are able to depend on

their husbands and family members. Another major difference which exists is in the aspect

of harmony and intimacy, whereby Asian-American women placed more importance on

harmony over intimacy, whereas European-American women placed a higher importance

on intimacy over harmony. Yet another significant difference which also plays a crucial

role is in the area of communication. According to Kagawa-Singer and Wellisch (2003)

again, Asian women prefer and value non-verbal communication over verbal

communication, whereas European-American prefer for verbal communication over non-

verbal communication. The second example although not related to the area of breast

cancer, is given by Huang and Mathers (2006) who indicated that more women from the

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United Kingdom had adequate information about sex during the post-natal period as

compared to Taiwanese women. In lieu to this issue, research on the South Asian

women’s cultural beliefs and values, in relation to health, indicated that the family

structures, traditional behaviour, modesty, norms and attitudes, play important roles in the

health system of this society (e.g. Bhakta et al., 1995; Bhopal, 1986; Nilchaikovit et al.,

1993). Sodhi (1995), in her study in Canada, identified several cultural barriers for South

Asian women in facing breast cancer, such as language, transportation and the lack of

extended family network for guidance and assistance. Again, in reference to Sodhi (1995),

discussing a sensitive health issue (i.e. breast health) could potentially be awkward in the

case of South Asian women. Based on the example of the research carried out in South

Asian Women by Bottorff et al. (1998), it is suggested that South Asian women have their

own beliefs regarding the issues of breast health, like keeping the honour of their families,

being modest, and putting others’ needs before their own. These practices play a crucial

role in the various aspects of a woman’s life, and they can also play a part in how women

view breast health practices in their lives. In relation to matters pertaining to cancer, South

Asian women feel that it is important for them to maintain the appearance of a healthy

family from a strong lineage and having the ability to cope with the tasks, duties and

routines they perform in their daily life. There are many cases in which women are afraid

that the standing of their family in the community will be affected and that their children’s

marriages are dependant on this standing. Quoting Bottoroff et al. (1998), South Asian

women protect their families’ honour, in cases related to breast cancer, in two ways. First,

these women did not even want to get themselves checked for breast cancer, stating that it

was as if there was something bad or wrong with her family when they contracted cancer

and that people would stop associating with her family; and second, these women kept

breast cancer private to protect their families’ honour. For example, some women

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refrained themselves from discussing cancer, and for many others, discussing cancer with

outsiders, who were not family members, was viewed as socially unacceptable. In the case

of other women, their cancer status and worries were kept secret in order to prevent

rumours from “dishonouring” the family. This is further exacerbated by the fact that

modesty is an integral and highly valued quality, which is cultivated among the South

Asian women from childhood. This modesty of women explains their reluctance for breast

examinations, even towards their physicians and it certainly explains why they hesitate

when they are asked to remove their clothing in the presence of a health professional.

Some women even went as far as being adamant on wanting to be examined by only

female physicians, while others revealed that they would be more comfortable with a

physician who is not from their culture. A woman’s modesty is not restricted only to

showing her body to others and how she treats her own, but it can also be seen in the

uncomfortable state they are in when they perform breast self-examination, in which they

believe that it is inappropriate for them to touch themselves in such a manner when

performing the self examination. What is worse is that they even feel uncomfortable

discussing and using the word “breast”. Another important belief, related to breast health

practice, is putting others first before oneself. The South Asian Women are proud in their

strength and the contribution of their commitment to their family members and

community. This kind of belief reflects that these women do not consider breast health as

a priority, and thus, they do not have the time for it. Meanwhile, in the aspect of their

belief about cancer, the South Asian women do realize that cancer is a hidden killer. This

aspect leads these women to conclude that anything, which is done to prevent, detect, or

treat breast cancer, is just a waste of time and is therefore useless. Without the

encouragement and support from their close friends and family members, these women

have been discovered to have a great deal of reluctance to seek for medical advice.

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Therefore, a good understanding of the cultural beliefs and practices of a particular culture

in the context of health is indeed essential.

Thus, based on the above general background discussion, the conceptualization and

justification of the conceptual framework of the study are outlined in the following

sections.

4.1 Conceptualization and Justification of the Conceptual Framework of the Study

The general rationale is addressed in terms of structuring the conceptual framework

of the study (see Figure 4.0). The psychosocial aspect of breast cancer, among women and

their husbands, was observed within the chemotherapy setting, which is divided into three

phases: prior to chemotherapy (Baseline), during chemotherapy (Phase Two) and post-

chemotherapy (Phase Three). The justification in structuring the study framework was

based on many previous studies which had been conducted surrounding the breast cancer

research, as well as outside of the breast cancer field. In addition, the conceptual

framework for this model was also based on the significance of the issues pertaining to the

quality of life, interpersonal relationship and coping strategies in the study of cancer,

particularly breast cancer. One of the main components in this conceptual framework is

the quality of life. In the issue of the life’s quality and chemotherapy treatment for breast

cancer, patients have been found to experience various symptoms resulted from the

treatment they went through, which are regarded as the causes for the deterioration of

quality in one’s life, such as headaches, feeling unwell, dry mouth, food tasting unusual

(Bottomley et al., 2004), sleep interruptions (Engel et al., 2003; Kurtz et al., 1993), as well

as nausea and vomiting, fatigue and hair loss (National Institutes of Health Consensus

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Development Conference Statement: Adjuvant Chemotherapy for Breast Cancer, 1986).

The treatment for breast cancer has also been found to cause the patients to undergo

psychological, social and role disruptions (Aranda et al., 2005; Chantler et al., 2005;

Chwalczyrska et al., 2004). According to Hoskin and Haber (2000), the psychological

disruption can be caused by the patients’ anxieties about their future, the long-term

prognosis and the possible recurrence of cancer. Meanwhile, the social and role

disruptions can be caused by the patients’ inability to perform their parenting roles, such as

taking care of their children, doing household chores and the like (Holmberg et al., 2001).

Another component in the quality of life, which is also found to be important in the

structuring of this conceptual model, is the aspect of sexuality. A few sexual symptoms

are found to be related to the chemotherapy treatment for breast cancer, such as hot flashes,

decrease in libido, as well as dryness and atrophy of vulva. In addition, chemotherapy

treatment also can cause problems in intercourse, as the vagina becomes easily irritated due

to the fragility and thinness of the mucosa in vagina (Hordern, 2000). The significant issue

of women’s sexuality, in research on quality of life of breast cancer patients, is also related

to the change of the women’s core feature of their self-identity, as a result from the loss of

the breast (Holmberg et al., 2001). They added that the treatment of breast cancer also

causes women to lose their sexual appeal, such as hair loss and awkwardness in dressing in

feminine clothing (Holmberg et al 2001). Women, who had undergone breast removal

surgery, were also found to have feelings of perceived ugliness of breast scars, feelings of

lost dignity, shame, and embarrassment with the body changes, low self-esteem and

difficulty in looking at their own bodies (Holmberg et al., 2001). The deterioration of

sexual health, among women with breast cancer, is also portrayed by the decrease in the

sex arousal, as well as the lower frequency of kissing from their spouses (Anderson and

Jobimsen, 1985). According to Kaplan (1992), the problem pertaining to sexuality among

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patients with breast cancer treatment is also related to the reduced level of the androgen

hormone.

The second component which was constructed in this conceptual framework is the

aspect of interpersonal relationship. The opinion of Petrie et al. (1999) was used in the

justification of the interpersonal relationship component; they suggested that several

positive consequences could be found from the experience of life crisis which heightened

empathy for others, improved interpersonal relationships, as well as led to changes in basic

values and priorities. Barker and Lemle (1984) proposed that a sick person receives her or

his partner’s responses in three distinguishable ways: firstly, by expressing sympathy,

cheer, comfort, and affection or reassurance; secondly, by giving advice or solving

problems; and thirdly, by listening passively. The view on the relationship changes and

the difficulties in breast cancer (caused by the distance in emotion) are also taken into

consideration. It is speculated that the feeling of distance of one’s emotion could be

originated from three sources. Firstly, unable to discuss the feeling of grief, loss and

potential death with each other; secondly, conflicts are resolved in a different manner in

order to protect each other, and thirdly, the negative perceptions of the women about their

femininity and their feelings of inadequacy (Holmberg et al., 2001). In relation to this

justification, the basic idea which supports the aspect of interpersonal relationship, as a

component in this conceptual framework, is that breast cancer is actually an illness which

can bring patients and their spouses closer (Dorval et al., 2005). This is exactly what

Leiber et al. (1976) stated, i.e. cancer patients have more than before the desire to be

physically close, such as having proximity, holding hands, embracing and kissing; the facts

which suggest that comforting and reassurances are highly demanded after cancer

diagnosis. Another finding supporting this fact indicated that breast cancer patients were

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reportedly demonstrating more tenderness and affection to and from their spouse in the

initial three months after diagnosis (Dorval et al., 2005).

The third component proposed in this conceptual framework is the aspect of coping

behaviour. In this aspect, Schaefer and Moos (1992) took into account the individuals who

were experiencing life crisis, which might have resulted in three positive outcomes - the

increased social resources, increased personal resources and the enhancement of the new

coping skills. In dealing with cancer, Lewis and Deal (1995) suggest that patients engage

with actions such as managing everyday illness, surviving, healing and preparing for death.

In the same vein, patients are said to undergo several stages in the coping process, like

reacting to the cancer diagnosis, identifying and evaluating potential strategies, choosing

the strategy (based on the influence of others and one’s goal), and deciding on the coping

strategy, which is contributed by both internal and external factors (Link et al., 2005).

To conceptualize this study, two more factors were included into this framework

and proposed as the supporting ideas to the main components. First is the factor in relation

to the spouse or the husband. The significance of this factor can not be undermined

because some studies revealed that the spouse of the patients also experienced

psychosocial morbidity due to their partner’s breast cancer (e.g. Omne-Ponten et al., 1993;

Wagner et al., 2006). Psychosocial morbidity of the spouse can also be caused by their

feeling of worries and uneasiness (Gotay, 1984), great concern about the partner’s

recovery, handling household chores (e.g. cooking, cleaning, etc.) and regretting or feeling

sad that their partners have lost a breast (Holmberg et al., 2001). In addition, the

psychosocial morbidity of the spouse (e.g. worries) is found to be caused by the concerns

about the possibility of the recurrence of the disease and the marital problems related to

cancer (Zahlis and Shands, 1993). The significance of spouse or partner in breast cancer

issue had also stated by Woloski-Wruble (2002) who reported that the spouse needed more

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information about the treatment as well as the disease. They also seemed to need more

information about sexuality and intimacy. According to Hughes (1996), husbands of the

breast cancer patients also experienced disturbance in their sexual life, due to their wives’

breast cancer, such as changes in the frequency and satisfaction with their sexual activities.

A few researchers have brought forward the issue concerning marital communication.

Among others, Halford et al. (2000) reported that many couples were not comfortable with

talking about the disease and thus preferred to avoid the topic altogether because they were

worried that it might distress their wives (the patients). In addition to this, there are also

growing number of studies which place emphasis on the importance of couples to mutually

and socially support each other in their relationship, and this is most likely in relation to

cancer (e.g. Cutrona, 1996; Halford et al., 2000). Dorval et al. (2005) discovered that

couples felt close 12 months after getting some specific types of support provided in the

first two weeks of post-treatment. Dorval et al. (2005) added that the couples, who were

doing well in their relationship, were those whose spouses had received advice from the

patients on how to cope with breast cancer, and who reported to be confiding in the

patients early after diagnosis. Based on Cutrona’s (1996) point of view, i.e. close

relationship can be attributed by the element of love, interdependence, trust and

commitment, it was noted that the survival of intimate relationships was dependent on the

partner’s response in times of need. According to Baxter (1986), relationship dissolution

can be caused by inadequacy of support. In relation to this, Vess et al. (1988) pointed out

that communication in cancer tends to be characterized by the element of avoidance, in

which spouse or family members avoid the topic which involves negative information or

emotion. Dunkel-Schetter and Wortman (1982) appended that communication could be

depreciated if family members (e.g. spouse) believed that it was detrimental for the patient

to dwell on unpleasant focus about the illness. Thus, problems in couple communication

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also can be created by the unwillingness of the spouse to communicate about any cancer-

related issues (Litchman et al., 1987).

The second factor, justified to support the components of the conceptual framework

of study, includes the medical-related factors (types of surgery, breast cancer stages,

duration of breast cancer), and the bio/socio-demographic factors (menopausal status, ages,

ethnicity, educational status, household monthly income, duration of marriage). A number

of past findings showed that the types of breast cancer surgery (mastectomy and

lumpectomy) had imposed negative effects on the patients’ perception of their body image,

especially among the women who had had mastectomy. Although not all researchers were

in agreement on this matter, some researchers found that women who had gone through

mastectomy were suffering from psychological morbidity (emotional disturbance, lower

physical and functional well-being), as compared to those who had lumpectomy (e.g.

Arora et al., 2001; Monteiro-Grillo et al., 2005). Meanwhile, in the aspect of breast cancer

stages, the comparison in terms of the psychosocial effects according to the stages of

cancer is important. Despite the fact that previous researchers did not really place a great

emphasis on this issue (e.g. Gottschalk and Hoigaard-Martin, 1986; Hernandez-Reif et al.,

2004), the seriousness of breast cancer, classified by the size of the tumour, involvement of

the lymph nodes and metastasis (American Joint Committee in Cancer, 2002), is believed

to have caused different effects on the physical, psychological and social well-being of the

patients. In the bio/socio-demographic aspect, the factor which has been given focal

attention is the menopausal status of the patients (pre-menopausal or post-menopausal);

this factor is found to be important in the psychosocial issue of breast cancer. In a

comparison study, a group of women who were pre-menopausal were found to be different

from the post-menopausal women because the later group of women were older. In this

case, a difference could particularly be seen in the body composition, whereby the most

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noticeable change would be the degeneration of muscle quality (Kallman et al., 1990;

Forrest et al. 2007; Landers et al., 2001; Newman et al., 2003). The major differences

were also observed in the area of bone density (Trotter et al., 1960), and the ratio of the

body K to total body water (Bruce et al., 1980; Cohn et al., 1980; Pierson et al., 1982).

The decrement of the estimated ratio of muscle mass to visceral mass is also exhibited

(Tzankoff and Norris, 1978). Similarly, older patients were found to be much weaker than

the younger ones after major surgery, and they faced more problems in recovery (Watters

et al., 1993). Health expectation (i.e. the expectation that one has on her own health) is

also affected by age (Carr et al., 2001). The second factor, which is given much attention

in the socio-economic aspect, is the ethnicity factor in the Malaysian population (namely

Malay, Chinese and Indian). Ethnicity, which is related to culture, is a medium in which

an individual perceives and understands the community that he/she resides in, learns how

to be emotionally in, and interacts in relation to other people, supernatural forces, God and

the natural environment (Helman, 2000). Through these, the philosophy of the traditional

medicine, which is unique among the races in Malaysia, (e.g. “Yin Yang” in the Chinese

community and “Ayurveda” in the Indian community) is hypothesized to possibly affect

the appraisal of one’s quality of life. This issue of culture was also put forward by several

researchers such as Wu et al. (2006), who found the differences in the perception of

susceptibility and seriousness related to breast cancer among the Chinese and Indians who

resided in America. The issue of culture was also brought up by Kagawa-Singer and

Wellisch (2003) who uncovered differences in the aspect of interpersonal relationship

among the Asian-American and Euro-American breast cancer patients. In their studies, the

Euro-American women were found to be more dependent, whereas the Asian-American

women were indicated as more self-sacrificing and nurturing to their families. In the

theme of harmony and intimacy, the Euro-American women focused on intimacy instead

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of harmony, while the Asian-American women emphasized on harmony rather than

intimacy. In terms of communication, the Asian-American women favoured non-verbal

communication over the verbal communication, and this was vice versa for the Euro-

Americans.

Finally, the structuring of the conceptual framework of this research was also based

on two philosophies - the “Elicit Meaning” philosophy (proposed by Degner et al., 2003)

and the “Experience Perspective” philosophy (termed by Jansen et al., 2005). The

philosophy of “Elicit Meaning” states that the patients view cancer as a challenge and

value, and this could have positive effects on their happiness. Meanwhile, the philosophy

of “Experience Perspective” outlines that experienced patients have a more favourable

attitude towards the treatment they have received than those inexperienced respondents.

These distinguished philosophies are used as examples to explain the psychological

morbidity pattern of the patients and their spouses in the different phases of their

treatment: prior-to, during and post-chemotherapy. Therefore, based on the arguments and

rationality given in this section, the hypotheses of the study were proposed. These

hypotheses were further divided into two sections - the hypotheses at the couple level, and

the individual level (women with breast cancer and their husbands' level separately). The

postulated hypotheses are as follows:

Hypotheses postulated at the couple’s level:

General Hypothesis:

• Treatment phases (prior-to, during and post-chemotherapy) have different effects

on the couples’ psychological aspects (anxiety and depression), relationship

satisfaction and coping strategies.

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Specific Hypotheses:

(a) There are similarities in the patterns of the psychological aspect (anxiety and

depression, relationship satisfaction and coping strategies, between women with

breast cancer and their husband’s overtime (prior-to, during and post-

chemotherapy); however, women with breast cancer indicate a higher level of

psychological problem (anxiety and depression), better relationship satisfaction

and greater use (higher level) of coping strategies, as compared to their husbands

in all occasions (prior-to, during and post-chemotherapy).

(b) Medical aspects (types of surgery and breast cancer stages) and selected bio/socio-

demographic aspects (ethnicity and menopausal status) have a significant effect on

couples’ psychological aspect (anxiety and depression), relationship satisfaction

and coping strategies.

Hypotheses postulated at the individual’s level (Women with breast cancer):

General Hypothesis:

• Treatment phases (prior-to, during and post-chemotherapy) have different effects

on women’s quality of life, interpersonal relationship and coping strategies.

Specific Hypotheses:

(a) Women’s quality of life, psychological well-being (anxiety and depression) and

sexuality aspects are worst during chemotherapy as compared to prior-to and post-

chemotherapy.

(b) Women’s interpersonal relationship aspects (perceived husband’s support, level of

disclosure, empathy, relationship satisfaction, helpfulness of disclosure,

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withdrawal, holding back and criticism) are better during chemotherapy as

compared to prior-to and post-chemotherapy.

(c) Women indicate greater use of coping strategies during chemotherapy than prior-

to and post-chemotherapy.

(d) Medical (types of surgery and breast cancer stages) and bio/socio-demographic

aspects (menopausal status and ethnicity) have significant impact on women’s

quality of life, sexuality, interpersonal relationship and coping strategies.

Hypotheses postulated at the individual’s level (Husband): General Hypothesis:

• Treatment phases (prior-to, during and post-chemotherapy) have different effects

on the psychological aspects (anxiety and depression) of breast cancer patients’

husbands, their view on their wives’ sexuality (body image and sexual

attractiveness), interpersonal relationship (perceived providing support, level of

disclosure, empathy, helpfulness of disclosure, withdrawal, holding back and

criticism) and coping strategies.

Specific Hypotheses:

(a) Husbands’ psychological aspects (anxiety and depression) and their view on their

wives’ sexuality (wives’ body image and sexual attractiveness) are worst during

chemotherapy as compared to prior chemotherapy and post-chemotherapy.

(b) Husbands’ interpersonal relationship aspects (perceived providing support, level of

disclosure, empathy, relationship satisfaction, helpfulness of disclosure,

withdrawal, holding back and criticism) are better during chemotherapy as

compared to prior and post-chemotherapy.

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(c) Husbands indicate greater use of coping strategies during chemotherapy than

prior-to and post-chemotherapy.

(d) Medical (types of surgery and breast cancer stages) and bio/socio-demographic

aspects (wives’ menopausal status and ethnicity) have significant impact on the

psychological aspect of breast cancer patients’ husband, their view on their wives’

sexuality, interpersonal relationship and coping strategies.

For the purpose of gathering the required data in this study, a set of hypotheses to

examine the connection between the different components in the quality of life,

interpersonal relationship and coping strategy, were proposed. The hypotheses would be

justified from the main components of the conceptual framework (Figure 4.1). The

association between the quality of life and the aspect of interpersonal relationship, shown

in Figure 4.1, could be explained from the bio-behavioural perspective. Firstly, Levy et al.

(1990) stated that the perception of the patients towards the quality of emotional support

(from their significant others) could have effects on their immunological systems in

fighting neoplastic cells. Secondly, Waxler-Morrison et al. (1991) found that the element

of relationship (such as the number of supportive persons) is important for survival in

cancer. Thirdly, these were also based on the opinions of Kiecolt-Glaser et al. (1984) and

Fox et al. (1994) who suggested the relationship, between the factors of ‘loneliness’ and

‘depressed immune system,’ as the possibilities for the development of cancer. Their

theory is in line with Kiecolt-Glaser et al.’s (1987) who stated that a poor quality of

marriage could cause a decline in the immune system, that is, lesser ability of the body to

fight cancer. Therefore, it is speculated that the feeling of satisfaction in a relationship

may have a connection with the hormonal stimulation in the immune system. All the three

theories of ‘bio-behavioural perspective’ have explained that the elements of relationship,

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such as the support from others and having the feeling of being “owned” (as opposed to

“loneliness”) can affect the ability of the immune system to fight diseases, and thus a

person’s happiness. Relationship could also be suggested to improve or affect one’s

internal motivation to maintain her/his health. This argument was put forward by Broman

(1993) and Umberson (1992) who explained that the patient’s spouse or friend could serve

as the source of motivation for an individual to have or lead a healthy life. The

manifestation of the bio-behavioural perspective could be seen in several studies which

yielded that spouse’s or partner’s response could be an important predictor for the patient’s

well-being (e.g. Stroud and Turner, 2006; Pistrang and Barker, 1995). Among others,

Wortman and Dunkel-Schetter (1979) stated that the social well-being of a cancer patient

could be affected by the situation of withdrawal, which one might experience in the social

network. Meanwhile, the feeling of empathy may arise due to the stigma and fear of

cancer. Cutrona (1996) suggested that both distress and burden, in a close relationship,

could be eased by supportive interactions, such as the sense of security and self-efficacy, as

well as the establishment of the construct of concern, reassurance, understanding and

willingness to help in the relationship. Cutrona also added that the partners’ support could

be given to the recipient through fulfilling the immediate needs, by guiding the support

recipient to deal with a difficult instructor in dealing with stressful live events. According

to Holmes and Rempel (1989), partner responded to the stressful situation by placing

expectation and trust; whereas, Cutrona (1996) mentioned that partner or spouse (as a unit

in relationship) played his roles in a close relationship by preparing and helping his partner

to deal with stressors and crisis. In this situation, open expression is needed, and this can

be characterized by the feeling of awareness towards spouse’s distress. The feeling of

depression, which occurs in a relationship, is believed to happen when one is not able to

influence the occurrence of negative events in one’s life; whereas, a depressive situation

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can be avoided when one is able to influence that particular event (Cutrona, 1996). This

finding is related to the result derived by Litchman et al. (1987) who found that husbands,

who are satisfied in their marriages, are usually aware of their wives’ anxiety and fear,

while at the same time, they are concerned about their wives’ emotional reaction to the

disease.

Meanwhile, the association between the quality of life and the aspect of coping

behaviour is apparent, as given in the definition of psychosocial distress by the National

Comprehensive Cancer Network (1999, as quoted by Hewitt et al., 2004), i.e. “multi-

factorial unpleasant emotional experience of a psychological (cognitive, behavioural,

emotional), social, and/or spiritual nature that may interfere with the ability to cope

effectively with cancer, its physical symptoms, and its treatment. Distress extends along a

continuum, ranging from common normal feelings of vulnerability, sadness and fears to

problems that can become disabling, such as depressions, anxiety, panic, social isolation

and existential and spiritual crisis”. This definition clearly shows that there is an element

of coping which affects an individual’s well-being. The manifestation of the association

between the quality of life (with specific reference to psychological well-being) and the

aspect of coping behaviour is clearly documented in Shontz (1975); it states that people

with serious physical illnesses or disabilities will undergo a series of coping strategies,

characterized by some psychological elements such as shock, encounter and retreat.

‘Shock’ is manifested by a feeling of detachment, whereas ‘encounter’ deals with the

element of helplessness, panic and disorganization. In line with the (two) earlier elements,

‘retreat’ is viewed as a natural means to avoid breakdown by permitting short-term

withdrawal into security. This conceptualization is parallel to the one given by Shapiro et

al. (1997) who indicate that confrontive copers have better physical and psychological

functioning as compared to the avoidant-confrontive, avoidant re-signed or resigned

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patterns. This is due to the fact that confrontive copers have certain characteristics, such as

willingness to discuss and think about the illness, optimism, information seeking and a

willingness to be involved in the treatment decisions (Felton and Revenson, 1984; Filipp et

al., 1990; Greet et al., 1979; Jenkins and Pargament, 1988; Keller, 1988; Langer et al.,

1975; Miller, 1979; Miller and Mangan, 1983; Miller et al., 1988; Shapiro et al., 1997).

Similarly, coping through cognitive adaptation was found to be influential, mainly on the

psychological well-being of a person, as indicated in Taylor’s (1983) opinion which

suggests that cognitive adaptation may cause the patients to be self-enhanced in managing

the effects of their treatment, their illnesses and reducing their negative emotional

responses. Referring to Manne et al. (2005) and Manne and Glassman (2000), the element

of avoidance in the coping strategy can be a mediator for the association between

unsupportive behaviour and distress situation. In addition, individuals who handle crisis

through the complexity style (multiple strategies) can be beneficial or detrimental to their

psychological well-being (Lazarus and Folkman, 1984).

Furthermore, as shown in Figure 4.1, the basic connection between the aspect of

interpersonal relationship and coping behaviour takes into account the meaning of support,

i.e. “as an action or behaviour that facilitates coping, mastery or control” (Tolsdort, 1976,

as quoted by Penner et al., 2000; Eyres and MacElveen-Hoehn, 1983, as quoted by Penner

et al., 2000). Based on this definition, the element of coping seems to be integrated with

the element of support. This conceptualization is in line with the one given by Thoits

(1986) who evaluates the element of support as an aid to coping, in which support is found

to be a social resource that could facilitate the management of stressful situations.

According to Cutrona (1996), adaptive coping is facilitated by the provision of

information, assistance or tangible resources which are conceptualized with some

supportive acts such as responsiveness to other’s needs, communicate caring, and validate

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others’ worth, feelings and actions. In relation to these, Lichtman et al. (1987) stated that

the patients’ relatives believed that their (patients’) adjustment could be hampered by the

communication about the recurrence of disease or death. On the contrary, adjustment was

observed to be better among patients who shared their concerns, communicated openly and

honestly with their spouses (Litchman et al., 1987). This observation is parallel to other

views which looked into the positive effects of support, whereby it was found that support

could enhance the effectiveness of coping and assist in the recuperation from hectic

situations (e.g. Kuuppelomaki, 1999). According to Champion (1990), the lack of

interpersonal supports (such as the lack of confiding in and intimacy with spouse) can be

the main vulnerability factor to the severely threatening life event which prevents the

supplement of psychosocial asset to patients, in which it may result in insufficiency of the

strength to activate their internal resources to manage the situation through the process of

coping. Another view, used in conceptualizing this aspect of interpersonal relationship and

coping behaviour, outlines that the effectiveness of coping and adjustment is influenced by

the characteristics of expressiveness and a strong family intimate relationship (spouse as a

unit in a family) (Friedman et al., 1988; Stanton et al., 2000; Wilmoth, 2001). At the same

time, justification is also given to the possibility of the characteristics of the spouse’s

interpersonal relationship (i.e. criticism and withdrawal) and their beneficial effects on

patient’s coping and adjustment in facing chronic disease (e.g. Manne et al., 2003; Manne

et al., 2006).

Thus, based on the conceptualization of the connection between quality of life,

interpersonal relationship and coping strategy, the hypotheses postulated in this study are

as follows:

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• The women’s factors (greater age, lower level of anxiety and depression,

higher level of relationship satisfaction), the husbands’ factors (greater age,

lower level of anxiety and depression, higher level of relationship satisfaction)

and the general factors (the longer the duration of marriage, the longer the

duration of breast cancer) are factors predictive of the better global health

status of the women with breast cancer post-chemotherapy.

• The higher level of positive view on sexual attractiveness of the women with

breast cancer post-chemotherapy is predicted by the general factors (the longer

the duration of marriage, the longer the duration of breast cancer), the

women’s factors (greater age, lower level of anxiety and depression, less

menopausal symptoms, better global health status, higher level of relationship

satisfaction, less negative view on body image) and the husbands’ factors

(greater age, lower level of anxiety and depression, higher level of relationship

satisfaction, less negative view on wives’ body image and sexual

attractiveness).

• The higher level of relationship satisfaction (with their husbands) of the women

with breast cancer post-chemotherapy is predicted by the general factors (the

longer the duration of marriage, the longer the duration of breast cancer), the

women’s factors (greater age, lower level of anxiety and depression, higher

level of perceived husband support, higher level of disclosure, higher level of

empathy, higher level of helpfulness of disclosure) and the husbands’ factors

(greater age, lower level of anxiety and depression, higher level of relationship

satisfaction, higher level of perceived providing support, higher level of

disclosure, higher level of empathy, higher level of helpfulness of disclosure).

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• The greater use of problem-focused coping strategy of the women with breast

cancer post-chemotherapy is predicted by the general factors (the longer the

duration of marriage, the longer the duration of breast cancer), the women’s

factors (greater age, lower level of anxiety and depression, higher level of

relationship satisfaction, higher level of perceived husband’s support) and the

husbands’ factors (greater age, lower level of anxiety and depression, higher

level of relationship satisfaction, higher level of perceived providing support,

greater use of problem-focused strategy).

[Note: The justification of the medical and socio-demographic factors, as well as the important

factor of the spouse/husband has already been clarified in the earlier paragraph]

In order to answer the proposed hypotheses (based on the rationale and justification

which have been described in the earlier section), this study implemented the research

methodology which will be thoroughly explained in the next chapter.

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CHAPTER FIVE

METHODOLOGY

The research procedure (methodology), which was implemented to answer the

various hypotheses postulated, is described in detail in this chapter.

5.0 Study Location

The three main hospitals, in the Klang Valley, located in central Malaysia were

included in this study. They are University of Malaya Medical Centre (UMMC), Kuala

Lumpur General Hospital (KLGH) and Hospital Universiti Kebangsaan Malaysia

(HUKM). The three hospitals were chosen as there are special clinics providing

chemotherapy treatment, namely Clinical Oncology Clinic, incorporated in the hospitals

with referrals made by other district hospitals (Hospital Klang, Hospital Kajang, Hospital

Putrajaya, etc.) for further management after surgery.

The University of Malaya Medical Centre (UMMC) is both a teaching and public

hospital, which comes under the Ministry of Higher Education, Malaysia. It is the first

learning centre which provides medical and paramedic staff for the health demand from the

population. Set up in 1968, it has 1200 beds with modern medical facilities to cater for the

Klang Valley area. Its Clinical Oncology Unit first started serving the public in 1997, with

800 to 1000 new cases of cancer patients annually.

Kuala Lumpur General Hospital (KLGH) is the main general hospital located in

Kuala Lumpur, Malaysia. It is the largest hospital, which is also placed under the Ministry

of Health, Malaysia, and it is also considered to be one of the biggest in Asia. Kuala

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Lumpur General Hospital (KLGH) is located on a 150 acre prime land, with 81 wards and

2502 beds. With a humble beginning, the hospital was started only as a small

Radiotherapy Unit in 1960; it is now moving ahead with the setting up of the Institute of

Radiotherapy, Oncology and Nuclear Medicine in 1968. Providing chemotherapy

consultation and treatment as one of its main functions, this institute aims to serve 4000

new cases of cancer annually.

Hospital Universiti Kebangsaan Malaysia (HUKM), which was set-up in 1998, is

also teaching hospital and a health center, where other hospitals in Malaysia refer their

cases to. It provides excellent health service, with the latest health and medical

infrastructure. As one of the best hospitals in Malaysia, HUKM possesses 21 operation

theaters, 10 specialist clinics and 1050 patient beds. Meanwhile, its Chemotherapy Unit,

under the management of the Department of Radiotherapy and Oncology, was upgraded

from its original Radiotherapy Unit in 2000, to make it more effective and optimal in

providing the treatment for cancer.

5.1 Sample Population

This study focused on evaluating the psychosocial aspect of women with breast

cancer, and those who were eligible for six cycles of adjuvant chemotherapy treatment

following breast cancer surgery. Hence, women with breast cancer (and their husbands)

were identified and selected from the Clinical Oncology Clinics at the three main hospitals

in the Klang Valley - University Malaya Medical Centre (UMMC), Kuala Lumpur General

Hospital (KLGH) and Hospital Universiti Kebangsaan Malaysia (HUKM). A total of 157

women with breast cancer and their husbands (157) were successfully chosen over the

three time evaluations of the chemotherapy treatment: prior-to, during and post-

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chemotherapy, which had taken a period of one and half years to complete its data

collection. Out of the 157 breast cancer patients selected from the three health centres,

about 16% (25) of them were referred by other health centres, for further treatment of

adjuvant chemotherapy after the breast cancer surgery was done. A list of breast cancer

patients, who were eligible to be treated with adjuvant chemotherapy following breast

cancer surgery, was obtained from the Oncologist and the medical registration of new

cases. Medical records were also referred to, in order to determine the eligibility of the

breast cancer patients as the sample of this study. At the beginning of the study, 85%

(n=160) of the women with breast cancer and 84% of their husbands (n=159) had agreed to

participate (An 188 initial breast cancer patients and their husbands were approached; and

they were not consecutive referrals). Those patients who refused to participate did not

differ in their clinical assessment (i.e., the eligibility for the adjuvant chemotherapy

treatment), as screened by the Oncologist. Since they were not included in the study, no

further information was obtained. Thus, a total of 160 of women with breast cancer and

159 husbands (one husband was not interested to participate) were assessed at the baseline.

However, a number of women had declined to proceed with their participation in the study

at various points of the follow-ups, leaving the researcher with only 158 women at the

second phase of study (during chemotherapy), and 157 at the third phase (post-

chemotherapy). Similarly, two of the patients’ husbands refused to participate at the

second phase of study, leaving the study with only 157 husbands participating at the third

phase of study. Fortunately, no further declinations of participation from husbands were

recorded at the third phase of study. A common reason documented for their withdrawals

was that some patients did not complete the six cycles of chemotherapy treatment, due to

the impacts of the side effects in the treatment received.

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5.2 Research Design

This research was conducted prospectively, in which women with breast cancer and

their husbands were followed up for three times, following the breast cancer surgery (Refer

to Section 5.8 for the procedure of the study).

5.3 The Selection of Women and Their Husbands

The selection of women with breast cancer and their husbands was done based on

the following inclusion and exclusion criteria:

5.3.1 Inclusion Criteria

The eligible subjects who fulfilled the inclusion criteria stated below were selected

for the study:

(a) Patient’s inclusion criteria

1. New cases of breast cancer

2. Had been decided by the oncologist to receive six cycles of adjuvant

chemotherapy following breast cancer surgery

3. 18 years old above and married

4. No current major diseases

5. No current chronic psychiatric condition

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(b) Husband’s inclusion criteria

1. No current major diseases

2. No current chronic psychiatric condition

5.3.2 Exclusion Criteria

(a) Patient’s exclusion criteria

1. Possesses a history of breast cancer surgery

2. Received other adjuvant therapy prior to chemotherapy after the breast

cancer surgery.

3. Received neo-adjuvant therapy before the surgery

4. Had undergone hysterectomy and/ or bilateral oophorectomy

5. Breast cancer women who delayed in making decision to undergo

chemotherapy after the surgery

(b) Husband’s exclusion criteria

1. Husbands of the women with breast cancer who did not meet the

inclusion criteria were automatically not chosen as respondents.

5.4 Operational Definitions

(a) Quality of life

Among women with breast cancer, their quality of life was measured using the

European Organization for Research and Treatment of Cancer Quality of Life

Questionnaire (EORTC-QLQ C30) and the Breast Module (QLQ BR-23) (Quality of Life

135

Unit, EORTC Data Centre, Brussels), the Hospital Anxiety and Depression Scale (HADS)

(Zigmond and Snaith, 1983) and Blatt Menopausal Index (BMI) (Carpenter and

Andrykowski, 1999) to determine the psychological well-being and menopausal symptoms

of these women, respectively. Meanwhile, the Hospital Anxiety and Depression Scale or

HADS was used to determine the psychological well-being of their husbands.

(b) Sexuality

For the women with breast cancer and their husbands, sexuality was measured

using the Body Image Scale (BIS) (Hopwood et al., 2001) and the Sexual Attractiveness-

Body Esteem Scale (SA-BES) (Franzoi and Shields, 1984).

(c) Interpersonal Relationship

Among women with breast cancer and their husbands, their interpersonal

relationship was measured using the Inventory Socially Supportive Behaviour (ISSB)

(Barrera and Ainlay, 1983), the Dyadic Satisfaction-Dyadic Adjustment Scale (DS-DAS)

(Spanier, 1976), Level of Disclosure (Pistrang and Barker, 1992), Holding Back (Pistrang

and Barker, 1992), Helpfulness of Disclosure (Pistrang and Barker, 1992), Criticism

(Pistrang and Barker, 1995), Withdrawal (Pistrang and Barker, 1995) and Empathy-

Revised Barrett-Lennard Relationship Inventory (E-RBLRI) (Barrett-Lennard, 1978).

(d) Coping Strategy

In this study, the coping strategies of the women with breast cancer and their

husbands were measured using the Brief COPE Scale (Carver, 1977).

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5.5 Sample Size

Assuming the standardized effect size of 0.4, the correlation was fixed at 0.70, as

suggested by Machin et al. (1997), with the test size of 5% and 80% of the power of study,

the sample size needed (without repeated measure) was 100 (by referring to the sample

size table by Machin et al., 1997). Furthermore, using a sample size table of multiplying

factor for repeated measures designs (Machin et al., 1997), the sample size for the repeated

measure design was calculated. Based on these data, the power of the study was therefore

fixed at 80%, with 5% level of significant to detect the existing minimum worthwhile

difference. Meanwhile, the correlation (ρ) of 0.70 was fixed, with pre-surgical evaluation

(ν) as zero and post-surgical evaluation (w), as three times measurement: observation one,

observation two and observation three. The correction factor revealed for the observation

at phase one was 100, while the correction factors at phase two and three were 85 and 80,

respectively. This indicated that the sample size requirement, for the three times repeated

measures, was 80 women with breast cancer. However, the sample size was adjusted

upwards to allow the non-response of as much as 20%, resulting in the final sample size

required for the study to be 96 women with breast cancer for the three times repeated

measurement.

5.6 Ethical Approval

Ethical approval was obtained from the Ethics Committee of the University Malaya

Medical Centre (UMMC), and the Ethics Committee of the Ministry of Health, Malaysia.

For the respondents from the Hospital Universiti Kebangsaan Malaysia (HUKM),

additional ethical approval was obtained from HUKM due to their policy (Appendix A).

137

5.7 Informed Consent

An informed consent in written form was obtained from each woman with breast

cancer and the husband. The information sheets, for both the patient and the husband

provided in various languages (English, Malay, Chinese and Tamil), were attached

together with the women and their husband’s signature forms, to cater for the multi-

ethnicity status of the respondents. The content of the information sheets was based on the

standard format as proposed by the ethical committee of the University of Malaya Medical

Centre (UMMC) (Appendix B).

5.8 Study Procedure

Women with breast cancer and their husbands were recruited following the breast

cancer surgery, and once they had decided to receive the six cycles of adjuvant

chemotherapy. The different phases of evaluation undertaken in this study are summarized

in Table 5.0, and the flow chart of the study procedure is shown in Figure 5.1 below.

138

Figure 5.0: The Flow Chart of the Study Procedure

Women who needed to undergo further treatment with chemotherapy, agreed to be treated with chemotherapy and

fulfilled other inclusion criteria. (Including their husbands)

PHASE ONE OF THE STUDY (BASELINE): Prior to chemotherapy/ before women received the first cycle of chemotherapy, at approximately two to three

weeks after surgery (n=160) [Including husbands, n=159]

Women had undergone surgery for breast cancer

Women who needed not to undergo further treatment with chemotherapy or women who

refused to be treated with chemotherapy

Oncologist consultation: Deciding on chemotherapy

PHASE TWO OF THE STUDY: During chemotherapy/ after the third cycle of chemotherapy, at approximately ten weeks

after surgery (n=158) [Including husbands, n=157]

PHASE THREE OF THE STUDY: After chemotherapy/ after the six cycles of

chemotherapy, at approximately twenty weeks after surgery (n=157)

[Including husbands, n=157]

EXCLUSION CRITERIA INCLUSION CRITERIA

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Table 5.0: The Follow-up Phases of the Study

PHASE OF CHEMOTHERAPY TIME OF EVALUATIONS

Phase one (Baseline): Prior to chemotherapy

Before women received the first cycle of chemotherapy, at approximately two to three weeks after surgery (n=160).

[Including their husbands, n=159]

Phase two: During chemotherapy After the third cycle of chemotherapy, at approximately ten weeks after surgery (158).

[Including their husbands, n=157]

Phase three: Post-chemotherapy After the six cycles of chemotherapy, at approximately twenty weeks after surgery (n=157).

[Including their husbands, n=157]

After all the scales had been validated (see Sections 5.10 and 5.11 for the cultural

adaptation and translation technique, and Section 5.12 for the pilot study) and the

approvals from the selected hospitals to recruit the patients had been obtained, the data

collection was started. The women with breast cancer and their husbands were approached

in the Clinical Oncology Clinic, after they had decided to receive the adjuvant

chemotherapy (following surgery) suggested by the oncologist. The list of eligible

women, for the chemotherapy treatment, was obtained from the oncologist and breast

surgeon (one of them is the supervisor of this study), and the selection of respondents was

done based on inclusion and exclusion criteria, as given in Section 5.3. The medical

reports of the patients were also referred to, in order to obtain their medical information.

The aims of the study were briefly outlined after the patients’ (and their husbands’)

eligibility for the study had been identified and confirmed. The breast cancer patients (and

their husbands) signed the consent form, after the confirmation of their participation in the

study was obtained. All the questionnaires were self-administered, where patients and

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their husbands answered the questionnaires in private consultation rooms provided. For

this purpose, separate rooms were provided for the women with breast cancer and their

husbands to avoid any discussion. In some cases, such as illiteracy (one illiterate Malay

woman agreed to participate) and those who had eye problem (two women had eye

problem), these women were assisted. Medical registration was always referred to in order

to track their appointment visits at the Oncology Clinic to receive the six cycles of

adjuvant chemotherapy. The breast cancer patients and their husbands could withdraw

from the study at anytime or whenever they wished to.

5.9 Study Instruments

The instruments, used to measure various psychosocial aspects on women with

breast cancer and their husbands in this study, are summarized in Table 5.1 below. All the

scales used in this study were standardised; the details of these instruments are described in

the subsequent sections, in four categories of classification.

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Table 5.1 Study Instruments

WOMEN WITH BREAST CANCER HUSBANDS

1. Quality of Life • European Organization for Research and

Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ C30)

• Breast Module (QLQ BR-23) • Hospital Anxiety and Depression Scale

(HADS) • Blatt Menopausal Index (BMI) 2. Sexuality • Body Image Scale (BIS) • Sexual Attractiveness: Body Esteem Scale (SA-BES) 3.Interpersonal Relationship • Inventory of Socially Supportive Behaviour

(ISSB) • Level of Disclosure • Helpfulness of Disclosure • Criticism • Withdrawal • Empathy: Revised Barrett-Lennard Relationship

Inventory (E-RBLRI) • Dyadic Satisfaction: Dyadic Adjustment Scale

(DS-DAS) 4. Coping • Brief COPE

5. Bio/Socio-demographic and medical information • Menopausal status, ethnicity, type of surgery, breast cancer stages, current diseases, age,

education, duration of marriage, monthly income, duration of breast cancer, and occupation.

1. Quality of Life • Hospital Anxiety and Depression Scale

(HADS) 2. Sexuality • Body Image Scale (BIS) - Modified • Sexual Attractiveness: Body Esteem

Scale) (SA-BES) - Modified

3. Interpersonal Relationship • Inventory of Socially Supportive

Behaviour (ISSB) - Modified • Level of Disclosure - Modified • Helpfulness of Disclosure - Modified • Criticism - Modified • Withdrawal - Modified • Empathy: Revised Barrett-Lennard

Relationship Inventory (E-RBLRI) • Dyadic Satisfaction: Dyadic Adjustment

Scale (DS-DAS) 4. Coping • Brief COPE

5. Socio-demographic and medical information

• Age, education, occupation, current diseases

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5.9.0 Quality of Life

Various standardized scales were used to measure health-related quality of life.

These include the European Organization for Research and Treatment of Cancer Quality of

Life Questionnaire (EORTC-QLQ C30), together with the Breast Module (QLQ BR-23),

the Hospital Anxiety and Depression Scale (HADS) and the Blatt Menopausal Index

(BMI). The EORTC QLQ C-30, QLQ-BR2 and BMI were only used for women with

breast cancer, whereas, the HADS was applied for both women with breast cancer and

their husbands. The details of the scales are further described in the subsequent sections

below.

5.9.0 (a) The European Organization for Research and Treatment of Cancer

Quality of Life Questionnaire (EORTC-QLQ C30) (Quality of Life

Unit, EORTC Data Centre, Brussels)

The EORTC QLQ–C30 Version 3.0 is the most recent version developed to assess

the quality of life of the cancer patients. It is a copyrighted instrument, which has been

translated and validated into 49 languages, and is used in more than 3000 studies

worldwide. This instrument is provided by the collaboration between the Quality of Life

Group and the Quality of Life Unit in Brussels, Belgium. It was designed to be cancer

specific, multi-dimensional in structure, appropriate for self-administration, applicable

across a range of cultural settings and suitable for use with additional site- or treatment-

specific modules. This EORTC QLQ-C30 Version 3.0 is incorporated in the three areas as

follows:

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• Functional scales – Comprises of physical functioning (five items), role functioning

(two items), cognitive functioning (two items), emotional functioning (four items)

and social functioning (two items);

• Symptom scales – Comprises of fatigue (three items), pain (two items), nausea and

vomiting (two items), dyspnoea (one item), loss of appetite (one item), insomnia

(one item), constipation (one item) and diarrhoea (one item), and financial

difficulties (one item);

• Global health status/ QOL scale (two items).

For the functional and symptom scales, the options for the items are rated on a four-point

scale, ranging from “not at all” (score one) to “very much” (score four). Meanwhile, the

options for the items on the global health status are rated on a seven-point scale, ranging

from “very poor” (score one) to “excellent” (score seven). All the scales and the single-

items measures range in scores from zero to 100. A linear transformation is used to

standardise the raw scores such as below:

Raw Score (RS) = Item 1 + Item 2 + ……+ Item x / N

Functional Scales = 1- [(RS – 1) / range] x 100

Symptoms Scales = [(RS – 1) / range] x 100

Global Health Status = [(RS – 1) / range] x 100

[Range is the difference between the maximum possible value of the raw score (RS) and the

minimum possible value. Therefore, the range of RS equals the range of the item value. Range

three is given for the Functional and Symptomatology Scales, while range six is given for the

Global Health Status].

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A high scale score represents a higher response level. Thus, a high score for a functional

scale represents a high/ healthy level of functioning and a high score for the global health

status represents a high quality of life. Meanwhile, a high level of symptomatology/

problems is presented by a high score for a symptom scale/ item. The reliability of most

of the sub-scales was established with the Cronbach’s alpha coefficient with more than 0.7,

except for the role functioning (Aaronson et al., 1993). The validity of the scale was

proven by the significant correlation of all the inter-scales, indicating that these scales

assessed the distinct components of the quality of life construct (Aaronson et al., 1993).

Similarly, the validity of the scale is also shown by the functional and symptom measures

which clearly discriminate the patients’ differing, in terms of their clinical status, as

defined by the Eastern Cooperative Oncology Group performance status scale, weight loss

and treatment toxicity. In addition, the validity of the scale had been indicated by

statistically significant changes in the expected direction, in physical and role functioning,

global quality of life, fatigue and nausea and vomiting for patients whose performance

status had improved or worsened during the treatment (Aaronson et al., 1993).

The translated versions of EORTC QLQ C-30 in the Malay language (Bahasa

Melayu), Mandarin (China) and Tamil (India) have been validated and are already

available in the EORTC library; these were implemented/ applied in the study after the

permission for its usage was obtained from the Quality of Life Unit, EORTC Data Centre,

in Brussels. The cultural adaptation was carried out for the Mandarin (China) and Tamil

(India) versions, to observe any difficulties or confusions in understanding the questions,

and to detect any offensive words or sentences. Internal consistency, Intraclass Correlation

Coefficient (ICC), sensitivity of the scales and discriminant validity of the original and

translated versions are reported in Chapter Six.

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5.9.0 (b) Breast Module (QLQ BR-23) (Quality of Life Unit, EORTC Data

Centre, Brussels)

The Breast Cancer Module (QLQ-BR23) was designed to be used together with

EORTC QLQ-C30 for breast cancer research. It has been validated in a larger cross-

cultural study involving 12 countries. This module is meant for use among patients

varying in disease stages and treatment modality (i.e. surgery, chemotherapy, radiotherapy

and hormonal treatment). The module which comprises 23 questions can be divided into

two areas:

• Functional scales – comprises of body image (four items), sexual functioning

(two items), sexual enjoyment (one item) and future perspective (one item); and

• Symptoms scales – comprises of systemic therapy side effects (seven items), breast

symptoms (four items), arms symptoms (three items) and upset by hair loss

(one item).

Rating for this scale is similar to EORTC QLQ-C30, where the functional scale and

symptom scale are rated on a four-point scale, ranging from “not at all” (score one) to

“very much” (score four). The linear transformation is used to standardise the raw score

(the formula to standardise the score is similar to one in EORTC QLQ-C30). A high scale

score represents a higher response level. Thus, a high score for the functional scale

represents a high/ healthy level of functioning, and a high score for the symptom scale/

item represents a high level of symptomology/ problems. The reliability of the sub-scales

had been established previously with the Cronbach’s alpha coefficients, which range from

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0.7 to 0.91 among the breast cancer patients in the United States, and 0.46 to 0.94 among

the breast cancer patients in Spain (Sprangers et al., 1996). Meanwhile, the validity of the

sub-scales had also established as indicated by a known-group comparison where selective

scales clearly distinguished the patients differing in disease stages, previous surgery,

performance status and treatment modality (Sprangers et al., 1996). The permission for

using this module was also obtained from the Quality of Life Unit, EORTC Data Centre, in

Brussel.

The original version was translated into Malay and Tamil languages, whereas for

the Chinese, the Mandarin (China) version, which had been validated and is available in

the EORTC library, was used. The translation of the original scale, into the Malay and

Tamil languages, was conducted based on the standard protocol of the European

Organization for Research and Treatment of Cancer (Cull et al., 2002). The approval from

the EORTC committee was retrieved after the validation and finalization of the translated

versions were done. Again, the cultural adaptation was carried out for Chinese Mandarin

(China) to determine any difficulties or confusions in understanding the questions, as well

as to detect any offensive words or sentences. The Internal consistency, Intraclass

Correlation Coefficient (ICC), sensitivity of the scales and discriminant validity of the

original and translated versions are reported in Chapter Six.

5.9.0 (c) Hospital Anxiety and Depression Scale (HADS) (Zigmond and Snaith,

1983)

The Hospital Anxiety and Depression Scale (HADS) is a self-administered

questionnaire which is used to detect the severity of emotional disorder. This scale can

distinguish between anxiety and depression, and it can also be easily used in the hospital,

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out-patient and community settings. The HADS contains 14 items and consists of two sub-

scales; one measuring anxiety (A scale) and the other measuring depression (D scale)

which are scored separately. Each item is rated on a four-point scale, giving a maximum

score of 21 for anxiety and 21 for depression. The option for every item varies. Besides

treating the scores as ordinal data, the interpretation of HADS scores can also be as

follows: 0-7 (normal), 8-10 (Mild), 11 to 14 (Moderate) and 15 to 21 (Severe). The

reliability of HADS had been established by many researchers. Among others, Moorey et

al. (1991) reported the Cronbach’s alpha of 0.93 for the Anxiety sub-scale, and 0.9 for the

Depression sub-scale. Other researchers also found the reliability of the HADS

satisfactory (Clark and Fallowfield, 1986). The construct validity of the scale, as a

measurement of the two factors, was confirmed in a factor analysis among cancer patients

(Moorey et al., 1991). The concurrent validity data for the HADS had been reported in

psychiatric patients (Bramley et al., 1988), in heterogeneous group of patients with

physical illness (Aylard et al., 1987) and in patients attending a genito-urinary clinic

(Barczak, 1988).

The copyrighted scale of the English HADS and the translated version of the

HADS (Malay and Chinese Versions) were purchased directly from the Nfer-NELSON

company, and were administered under the company’s regulation and policy. Meanwhile,

the original version was also translated into Tamil language to cater for the Indian

respondents. The standard translation technique was implemented for the version (see

Section 5.11). The approval for the usage of the translated version was obtained from the

Nfer-NELSON company after the version had been validated locally and finalized.

Internal consistency, Intraclass Correlation Coefficient (ICC), sensitivity of the scales and

discriminant validity of the original and the translated versions are reported in Chapter Six.

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5.9.0 (d) Blatt Menopausal Index (BMI) (Brambilla, et al., 1994; Carpenter and

Andrykowski, 1999; Delaplaine et al., 1952; Neugarten & Kraines,

1965)

Menopausal symptoms were assessed using an adapted version of the 13 items of

the Blatt Menopausal Index (Carpenter and Andrykowski, 1999). The original Blatt

Menopausal Index, which consisted of 11 items (Delaplaine et al., 1952; Neugarten &

Kraines, 1965), was amended to include two additional symptoms: vaginal dryness and

painful intercourse. Women were asked if they had experienced each symptom in the

previous two weeks, using the four-point scales: zero-not at all, one-slightly, two-

moderately, three-quite a bit and four-extremely. A total menopausal severity score was

calculated for each participant, by summing up the severity ratings for the 13 menopausal

symptoms, where the total menopausal severity scores ranged from zero (no severity) to 52

(extremely severe). Carpenter and Andrykowski (1999) indicated the Cronbach’s alpha of

0.84 for the internal consistency of the scale. The original scale (English) was translated

into Malay, Chinese and Tamil languages, using the back-translation technique (see

Section 5.11 for this). All the translation versions have been validated locally and their

reliability and validity are reported in Chapter Six.

Meanwhile, questions pertaining to the patients’ menopausal status and its

classification were adapted from the Massachusetts Women’s Health Study (Brambilla et

al., 1994). Pre-menopausal is defined as having had a menstrual period in the last three

months. Women, who had experienced three to 11 months of amenorrhea or increased

menstrual irregularity (if still cycling), are categorized as perimenopausal. Post-

menopausal is defined as having 12 or more months of amenorrhea (Brambilla et al.,

1994).

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5.9.1 Sexuality

The Body Image Scale (BIS) and Sexual Attractiveness-Body Esteem Scale (SA-

BES) were used to measure women’s sexuality aspects (the view on their body image and

sexual attractiveness), and to measure their husbands’ view on their wives’ sexuality.

However, the original scales of the BIS and SA-BES were modified to suit the needs or

requirements of this study, in assessing the husbands’ responses. The details of the scales

are further described in the sections below.

5.9.1 (a) Body Image Scale (BIS) (Hopwood et al., 2001).

The scale is designed to be applicable to patients with any cancer site and any form

of cancer therapy. The instruction of the scale requires the patients to complete the

questionnaire with reference to the past weeks. The scale has ten items which are further

classified into three categories - affective items (e.g. feeling less-feminine and less

attractive), behavioural items (e.g. find it hard to look at self naked, avoid people because

of the appearance) and cognitive items (e.g. dissatisfied with the appearance, dissatisfied

with the scars). The questions are rated by four points scale – “not at all” (score zero), “a

little” (score one), “quite a bit” (score two), and “very much” (score three). The overall

score ranges from zero to 30, where zero score represents no symptom/ distress and the

higher score represents increasing in symptoms/ distress. The reliability of the scale is

excellent with Cronbach’s alpha of 0.93 (Hopwood et al., 2001). The discriminant validity

had also been established, where the difference in the median score between the two

groups of breast cancer surgery (mastectomy vs. breast conserving surgery) was highly

statistically significant (Hopwood et al., 2001). The sensitivity to change was also

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reported, where there was a significant increase in the reporting of body image disturbance

over time, as assessed at two weeks and four months (Hopwood et al., 2001).

Nevertheless, this inventory was modified to suit the need of this study in capturing the

body image of the breast cancer patients from their husband’s perspective. The same scale

was also used to rate the husband’s answers, but the items and instructions of the scale

were changed. An example of the scale is given as follows:

Example of question one:

• Original question for women with breast cancer:

Have you been feeling self-conscious about your appearance?

• Modified question for the husband:

Have you been feeling self-conscious about your wife’s appearance?

Instructions of BIS:

• Original instruction for women with breast cancer:

In this questionnaire, you will be asked on how you feel about your

appearance and about any changes that may have resulted from your disease

or treatment. Please read each item carefully and place a firm tick on the

line alongside the reply which comes closest to the way that you have been

feeling about yourself during the past week.

• Modified instruction for the husband:

In this questionnaire, you will be asked on how you feel about your wife’s

appearance and about any changes that may have resulted from your wife’s

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disease or treatment. Please read each item carefully and place a firm tick

on the line alongside the reply which comes closest to the way that you

have been feeling about your wife during the past week

The translation of the original version (English) into various languages in the

Malaysian population (Malay, Chinese and Tamil) was carried out, and validated locally.

The reliability and validity of the scales are presented in Chapter Six.

5.9.1 (b) Sexual Attractiveness Subscale: Body Esteem Scale (SA-BES)

(Franzoi and Shields, 1984)

The Sexual Attractiveness scale is a sub-set scale of the Body Esteem Scale. The

Body Esteem Scale is a scale which can be used in any setting. It comprises of three

dimensions of measurement: Physical/ sexual attractiveness, upper body strength/ weight

concern and physical condition. In this breast cancer study, the items on the physical/

sexual attractiveness are the most relevant. In total, there are 13 items under this

dimension, rated by the five-points scale – “have strong negative feelings” (score one),

“have moderate negative feelings” (score two), “have no feeling one way or the other”

(score three), “have moderate positive feelings” (score four), “have strong positive

feelings” (score five). For this dimension, the higher an individual’s summed score for a

particular sub-scale (e.g. Sexual Attractiveness Sub-scale), the more positive their body

esteem is for that dimension. The Cronbach’s alpha coefficient of the sub-scale, which

carried out among the female respondents, was reported as reasonably internally consistent

(0.78). Similarly, the convergent and discriminant validity had also been established

(Franzoi and Shields, 1984). This inventory was also modified to suit the need of the

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current study in measuring the sexual attractiveness of the women with breast cancer, from

the perspective of their husbands. The same scale and items were used to rate the

husband’s answers, but the instruction of the scale was changed (marked with underline) to

suit the husbands, such as below:

• Original instructions for the women with breast cancer:

On this page, listed are a number of body parts and functions. Please read

each item and indicate how you feel about this part or function of your own

body using the following scale.

• Modified instructions for the husband:

On this page, listed are a number of body parts and functions. Please read

each item and indicate how you feel about this part or function of your

wife’s body using the following scale.

To cater for the multi-ethnicity of the Malaysian population, the original version

(English) was translated into Malay, Chinese and Tamil languages, using a standard

translation technique, as elaborated in Section 5.11. All versions have been validated

locally, and the validity and reliability of the scales are reported in Chapter Six.

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5.9.2 Interpersonal Relationship

A standardized scale was used to evaluate the women’s and their husbands’

interpersonal relationship aspect. The scales are Inventory of Socially Supportive

Behaviour (ISSB), Level of Disclosure, Holding Back, Helpfulness of Disclosure,

Criticism, Withdrawal, and Empathy sub-scale of Revised Barrett-Lennard Relationship

Inventory (E-RBLRI), Dyadic Satisfaction subscale of Dyadic Adjustment Scale (DS-

DAS). Holding Back, Helpfulness of Disclosure, Criticism and Withdrawal, are the single

measure scales which have only one question in each. All these original scales: ISSB,

Level of Disclosure, Holding Back, Helpfulness of Disclosure, Criticism, Withdrawal, E-

RBLRI and DS-DAS, were used to evaluate the women’s interpersonal relationship.

Meanwhile, certain scales were modified to evaluate the husbands, which was suitable

according to the need of the current study. These were the ISSB, Level of Disclosure,

Holding Back, Helpfulness of Disclosure, Criticism and Withdrawal. As for the E-RBLRI,

the original scale is available in two versions, which are suitable to be used for both the

women and their husbands. At the same time, the DS-DAS is a unisex scale which can

also be used for the women with breast cancer and their husbands. The scales are

described in detail in the subsequent sections below.

5.9.2 (a) The Inventory of Socially Supportive Behaviour (ISSB) (Barrera &

Ainlay, 1983)

The Inventory of Socially Supportive Behaviour (ISSB) consists of a 40-item self-

report measure which was designed to assess how often individuals received various forms

of assistance during the preceding month. The subjects were asked to rate the frequency of

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each item on the five-point Likert scales, ranging from “not at all” (score zero) to “about

every day” (score five). A higher score indicates a better supportive behaviour received by

the respondent. The reliability of the scale had been consistently above 0.9 (Barrera, 1981;

Barrera et al., 1981; Cohen et al., 1984; Cohen & Hoberman, 1983; Stokes & Wilson,

1984). In the present study, five questions were omitted from the original scale, as they

were not applicable for the marital relationship setting in the current study. These include

question 17 (Gave you over USD25), question 22 (Gave you under USD25), question 34

(Loaned you over USD25), question 38 (Provided you with a place to stay) and question

40 (Loaned you under USD25). The inventory was modified to suit the requirement of the

current study in measuring the perception of providing support from the perspective of the

patients’ husband. The same scale was used to rate the husband’s answers, but the items

and instruction were changed to measure the husbands, as below:

Example of question one:

• Original question for the women with breast cancer:

Looked after a family member when you were away

• Modified question for husband:

Looked after a family member when she was away

Instruction:

• Original instructions:

We are interested in learning about some of the ways which you feel people

have helped you or tried to make life pleasant for you over the past four

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weeks. Below, you will find a list of activities which other people might

have done for you, to you or with you in the recent weeks. Please read each

item carefully and indicate how often these activities happened to you

during the past four weeks.

• Modified instructions for women with breast cancer:

We are interested in learning about some of the ways which you feel your

husband has helped you or tried to make life pleasant for you over the past

four weeks. Below, you will find a list of activities which your husband

might have done for you, to you or with you in the recent weeks. Please

read each item carefully and indicate how often these activities happened to

you during the past four weeks.

• Modified instructions for husband:

We are interested in learning about some of the ways which you feel you

have helped your wife or tried to make life pleasant for her over the past

four weeks. Below, you will find a list of activities which you might have

done for her, to her or with her in the recent weeks. Please read each item

carefully and indicate how often these activities happened to you during the

past four weeks.

The translation of the original version (English) into Malay, Chinese and Tamil

languages was carried out (see Section 5.11) and validated locally. The reliability and

validity of all the versions are reported in Chapter Six.

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5.9.2 (b) The Level of Disclosure (Pistrang and Barker, 1992)

There were six questions which assess the extent to which the respondents talked

about their concerns, their illness and treatment to their most important helper (i.e.

husband). For this, the respondents were asked to rate their level of disclosure on a five

points scale, ranging from “talked about none of what I felt” (score zero) to “talked about

all of what I felt” (score four). The level of disclosure was rated as ‘eight’ if the women

responded ‘not at all concerned’ to that particular item. The six items from this scale were

modified to suit the need of this study in measuring the level of disclosure from the

husband’s perspective. The same scale was also used to rate the husband’s answer, but the

items to measure husband were changed, such as in the following examples:

Example for question one:

• Original question for the women with breast cancer:

My physical problems or discomfort due to the treatment

• Modified question for the husband:

Her physical problems or discomfort due to the treatment

To cater for the multi-ethnicity population in Malaysia, the translation of the

original version (English) into Malay, Chinese and Tamil languages was done by using the

standardized translation technique, as explained in Section 5.11. The validation of the

original and translated version on the local population was carried out and is reported in

Chapter Six.

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5.9.2 (c) Holding Back (Pistrang and Barker, 1992)

A single item asked, “To what extent have you held back from talking to (most

important helper) about your concerns and feelings?” The respondents answered on a

four-point scale, ranging from “not at all” (score zero) to “a lot” (score three).

This single item is provided in two versions as below:

• The women’s version:

To what extent have you held back from talking to your husband about your

concerns or feelings.

• The husband’s version:

To what extent have you held back from talking to your wife about your

concerns or feelings.

The original scale (English) was translated into various languages in the Malaysian

population namely Malay, Chinese and Tamil languages, using the standardized translation

technique, as illustrated in Section 5.11. For this, the validation of the versions on the

local population had been made and their Intraclass Correlation Coefficient (ICC),

sensitivity to change and discriminant validity are reported in Chapter Six.

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5.9.2 (d) Helpfulness of Disclosure (Pistrang and Barker, 1992)

A single item asked, “How helpful or unhelpful to you has it been when you have

talked about your concerns and feelings with (most important helper)?” The respondents

answered on a six-point scale, which ranged from “very unhelpful” (score one) to “very

helpful” (score six). This global index of helpfulness had been used in the previous studies

on informal helping and counselling (Elliott et al., 1982; Barker and Lemle, 1987).

This single item is provided in two versions, as below:

• The women’s version:

How helpful or unhelpful to you has it been when you have talked about your

concerns and feelings with your husband?

• The husband’s version:

How helpful or unhelpful to her has it been when you have talked about your

concerns and feelings with your wife?

All the Malay, Chinese and Tamil versions were provided by the translation which

was carried out from the original version (English), in order to cater for the multi-ethnicity

of the Malaysian population (see Section 5.11). All the versions were validated locally and

their Intraclass Correlation Coefficients (ICC), sensitivity to change and discriminant

validity are reported in Chapter Six.

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5.9.2 (e) Criticism (Pistrang and Barker, 1995)

A single item asked, “How critical towards you has your partner been since your

illness?” The respondents answered this question on a five-point scale, ranging from “not

at all critical” (score zero) to “extremely critical” (score four).

This single item is provided in two versions, as below:

• The women’s version:

How critical towards you has your husband been since your illness?

• The husband’s version:

How critical towards her have you been since her illness?

The original scale (English) was translated into various languages (Malay, Chinese

and Tamil) to cater for the multi-ethnicity of the Malaysian population (see Section 5.11).

All these versions were validated locally and their Intraclass Correlation Coefficient (ICC),

the sensitivity to change and discriminant validity are reported in Chapter Six.

5.9.2 (f) Withdrawal (Pistrang and Barker, 1995)

A single item asked, “How withdrawn from you has your partner been since your

illness?” The respondents answered on a five-point scale, ranging from “not at all

withdrawn” (score zero) to “extremely withdrawn” (score four).

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This single item was provided in two versions, as below:

• The women’s version:

How withdrawn from you has your husband been since your illness?

• The husband’s version:

How withdrawn to her have you been since her illness?

The original scale (English) was translated into various languages (Malay, Chinese

and Tamil) to cater for the multi-ethnicity of the Malaysian population (see Section 5.11).

These versions were validated locally, and their Intraclass Correlation Coefficient,

sensitivity to change and discriminant validity are reported in chapter six.

5.9.2 (g) Empathy Sub-scale: Revised Barrett-Lennard Relationship Inventory

(E-RBLRI) (Barrett-Lennard, 1978)

A sub-set scale, from the Revised Barrett-Lennard Relationship Inventory, was

taken to measure empathy. The Revised Barrett-Lennard Relationship Inventory was

designed to measure the four dimensions of the interpersonal relationship, adapted from

Rogers’ (1957, 1959) conception of the necessary conditions for the therapeutic

personality change. The original version of empathy has 16 questions, but only 10 were

used in this study. The selection of the 10 questions was based on the factor loadings

(Cramer, 1986). The inventory could be used to measure the relationship dimension in any

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setting. The original inventory was designed in two versions, as indicated in the examples

below:

Version one: S/he nearly always know what exactly I mean

Version two: I nearly always know exactly what s/he means

In the present study, version one was applied to the women with breast cancer and version

two was applied to their husbands. The respondents rated the five positive items on a six-

point scale, ranging from “Yes, I strongly feel that it is true” to “No, I strongly feel that it

is not true”. The other five negative items were rated reversely using the same rating scale.

The higher score indicates better understanding by their most important helper (i.e.

husband) on their life condition of having breast cancer. Pistrang and Barker (1992)

indicated the Cronbach’s alpha of 0.83 for the internal consistency of the E-RBLRI.

The original scale (English) was translated into various languages (Malay, Chinese

and Tamil) to cater for the multi-ethnicity of the Malaysian population (see Section 5.11

for this). These versions were validated locally, and the reliability and validity of the scale

are reported in Chapter Six.

5.9.2 (h) Dyadic Satisfaction Subscale: Dyadic Adjustment Scale (DS-DAS)

(Spanier, 1976)

The Dyadic Adjustment Scale (DAS) was designed to serve a number of different

needs. This scale has four dimensions – dyadic consensus, dyadic satisfaction, dyadic

cohesion and affectional expression. The scale can actually be used overall, or only a

certain part of it to meet the aim of the research or the time constraints, and it can be used

in any setting. The overall measure of the DAS contains 23 items, whereas the sub-set of

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the relationship satisfaction contains 10 items. This Dyadic Satisfaction of Dyadic

Adjustment Scale (Spanier, 1976) asked the respondents about their satisfaction on their

relationship with their partner. Five questions were rated on a six-point scale, ranging

from “all the time” (score zero) to “never” (score five); whereas, two questions were rated

reversely using the same rating scale. The other three questions were rated separately.

One question asked, “Do you kiss your mate?” which was rated on the five-point scale,

ranging from “never” (score zero) to “everyday” (score four). Another one question

required the respondents to describe the degree of happiness in their relationship with

partner. It was rated using a seven-point scale, ranging from “extremely unhappy” (score

zero) to “perfect” (score six). The last question requested the respondents to describe their

feeling towards their future relationship with their partner, using a six-point scale, where

each answer option was varied with the score of six, to indicate the highest positive feeling

of the future relationship, whereas the score of one indicated the lowest positive feeling of

their future relationship with the partner. The reliability of the scale had been established

with the Cronbach’s alpha of 0.94 for the subscale of Dyadic Satisfaction (Spanier, 1976).

Similarly, the criterion-related validity was established by conducting the scale among two

groups of respondents, which were married respondents and divorced respondents. The

divorced sample differed significantly from the married sample (Spanier, 1976). The

constructed validity was established by comparing the scale with other established marital

adjustment scale. The result indicated that the DAS measured the same general construct,

as a well-accepted marital adjustment scale with the correlation observed was 0.86, among

married the respondents and 0.88 among the divorced respondents (Spanier, 1976).

The translation of the original version (English), into Malay, Chinese and Tamil

languages, was carried out (see section 5.11) and validated locally. The reliability and

validity of all the versions are reported in Chapter Six.

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5.9.3 Coping Strategies

The Brief COPE scale was used in the measurement of the women’s and their

husbands’ coping strategies. In this study, the scale was suitable to be used for both the

women with breast cancer and their husbands. The information of the scales is further

described in detail, as follows:

5.9.3 (a) Brief COPE (Carver, 1997)

This scale was designed to assess a broad range of coping responses among adults

for all diseases. It contains 28 items and is rated by the four-point likert scale, ranging

from “I haven’t been doing this at all” (score one) to “I have been doing this a lot” (score

four). In this study, the higher the score of positive coping strategies (i.e. active coping,

use of emotional support, use of instrumental support, venting, positive reframing,

planning, humor, acceptance and religion) and the lower the score of negative coping

strategies (i.e. denial, substance use, behavioral disengagement and self-blame) indicate the

greater use or better coping strategies. In total, 14 dimensions are covered by this scale.

These are self-distraction, active coping, denial, substance use, use of emotional support,

use of instrumental support, behavioural disengagement, venting, positive reframing,

planning, humour, acceptance, religion and self-blame. Every dimension has two items.

The coping dimensions also can be divided into two major categories: Problem-focused

Strategies (i.e. active coping, planning and using instrumental support) and Emotion-

focused Strategies (i.e. positive reframing, acceptance, religion, using emotional support

and denial). This classification of the coping strategies was based on the previous

research, and some of the dimensions were considered as less efficient strategies (Ben-Zur

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& Zeidner, 1995). Most of the sub-scales of the Brief COPE indicated the Cronbach’s

alpha of at least 0.6 except for Venting, Denial and Acceptance, indicating the values

lower than 0.6 (Carver, 1997).

To cater for the multi-ethnicity of the Malaysian population, the original version

(English) was translated into Malay, Chinese and Tamil languages, using the standardized

translation technique as explained in Section 5.11. All the versions were validated locally,

and the reliability and validity of the scale are reported in Chapter Six.

5.9.4 Bio/socio-demographic and Medical Information

Several questions related to socio-demography were gathered from both the women

with breast cancer and their husbands. The bio/socio-demographic information gathered

from the women included their menopausal status (based on the sign as proposed by

Brambilla et al., 1994), age, ethnicity, education level, type of occupation, household

monthly income, number of children, years of marriage. Meanwhile, the socio-

demographic information gathered from the husbands included their age, ethnicity,

education level, type of occupation and current diseases. Related medical information

which was obtained from the women with breast cancer were the types of breast cancer

surgery (mastectomy and lumpectomy), breast cancer stages, diagnosis date, family history

of breast cancer and current diseases.

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5.10 Cultural Adaptation of the English Original Scale

The cultural adaptation of the English original scale was done to make sure that the

meanings intended in the English language used in the original scale could be understood

by the Malaysian population.

5.11 The Translation of the English Original Scales

The translation of the English original scale into Malay, Chinese and Indian

languages was done to cater for the multi-cultural ethnicity of the women with breast

cancer and their husbands. In order to obtain the instrument equivalent to the English

original, bilingual translators were used to carry out the translation work, based on the

back translation technique proposed by Brislin (1970) and Koller et al. (2007), as indicated

in Figure 5.1 below.

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Figure 5.1: The Flow Chart of Translation Technique (Brislin, 1970; Koller et al., 2007)

Forward Translation (English to the Target Language)

Discussion and Decision

Revision 1

Backward Translation (Target Language to English)

Discussion and Decision

Original Version (English)

Revision 2

Discussion and Decision

Finalization

167

5.12 Pilot Test

In this study, the translated versions were pre-tested on the women with breast

cancer and their husbands separately. For this purpose, five Malay couples (Malay

Version), five Chinese couples (Chinese Version) and five Indian couples (Tamil Version)

were involved in the pilot test. The women with breast cancer and their husbands were

approached in the Oncology Clinics, where a list of eligible respondents for this pilot

testing was retrieved from the oncologist. The medical record of the patients was also

referred in order to obtain their medical information, as well as justify their eligibility as

pilot respondents. The variation of their education levels, age group and medical phase

were also taken into consideration in the selection process of the respondents. The

majority of the women with breast cancer have had at least lower secondary education with

a mean age of 44 years (sd±8.9). Most of them were in stages two and three, had

undergone mastectomy and were on chemotherapy. The characteristics of the husbands

mirrored the breast cancer patients, where they have at least lower secondary education

level. The husbands were older than the women, with a mean age of 50 years (sd±7.9).

After the respondents were selected, they were briefed on the aim of the pilot study.

Before the questionnaires were distributed, the agreement of participation in the pilot study

was obtained from both the women with breast cancer and their husbands, by getting a

signature for the consent form. The information sheets for the patients and their husbands

followed the standard format taken from the Ethics Committee of the University Malaya

Medical Centre (UMMC), Kuala Lumpur, Malaysia, were also attached to the consent

form. The women with breast cancer and their husbands answered the questionnaire

themselves (self-administrated) in separate rooms which were provided at the clinic to

avoid any discussion. The respondents’ feedback and comments on the difficulties in

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understanding or ambiguous meaning of certain words or sentences were recorded. The

backward translation was re-implemented for the controversial words or sentences

reported. The questionnaire and inventory were then finalized and pre-tested for the

second time, on another 15 couples with breast cancer. The flow chart of the pilot testing

undertaken is summarized in Figure 5.2 below.

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Figure 5.2: The Flow Chart of the Pilot Testing

Briefing of the Study

Distribution of Questionnaire

Recording any controversial word or sentence

Re-translation of the controversial word or sentence

Discussion, decision and finalization

Selection of the Respondents

Re-testing

Finalization

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5.13 Data Processing and Statistical Analysis

The raw data obtained were analysed using their own scoring items for each

questionnaire. The computer software, i.e. the Statistical Package of Social Science

(SPSS) version 15.0, was used in the data analysis of the current study. Univariate,

bivariate and multivariate analysis was also used to examine the various hypotheses

postulated.

Using the above methodology, which had been described in detail, the findings

obtained from the study are presented in the next chapter. The reliability and validity of

the scales are reported in another chapter, prior to the presentation of the main findings of

the current study.

171

CHAPTER SIX

RESULTS: PART ONE

RELIABILITY AND VALIDITY OF THE SCALES

In this chapter, the results of the reliability and validity of the scales are

presented, prior to the presentation of the main findings in the next chapter. The results

of the reliability and validity of the scales are divided into two sections: Women’s

questionnaires and inventories; and Husbands’ questionnaires and inventories. In each

section, the results are reported according to the groups of the questionnaires and

inventories. For the breast cancer patients (women), the questionnaires and inventories

are further grouped into four sub-sections. They are the measurements of quality of

life, sexuality, interpersonal relationship and coping strategies. Likewise, the

questionnaires and inventories for the husbands are also further grouped into four sub-

sections, which include the measurements of psychological well-being, sexuality,

interpersonal relationship and coping strategies.

The analyses were carried out based on the various versions of the

questionnaires and inventories answered by the women and their husbands to cater for

their multi-ethnicity status of these respondents. These were the English Version,

Malay Version, Chinese Version and Tamil Version. The test-retest measurements, at

the phase of prior-to and during chemotherapy, were carried out to observe the

Intraclass Correlation Coefficient (ICC) and the sensitivity of the scales. Meanwhile,

the discriminant validity was determined by comparing the two groups: the women

who had undergone mastectomy and the women who had undergone lumpectomy

operation for breast cancer. The internal consistency of the scales, by looking at the

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Cronbach’s alpha values, was obtained from the baseline data. The same analysis was

performed for the questionnaires and inventories meant for the patients’ husbands in

order to examine the reliability and validity of the scales used in this study.

6.0 The Women’s Questionnaires and Inventories

The questionnaires and inventories of the women with breast cancer were sub-

grouped into four - the measurements of quality of life, sexuality, interpersonal

relationship and coping strategies.

6.0.1 The Measurement of the Women’s Quality of Life

The scales used for measuring the quality of life of these women are known as

the European Organization of Research and Treatment of Cancer Quality of Life scale

(EORTC QLQ C-30), together with the Breast Module (QLQ-BR23), Hospital Anxiety

and Depression Scale (HADS) and Blatt Menopausal Index (BMI).

6.0.1 (a) European Organization of Research and Treatment of Cancer

Quality of Life scale (EORTC QLQ C-30)

The overall internal consistencies of the EORTC QLQ C-30 for the Global

Health Status and Functioning sub-scale (Physical, Role, Emotional, Cognitive and

Social Functioning) were acceptable with the Cronbach’s alpha values, ranging from

0.63 to 0.92. Similarly, the Symtomatology sub-scale of EORTC QLQ C-30 (Fatigue,

Nausea and Vomiting, Pain) also showed excellent Cronbach’s alpha values which

ranged from 0.75 to 0.96, indicating the high level of homogeneity among the items in

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the scale. The test-retest values of the Intraclass Correlation Coefficient (ICC), for the

Global Health Status and Functioning scale of EORTC QLQ C-30, ranged from 0.12 to

0.99, indicating the change ranges of the various sub-scales from the baseline to the

second phase of the study. Meanwhile, the ICC value for the Symtomatology sub-scale

of the EORTC QLQ C-30 ranged from 0.11 to 0.99, as shown in Table 6.0.

The Cronbach’s alpha value for the original English Version of the EORTC

QLQ C-30 for the Global Health and Functioning sub-scales also showed the range of

values from 0.40 to 0.90, indicating the low to high internal consistency among the sub-

scales; whereas, the Symtomatolgy sub-scales indicated the high Cronbach’s alpha

values ranging from 0.75 to 1.00. On the contrary, the Intraclass Correlation

Coefficient (ICC) value for Global Health Status and Functioning sub-scales ranged

from 0.03 to 0.80; whereas, the Symtomatology sub-scales ranged from 0.02 to 1.00,

indicating that there was a change after the re-test among the sub-scales, as given in

Table 6.1.

Similarly, the Global Health Status, Functioning and Symtomatology sub-

scales, from the Malay version of the EORTC QLQ C-30, showed an acceptable

internal consistency (Cronbach’s alpha ranged from 0.50 to 0.91 for the Global Health

and Functioning, and 0.75 to 0.99 for Symtomatology). The values of the Intraclass

Correlation Coefficient (ICC) ranged from 0.05 to 0.99 for the Global Health Status

and Functioning, and 0.16 to 1.00 for the Symtomatology sub-scales, as indicated in

Table 6.2.

Similarly, most of the sub-scales of the Global Health and Functioning for the

Chinese version of the EORTC QLQ C-30 indicated a good internal consistency, with

Cronbach’s alpha values ranging from 0.54 to 0.94, and the test-retest ICC values from

0.28 to 1.00. The Cronbach’s alpha values for the Symtomatology sub-scales were also

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consistent, ranging from 0.68 to 0.92, and with the ICC from 0.02 to 0.99, indicating

the change after the re-test (Table 6.3).

Similarly, for the Global Health Status and Functioning sub-scales of the Tamil

version of EORTC QLQ C-30, the instrument also showed acceptable Cronbach’s

alpha values ranging from 0.56 to 0.89, and the Symtomatology sub-scales indicated

the range values from 0.7 to 1.00. The values of the test-retest ICC ranged from 0.25 to

1.00 for the Global Health Status and Functioning sub-scales; and from <0.00 to 0.98

for the Symtomatology sub-scales, as shown in Table 6.4.

The sensitivity of the scales, which was indicated by the mean differences

between the two measurements, was observed for most of the sub-scales with the value

of the effect size below the moderate level. This could be observed for the overall

value (ranging from 0.00 to 0.34) presented in Table 6.0; the English version (ranging

from 0 to 0.30) as in Table 6.1; the Malay version (ranging from 0 to 0.35) given in

Table 6.2; the Chinese version (ranging from 0 to 0.45) as presented in Table 6.3; and

the Tamil version (ranging from 0 to 0.43) as in Table 6.4. The overall values of the

mean differences were highly significant for the Global Health Status (ESI = 0.25;

p<0.001) and most of the Functioning sub-scales [Role Functioning (ESI = 0.34;

p<0.001), Emotional Functioning (ESI = 017; p<0.001), Cognitive Functioning (ESI =

0.01; p<0.05), Social Functioning (ESI = 0.33; p<0.001)], as presented in Table 6.0.

Similarly, the Global Health Status and most of the Functioning sub-scales from all the

versions indicated high differences between the two measurements [English version:

Global Health Status (ESI = 0.30; p<0.001), Role Functioning (ESI = 0.31; p<0.001),

Emotional Functioning (ESI = 0.20; p<0.001), Social Functioning (ESI = 0.34; p<0.01)

(see Table 6.1); Malay version: Global Health Status (ESI = 0.26; p<0.001), Role

Functioning (ESI = 0.32; p<0.001), Emotional Functioning (ESI = 0.17; p<0.001),

Cognitive Functioning (ESI = 0.02; p<0.05), Social Functioning (ESI = 0.27; p<0.01)

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(see Table 6.2); Chinese version: Global Health Status (ESI = 0.21; p<0.001), Role

Functioning (ESI = 0.45; p<0.001), Emotional Functioning (ESI = 0.19; p<0.001),

Social Functioning (ESI = 0.39; p<0.001) (see Table 6.3); Tamil version: Global Health

Status (ESI = 0.25; p<0.001), Role Functioning (ESI = 0.32; p<0.001), Emotional

Functioning (ESI = 0.14; p<0.001), Social Functioning (ESI = 0.43; p<0.01) (see Table

6.4)]. Meanwhile, as expected, some scales showed significant differences for the

Symtomatology sub-scales, which is almost similar between the versions and the

overall sensitivity [the overall mean differences: Fatigue (ESI = 0.11; p<0.05), Nausea

and Vomiting (ESI = 0.41; p<0.001), Pain (ESI = 0.02; p<0.01), Insomnia (ESI = 0.03;

p<0.05), Appetite Loss (ESI = 0.24; p<0.001) (Table 6.0); English version: Nausea and

Vomiting (ESI = 0.51; p<0.001), Appetite Loss (ESI = 0.37; p<0.01) (see Table 6.1);

Malay version: Nausea and Vomiting (ESI = 0.35; p<0.001), Appetite Loss (ESI =

0.18; p<0.05) (see Table 6.2); Chinese version: Nausea and Vomiting (ESI = 0.51;

p<0.001), Insomnia (ESI = 0.08; p<0.05), Appetite Loss (ESI = 0.34; p<0.01) (see

Table 6.3); and Tamil version: Fatigue (ESI = 0.31; p<0.05), Nausea and Vomiting

(ESI = 0.35; p<0.01) (see Table 6.4)].

With the exception of the Nausea and Vomiting sub-scales of the overall value

(p<0.05), an analysis of the discriminant validity showed that all the Functional and

Symtomatology sub-scales of the EORTC QLQ C-30 (from all the versions) did not

show any significant differences between the mastectomy and lumpectomy groups

(Tables 6.0, 6.1, 6.2, 6.3, and 6.4).

In term of the construct validity of the EORTC-QLQ C-30, the analysis of

Pearson Correlation was undertaken to examine the inter-correlation among the

domains (see Table 6.5). Global Health Status (GH) indicated a significant correlation

with Social Functioning (SF) (p<0.01), Nausea and Vomiting (NV) (p<0.01), Loss of

Appetite (LA) (p<0.01), Constipation (C) (p<0.01), Diarrhea (D) (p<0.01) and

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Dysponea (p<0.05). A significant correlation was also observed between the Global

Health Status (GH) and the Anxiety-HADS (A) (p<0.05)/ Depression-HADS (D)

(p<0.001).

Physical Functioning (FP) exhibited the significant correlation (p<0.001) with

nearly all the EORTC-QLQ C-30 domains. They were Cognitive Functioning (CF),

Emotional Functioning (EF), Social Functioning (SF), Pain (P), Nausea and Vomiting

(NV), Dysponea (D), Loss of Appetite (LA), Constipation (C), Diarrhea (D) and

Financial Difficulties (FD). A significant correlation was also exhibited between

Physical Functioning (FP) and Anxiety-HADS (A)/ Depression-HADS (D), as well as

with Blatt Menopausal Index (BMI) (p<0.001).

Similarly, Role Functioning (RF) demonstrated a significant correlation with

most of the EORTC QLQ C-30 domains [Physical Functioning (PF) (p<0.001),

Cognitive Functioning (CF) (p<0.01), Emotional Functioning (EF) (p<0.001), Social

Functioning (SF) (p<0.001), Fatigue (Ft) (p<0.001), Pain (P) (p<0.01), Nausea and

Vomiting (NV) (p<0.01), Dysponea (D) (p<0.001), Loss of Appetite (LA) (p<0.01),

Constipation (C) (p<0.01), Diarrhea (D) (p<0.01) and Financial Difficulties (FD)

(p<0.001)] and Hospital Anxiety and Depression Scales [Anxiety (A) (p<0.001) and

Depression (D) (p<0.05)]

Likewise, significant correlation was observed between Cognitive Functioning

and nearly all the domains of EORTC-QLQ C-30 [Physical Functioning (PF),

Emotional Functioning (EF), Social Functioning (SF), Fatigue (Ft), Pain (P), Nausea

and Vomiting (NV), Constipation (C), Diarrhea (Diar) (p<0.001); Role Functioning

(RF), Dysponea (Dys) , Loss of Appetite (LA) (p<0.01); Global Health Status (GH)

(p<0.05)]

For the Emotional Functioning (EF), a significant correlation was observed for

most of the EORTC-QLQ C-30 domains such as Role Functioning (RF) (p<0.001),

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Cognitive Functioning (CF) (p<0.001), Social Functioning (SF) (p<0.001), Fatigue (Ft)

(p<0.001), Pain (P) (p<0.001), Constipation (C) (p<0.001), Physical Functioning (PF)

(p<0.01), Nausea and Vomiting (NV) (p<0.01), Loss of Appetite (LA) (p<0.01),

Diarrhea (Diar) (p<0.01), Financial Difficulties (FD) (p<0.01) and Dysponea (Dys)

(p<0.05). Anxiety-HADS (A)/ Depression-HADS (D) and Blatt Menopausal Index

(BMI) also exhibited a strong correlation with Emotional Functioning (p<0.001).

In term of Social Functioning (SF), almost all the domains of EORTC QLQ C-

30 indicated the significant correlation with this domain [Global Health Status (GH)

(p<0.01), Physical Functioning (PF) (p<0.01), Role Functioning (p<0.001), Cognitive

Functioning (p<0.001), Emotional Functioning (EF) (p<0.001), Ft (Fatigue) (p<0.001),

Pain (P) (p<0.001), Nausea and Vomiting (NV) (p<0.01), Dysponea (Dys) (p<0.01),

Loss of Appetite (LA) (p<0.01), Constipation (C) (p<0.01), Financial Difficulties (FD)

(p<0.05]. Similarly, the significant correlation was also exhibited between Social

Functioning (SF) and Anxiety-HADS (A)/Depression-HADS (D) (p<0.001); and Blatt

Menopausal Index (BMI) (p<0.01).

As indicated in Table 6.5, all the symptomatology scales of EORTC QLQ C-30

[Fatigue (Ft), Pain (P), Nausea and Vomiting (NV), Dysponea (D), Loss of Appetite

(LA), Insomnia (I), Constipation (C), Diarrhea (D) and Financial Difficulties (FD)]

exhibited a significant inter-correlation among the domains. A significant correlation

was also demonstrated between the symptomatology scales and Global Health Status

(GH)/ Functional Scale [Physical Functioning (PF), Role Functioning (RF), Cognitive

Functioning (CF), Emotional Functioning (EF), Social Functioning (SF)]

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189

6.0.1 (b) Breast Module (QLQ-BR23)

The overall internal consistency was excellent for the Functional sub-scales of

QLQ BR-23, with the Cronbach’s alpha value of 0.87 for the Body Image, and 0.89 for

the Sexual Functioning. The test retest value of the Intraclass Correlation Coefficient

(ICC) ranged from 0.36 to 0.99, indicating that the change was observed after the re-

test. Similarly, acceptable Cronbach’s alpha values (ranging from 0.73 to 0.82) were

observed in all the Symtomatology sub-scales, with the ICC value ranging from 0.16 to

0.40, as shown in Table 6.0.

The English version of the QLQ BR-23 indicated high values of the Cronbach’s

alpha for its Functioning sub-scales (0.88 to 0.91), as well as for the Symtomatology

sub-scales, with the values ranging from 0.77 to 0.88. The test-retest values of the ICC

were excellent for the Sexual Functioning and Future Perspective (0.97 and 0.96,

respectively), except for the Sexual Enjoyment and Body Image sub-scales and all the

Symtomatology subscales (see Table 6.1).

Similarly, the sub-scales for the Body Image and Sexual Functioning, from the

Malay version of the QLQ BR-23, indicated an excellent internal consistency, with the

Cronbach’s alpha values of 0.89 and 0.84, respectively. The test-retest values of the

ICC were also excellent for the Sexual Functioning and Future Perspective, with 1.00

and 0.90, respectively; nevertheless, this value was low for other sub-scales, indicating

the changes after the retest among the sub-scales. The Symtomatology sub-scales also

showed an excellent internal consistency; the Cronbach’s alpha values ranged from

0.70 to 0.82, and the ICC values from 0.26 to 0.58, as presented in Table 6.2.

The internal consistency of the Functioning sub-scales for the Chinese version

of the QLQ BR-23 was also excellent, with the Cronbach’s alpha value of 0.82 for the

Sexual Functioning and 0.88 for the Body Image. Similarly, the test-test values of the

190

ICC for these sub-scales were also high, ranging from 0.82 to 1.00, except for the

Sexual Enjoyment. In the same vein, acceptable Cronbach’s alpha values were

observed for the Symtomatology subscales (from 0.58 to 0.78), with low ICC values

ranging from 0.09-0.34 (see Table 6.3).

The Cronbach’s alpha values were high for the Functioning sub-scales of the

Tamil version for the QLQ BR-23, i.e. ranging from 0.84 to 0.92. The excellent

Cronbach’s alpha values were also observed for the Symtomatology sub-scales

(ranging from 0.82 to 0.87). All the sub-scales for the Functioning had high ICC

values (both 1.00), except for the Body Image and the Sexual Enjoyment.

Nevertheless, the ICC values were quite low for the Symtomatology sub-scales, these

were ranging from 0.08 to 0.43 (see Table 6.4).

The sensitivity of the scale was indicated by the effect size (below moderate

level) as observed in most of the subscales: the overall values (ranging from 0.01 to

0.58), the English version (ranging from 0 to 0.46), the Malay version (ranging from 0

to 0.65), the Chinese version (ranging from 0 to 0.42) and the Tamil version (ranging

from 0 to 0.79). The two Functioning sub-scales from all the versions (and the overall

values), which were Body Image and Sexual Enjoyment, indicated high significant

differences between the two measurements [the overall mean differences: Body Image

(ESI = 0.33; p<0.001) and Sexual Enjoyment (ESI = 0.58; p<0.001) (see Table 6.0);

English version: Body Image (ESI = 0.34; p<0.01) and Sexual Enjoyment (ESI = 0.46;

p<0.01) (see Table 6.1); Malay version: Body Image (ESI = 0.28; p<0.001) and Sexual

Enjoyment (ESI = 0.65; p<0.001) (see Table 6.2); Chinese version: Body Image (ESI =

0.39; p<0.001) and Sexual Enjoyment (ESI = 0.22; ns) (see Table 6.3); and Tamil

version: Body Image (ESI = 0.35; p<0.01) and Sexual Enjoyment (ESI = 0.79; p<0.01)

(see Table 6.4)]. Meanwhile, some Symtomatology sub-scales, such as the Systemic

Therapy Side Effect and Arm symptoms, showed high significant differences between

191

these two measurements [the overall value: Systemic Therapy Side Effect (ESI = 0.46;

p<0.001) and Arm Symptoms (ESI = 0.21; p<0.001) (see Table 6.0); English version:

Systemic Therapy Side Effect (ESI = 0.40; p<0.001) and Arm Symptoms (ESI = 0.30;

p<0.01) (see Table 6.1); Malay version: Systemic Therapy Side Effect (ESI = 0.47;

p<0.001) and Arm Symptoms (ESI = 0.25; p<0.001) (see Table 6.2); Chinese version:

Systemic Therapy Side Effect (ESI = 0.42; p<0.001) and Arm Symptoms (ESI = 0.21;

p<0.05) (see Table 6.3); Tamil version: Systemic Therapy Side Effect (ESI = 0.60;

p<0.001) and Arm Symptoms (ESI = 0; ns) (see Table 6.4)].

An analysis of the discriminant validity indicated that almost all the Functioning

and Symtomatology sub-scales of the QLQ-BR23 (from all versions) did not show any

significant differences between the mastectomy and lumpectomy groups, except for the

Sexual Enjoyment sub-scale of the overall value (p<0.05), and the English version

(p<0.001) (see Tables 6.0, 6.1, 6.2, 6.3, and 6.4).

Table 6.6 depicts the construct validity of the Breast Module (BR-23) which

was demonstrated by the inter-correlation among the domains of BR-23, Hospital

Anxiety and Depression Scale (HADS) and Blatt Menopausal Index (BMI).

Body Image BR23 (BI) indicated a significant correlation among the BR-23

domains [i.e. Future Perspective (FP) (p<0.001), Systemic Therapy Side Effect (STS)

(p<0.001), Breast Symptoms (BS) (p<0.001), Arm Symptoms (AS) (p<0.01) and Upset

by Hair Loss (HL) (p<0.05)]. A significant correlation was also discovered between

Body Image-BR23 (BI) and most of the EORTC QLQ C-30 domains such as Global

Health Status (GH) (p<0.01), Physical Functioning (PF) (p<0.001), Role Functioning

(RF) (p<0.001), Cognitive Functioning (CF) (p<0.001), Emotional Functioning (EF)

(p<0.001), Social Functioning (SF) (p<0.001), Fatigue (Ft) (p<0.01), Pain (P)

(p<0.001), Nausea and Vomiting (NV) (p<0.01), Dysponea (Dys) (p<0.05),

Constipation (C) (p<0.01), Diarrhea (Diar) (p<0.01), Financial Difficulties (FD)

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Table 6.6: Construct Validity of the Breast Module (BR-23): Inter-correlation (Pearson’s r) With the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ C30), Breast Module (BR-23)’s Domains, Hospital Anxiety and Depression Scale (HADS) and Blatt Menopausal Index (BMI).

BI SexF SexE FP STS BS AS HL GH 0.27b -0.20a -0.06 0.14 -0.30c -0.20a -0.07 -0.22 PF 0.29c 0.11 0.10 0.25b -0.47c -0.43c -0.49c -0.12 RF 0.34c 0.03 0.02 0.20a -0.18a -0.41c -0.29c -0.05 CF 0.27c 0.11 -0.00 0.25 -0.56c -0.36c -0.36c -0.25a

EF 0.36c 0.09 0.08 0.46c -0.38c -0.35c -0.36c -0.44c

SF 0.36c 0.06 -0.01 0.32c -0.24b -0.26b -0.21b 0.01 Ft -0.26b -0.14 -0.18 -0.24b 0.58c 0.38c 0.44c 0.16 P -0.28c -0.12 -0.12 -0.29c 0.47c 0.58c 0.19a 0.26a

NV -0.24b -0.08 -0.02 -0.08 0.57c 0.16a 0.59c 0.14 Dys -0.19a 0.05 0.00 -0.10 0.27b 0.28c 0.25b 0.05 LA -0.12 -0.06 -0.03 -0.08 0.43c 0.28c 0.28b 0.06 I -0.05 0.06 -0.18 0.03 0.15 0.05 0.05 0.06 C -0.20b 0.01 -0.17 -0.15 0.51c 0.39c 0.40b 0.34b

Diar -0.27b -0.06 -0.10 -0.12 0.45c 0.28c 0.29c 0.18 FD -0.24b 0.07 -0.13 -0.17a 0.14 0.232 0.27b 0.03 BI - 0.01 0.02 0.47c -0.37c -0.30c -0.23b -0.28a

SexF 0.01 - -0.03 0.14 -0.06 -0.09 -0.17a 0.01 SexE 0.02 -0.03 - 0.19a -0.04 -0.05 -0.11 0.24 FP 0.47c 0.14 0.19a - -0.25b -0.21b -0.19a -0.22 STS -0.37c -0.06 -0.04 -0.25b - 0.40c 0.38c 0.60c

BS -0.29c -0.09 -0.05 -0.21b 0.36c - 0.71b 0.27a

AS -0.23b -0.17a -0.11 -0.19a 0.38c 0.70c - 0.32b

HL -0.28a 0.01 0.24 -0.22 0.60c 0.26a 0.32b - A -0.36c -0.00 -0.12 -0.34c 0.30c 0.27b 0.22b 0.17 D -0.39c 0.17a -0.06 -0.21b 0.26b 0.21b 0.08 0.17 BMI -0.13 -0.02 -0.12 -0.30c 0.46c 0.23b 0.31c 0.27a

p<0.05a; p<0.01b; p<0.001c

GH=Global Health Status (EORTC-QLQ C-30); PF=Physical Functioning (EORTC-QLQ C-30); RF=Role Functioning (EORTC-QLQ C-30); CF=Cognitive Functioning (EORTC-QLQ C-30); EF=Emotional Functioning (EORTC-QLQ C-30); SF=Social Functioning (EORTC-QLQ C-30); Ft=Fatigue (EORTC-QLQ C-30); P=Pain (EORTC-QLQ C-30); NV=Nausea and Vomiting (EORTC-QLQ C-30); Dys=Dysponea (EORTC-QLQ C-30); LA=Loss of Appetite (EORTC-QLQ C-30); I=Insomnia (EORTC-QLQ C-30); C=Constipation (EORTC-QLQ C-30); Diar=Diarrhea (EORTC-QLQ C-30); FD=Financial Difficulties (EORTC-QLQ C-30); BI=Body Image (BR-23); SexF=Sexual Functioning (BR-23); SexE=Sexual Enjoyment (BR-23); FP=Future Perspective (BR-23); STS=Systemic Therapy Side Effect (BR-23); BS=Breast Symptoms (BR-23); AS=Arms Symptoms (BR-23); HL=Upset by Hair Loss (BR-23); A=Anxiety (Hospital Anxiety and Depression Scale-HADS); D=Depression (Hospital Anxiety and Depression Scale-HADS); BMI=Blatt Menopausal Index.

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(p<0.01)] and Hospital Anxiety and Depression Scale [Anxiety (A) (p<0.001) and

Depression (D) (p<0.001)].

Only a few domains of BR-23 and EORTC QLQ C-30 indicated a significant

correlation with Sexual Functioning-BR23 (SexF) and Sexual Enjoyment-BR23

(SexE). Sexual Functioning-BR23 (SexF) indicated a weak correlation (p<0.05) with

Arms Symptoms-BR23 (AS), Global Health Status-EORTC QLQ C-30 (GH) and

Depression-HADS (D). Meanwhile, Sexual Enjoyment-BR23 (SexE) exhibited a weak

correlation (p<0.05) with Future Perspective-BR23 (FP).

For the Future Perspective-BR23 (FP), a number of domains from BR23

showed a significant correlation with this domain, such as Body Image (BI) (p<0.001),

Sexual Enjoyment (SE) (p<0.05), Systemic Therapy Side Effect (STS) (p<0.01), Breast

Symptoms (BS) (p<0.01) and Arms Symptoms (AS) (p<0.05). Similarly, a number of

EORTC QLQ C-30 domains exhibited a significant correlation with the Future

Perspective-BR23 (FP) i.e. Physical Functioning (PF) (p<0.01), Role Functioning (RF)

(p<0.05), Emotional Functioning (EF) (p<0.001), Social Functioning (SF) (p<0.001),

Fatigue (Ft) (p<0.01), Pain (P) (p<0.001) and Financial Difficulties (FD) (p<0.05).

Anxiety-HADS (p<0.001), Depression-HADS (p<0.01) and Blatt Menopausal Index

(BMI) (p<0.001) also revealed the significant correlation with Future Perspective-

BR23 (FP).

The symptomatology scales of BR-23 [i.e. Systemic Therapy Side Effect (STS),

Breast Symptom (BS), Arms Symptoms (AS) and Upset by Hair Loss (HL)] indicated a

significant correlation with most the domains in BR-23, EORTC QLQ C-30, Hospital

Anxiety and Depression Scale (HADS) and Blat Menopausal Index (BMI), as depicted

in Table 6.6.

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6.0.1 (c) Hospital Anxiety and Depression Scale (HADS)

Acceptable overall Cronbach’s-alpha values were observed for the Anxiety and

Depression sub-scales of the HADS (0.77 and 0.74, respectively), with the test-retest

values of the Intraclass Correlation Coefficient (ICC) at 0.25 and 0.29, respectively (see

Table 6.0). An excellent internal consistency was maintained in the English version of

the HADS, with the Cronbach’s alpha values of 0.72 and 0.79, respectively. For this,

the ICC values for the Anxiety and Depression sub-scales were found to be 0.26 and

0.47, respectively (see Table 6.1). Similarly, acceptable Cronbach’s alpha values were

also indicated by the Malay versions for the HADS (0.67 and 0.82, respectively), with

the ICC value of 0.11 for Anxiety and 0.28 for Depression sub-scales (see Table 6.2).

The internal consistency of the Chinese version for the HADS was also at an acceptable

value with the Cronbach’s alpha value of 0.77 for Anxiety and 0.69 for Depression.

The test-retest values of the ICC gathered were at 0.39 and 0.28, respectively (see

Table 6.3). The Cronbach’s alpha values of the Tamil version for the HADS showed

not much of differences, as compared to the other versions; they were 0.62 for the sub-

scale of Anxiety and 0.80 for Depression. The values of the Intraclass Correlation

Coefficient also did not differ too much from the other versions, with the values of 0.43

and 0.21 for Anxiety and Depression, respectively (Table 6.4).

With the exception for the English Version (ESI = 0.26; ns) (Table 6.1), the

sensitivity of the anxiety sub-scale was indicated by all the versions with significant

differences existing between the two measurements, and with the effect size below the

moderate level [the overall (ESI = 0.17; p<0.001) (see Table 6.0); Malay version (ESI

= 0.20, p<0.001) (see Table 6.2), Chinese version (ESI = 0.22; p<0.01) (see Table 6.3);

and Tamil version (ESI = 0.25; p<0.05) (see Table 6.4)]. The Depression sub-scale of

the overall value (ESI = 0.22; p<0.001) (Table 6.0) and the Malay version (ESI = 0.35;

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p<0.01) (Table 6.2) showed significant differences between the two measurements with

below the moderate level of the effect size, and this was vice versa for the English

version (ESI = 0.05; ns) (Table 6.1), Chinese (ESI = 0.18; ns) (Table 6.3) and Tamil

(ESI = 0.19; ns) (Table 6.4).

The discriminant validity analysis indicated that no significant differences were

found between the mastectomy and lumpectomy groups for the Anxiety and Depression

sub-scales in all versions (see Tables 6.0, 6.1, 6.2, 6.3, and 6.4).

In terms of construct validity of the Hospital Anxiety and Depression Scale

(HADS), the Anxiety subscale (A) demonstrated a strong correlation with Physical

Functioning-EORTC QLQ C-30 (PF) (p<0.001), Role Functioning-EORTC QLQ C-30

(RF) (p<0.001), Cognitive Functioning-EORTC QLQ C-30 (CF) (p<0.001), Emotional

Functioning-EORTC QLQ C-30 (EF) (p<0.001), Social Functioning-EORTC QLQ C-

30 (SF) (p<0.001), Fatigue-EORTC QLQ C-30 (Ft) (p<0.001), Pain-EORTC QLQ C-

30 (P) (p<0.001), Nausea and Vomiting-EORTC QLQ C-30 (NV) (p<0.01), Dysponea-

EORTC QLQ C-30 (Dys) (p<0.01), Loss of Appetite-EORTC QLQ C-30 (LA)

(p<0.01), Constipation-EORTC QLQ C-30 (C) (p<0.01), Diarrhea-EORTC QLQ C-30

(Diar) (p<0.001), Financial Difficulties- EORTC QLQ C-30 (FD) (p<0.01),

Depression-HADS (D) (p<0.001) and Blatt Menopausal Index (BMI) (p<0.001) (see

Table 6.5).

Likewise, Depression-HADS exhibited the strong correlation with nearly all the

EORTC QLQ C-30 Domains [i.e. Global Health Status (GH) (p<0.001), Physical

Functioning (PF) (p<0.001), Cognitive Functioning (CF) (p<0.001), Emotional

Functioning (EF) (p<0.001), Social Functioning (SF) (p<0.001), Fatigue (Ft) (p<0.01),

Pain (P) (p<0.01), Loss of Appetite (LA) (p<0.01) and Diarrhea (D) (p<0.01). The

similar situation was observed for Anxiety-HADS (A) (p<0.001) and Blatt Menopausal

Index (BMI) (p<0.01) (see Table 6.5).

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6.0.1 (d) Blatt Menopausal Index (BMI)

The overall internal consistency was excellent for this scale, with the

Cronbach’s alpha value at 0.88, as shown in Table 6.0. Similarly, the other versions

also indicated excellent Cronbach’s alpha values. These were 0.85 for the English

(Table 6.1), 0.90 for the Malay (Table 6.2), 0.88 for the Chinese (Table 6.3) and 0.87

for the Tamil (Table 6.4) versions. The overall value (0.22) (Table 6.0), English

Version (0.19) (Table 6.1), Malay Version (0.30) (Table 6.2), Chinese Version (0.21)

(Table 6.3) and Tamil Version (0.18) (Table 6.4) showed low test-retest values for the

Intraclass Correlation Coefficient, indicating only a little change after the re-test.

The sensitivity of the scales were also detected, where the significant mean

differences between the two measurements were shown by the effect size values of all

versions below the moderate level [the overall (ESI = 0.32; p<0.001) (see Table 6.0),

English version (ESI = 0.31; p<0.01) (see Table 6.1), Malay version (ESI = 0.29;

p<0.001) (see Table 6.2), Chinese version (ESI = 0.30; p<0.01) (see Table 6.3), Tamil

Version (ESI = 0.48; p<0.01) (see Table 6.4)].

An analysis of the discriminant validity, for all the versions, exhibited

insignificant differences between the mastectomy and lumpectomy groups (Tables 6.0,

6.1, 6.2, 6.3, and 6.4).

Construct validity of the Blatt Menopausal Index (BMI) was proven by the

significant inter-correlation with most of the EORTC-QLQ C-30 domains [i.e. Physical

Functioning (PF) (p<0.001), Cognitive Functioning (CF) (p<0.001), Emotional

Functioning (EF) (p<0.001), Social Functioning (SF) (p<0.01), Fatigue (Ft) (p<0.001),

Pain (P) (p<0.001), Nausea and Vomiting (NV) (p<0.001), Dysponea (Dys) (p<0.05),

Loss of Appetite (LA) (p<0.01), Insomnia (I) (p<0.05), Constipation (C) (p<0.001) and

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Diarrhea (Diar) (p<0.01)] and Hospital Anxiety and Depression Scale [Anxiety (A)

(p<0.001)and Depression (D) (p<0.01)] (see Table 6.5).

6.0.1 (e) Summary of the Results

In measuring the quality of life, nearly all the sub-scales used in this study

indicated a good internal consistency with the Cronbach’s alpha value of more than

0.75. These could particularly be observed in the overall value (Global Health Status,

Emotional Functioning, Social Functioning, Fatigue, Nausea and Vomiting, Pain, Body

Image, Sexual Functioning, Systemic Therapy Side Effect, Breast Symptoms, Anxiety

and menopausal symptoms), the English version (Global Health Status, Emotional

Functioning, Social Functioning, Fatigue, Nausea and Vomiting, Pain, Dyspnoea, Body

Image, Sexual Functioning, Systemic Therapy Side Effect, Breast Symptoms,

Depression and menopausal symptoms), the Malay version (Global Health Status,

Emotional Functioning, Social Functioning, Fatigue, Nausea and Vomiting, Pain, Body

Image, Sexual Functioning, Systemic Therapy Side Effect, Breast Symptoms, Anxiety

and menopausal symptoms), the Chinese version (Global Health Status, Emotional

Functioning, Fatigue, Nausea and Vomiting, Body Image, Sexual Functioning,

Systemic Therapy Side Effect, Anxiety and menopausal symptoms) and the Tamil

version (Global Health Status, Role Functioning, Cognitive Functioning, Nausea and

Vomiting, Pain, Body Image, Sexual Functioning, Systemic Therapy Side Effect,

Breast Symptoms, Arms symptoms, Depression and menopausal symptoms). In the

overall Intraclass Correlation Coefficients, a high agreement between the two

measurements was indicated in the Global Health Status (0.85), Emotional Functioning

(0.99), Cognitive Functioning (0.99), Pain (0.96), Dyspnoea (0.97), Insomnia (0.94),

Constipation (0.99), Diarrhea (0.99), Sexual Functioning (0.99) and Future Perspective

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(0.96). In the English version, the high agreement in the test-retest was observed for

Global Health Status (0.80), Emotional Functioning (0.92), Cognitive Functioning

(1.00), Pain (0.97), Dyspnoea (1.00), Insomnia (0.94), Constipation (0.95), Diarrhea

(0.96), Sexual Functioning (0.97), and Future Perspective (0.96). This is almost similar

in the Malay version, where a high agreement could be observed for the Global Health

Status (0.96), Role Functioning (0.83), Emotional Functioning (0.99), Cognitive

Functioning (0.98), Pain (0.99), Dyspnoea (0.98), Insomnia (1.00), Constipation (1.00)

and Diarrhea (1.00). Similarly, the Chinese version also indicated a high agreement in

the test-retest, which could be seen in the sub-scales of the Global Health Status (0.88),

Emotional Functioning (0.92), Cognitive Functioning (1.00), Pain (0.99), Insomnia

(0.88), Constipation (1.00) and Diarrhea (0.97), Sexual Functioning (0.99) and Future

Perspective (1.00). Likewise in the Tamil version, several sub-scales indicated a high

agreement in the test-retest, such as the Global Health Status (0.88), Emotional

Functioning (0.95), Cognitive Functioning (1.00), Pain (0.98), Dyspnoea (0.85),

Insomnia (0.93), Constipation (1.00), Diarrhea (1.00), Sexual Functioning (1.00) and

Future Perspective (1.00). In total, all the scales from the various versions used in this

study indicated a small sensitivity to change. However, the highly significant

differences were obtained in some of the sub-scales. These sub-scales were the overall

Global Health Status (p<0.001), Role Functioning (p<0.001), Emotional Functioning

(p<0.001), Social Functioning (p<0.001), Social Functioning (p<0.001), Nausea and

Vomiting (p<0.001), Pain (p<0.01), Appetite Loss (p<0.001), Body Image (p<0.001),

Sexual Enjoyment (p<0.001), Systemic Therapy Side Effect (p<0.001), Anxiety

(p<0.001), Depression (p<0.001) and Menopausal Symptoms (p<0.001). In the English

version, the significant differences in the test-retest were noticed in the Global Health

Status (p<0.001), Role Functioning (p<0.001), Emotional Functioning (p<0.001),

Social Functioning (p<0.01), Nausea and Vomiting (p<0.001), Appetite Loss (p<0.01),

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Body Image (p<0.01), Sexual Enjoyment (p<0.01), Systemic Therapy Side Effect

(p<0.001), Arms Symptoms (p<0.01) and Menopausal Symptoms (p<0.01). Almost

similar situation was also observed in the Malay version, whereby the sub-scales for the

Global Health Status (p<0.001), Role Functioning (p<0.001), Emotional Functioning

(p<0.001), Social Functioning (p<0.01), Nausea and Vomiting (p<0.001), Body Image

(p<0.001), Sexual Enjoyment (p<0.001), Systemic Therapy Side Effects (p<0.001),

Arms Symptoms (p<0.001), Anxiety (p<0.001), Depression (p<0.01) and menopausal

symptoms (p<0.001) indicated significant differences in the test-retest. Similarly, some

sub-scales were highly significant in the test-retest of the Chinese version, such as the

Global Health Status (p<0.001), Role Functioning (p<0.001), Emotional Functioning

(p<0.001), Social Functioning (p<0.001), Nausea and Vomiting (p<0.001), Appetite

Loss (p<0.01), Body Image (p<0.001), Systemic Therapy Side Effect (p<0.001),

Anxiety (p<0.001) and menopausal symptoms (p<0.01). In the Tamil version, the

Global Health Status (p<0.001), Role Functioning (p<0.001), Emotional Functioning

(p<0.001), Social Functioning (p<0.01), Nausea and Vomiting (p<0.01), Body Image

(p<0.01), Sexual Enjoyment (p<0.01), Systemic Therapy Side Effects (p<0.001) and

menopausal symptoms (p<0.001) indicated significant differences in the test-retest. In

term of discriminant validity, most of the sub-scales from all the versions revealed

insignificant results for the differences between the mastectomy and lumpectomy

groups. Meanwhile, the construct validity of the quality of life scale was proven by the

significant inter-correlation observed among domains.

6.0.2 The Measurement of the Women’s Sexuality

In this study, the Body Image Scale (BIS) and the Sexual Attractiveness-Body

Esteem Scale (SA-BES) were used to measure the women’s sexuality aspects.

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6.0.2 (a) The Body Image Scale (BIS)

The overall values and all the versions showed an excellent internal consistency

with high Cronbach’s alpha values: the overall value (0.95), English version (0.90),

Malay version (0.96), Chinese version (0.97) and Tamil version (0.96). The test-retest

values for the Intraclass Correlation Coefficient (ICC) were consistent and did not

distinguished too much from each other: the overall ICC value (0.56), English version

(0.52), Malay version (0.54), Chinese version (0.64) and Tamil version (0.63), as

shown in Table 6.7.

The overall (ESI = 0.12; p<0.01), English version (ESI = 0.19; p<0.05) and

Malay version (ESI = 0.30; p<0.01) showed significant differences with a small effect

size, indicating the sensitivity of the scale. Meanwhile, the Chinese version (ESI =

0.04; ns) and Tamil version (ESI = 0.09; ns) indicated insignificant differences, also

with a small effect size below the moderate level (Table 6.7).

However, a significant difference was detected between the mastectomy and

lumpectomy groups for all the versions, except for the English Version, indicating the

ability of the scale to discriminate the differences in body image between the two

groups (Table 6.7).

6.0.2 (b) The Sexual Attractiveness-Body Esteem Scale (SA-BES)

The Cronbach’s alpha values were excellent in all the versions [the English

version (0.96), Malay version (0.93), Chinese version (0.93) and Tamil version (0.88),

and the overall value (0.93)], as shown in Table 6.7, indicating the excellent internal

consistency of the various versions of the scale. For this scale, the test-retest values of

the Intraclass Correlation Coefficient (ICC) were consistent among the different

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versions and the values did not differ too far from each other, with the overall ICC

(0.34), English version (0.28), Malay version (0.42), Chinese version (0.22) and Tamil

version (0.31), as presented in Table 6.7.

The overall value (ESI = 0.14; p<0.01), English Version (ESI = 0.16; ns),

Malay Version (ESI = 0.10; ns), Chinese Version (ESI = 0.15; ns) and Tamil Version

(ESI = 0.25; ns) showed the mean differences with a small effect size, confirming that

the versions had a small sensitivity to change (Table 6.7).

Nevertheless, the analysis of the discriminant validity (for all versions) did not

exhibit any significant differences between the mastectomy and lumpectomy groups

(Table 6.7).

Table 6.7: Reliability and Validity of the Body Image Scale (BIS) and the Sexual Attractiveness-Body Esteem Scale (SA-BES) (the Women’s version)

Test-

retest (ICC)

Internal consistency (Cronbach’s alpha)

Sensitivity to change Mean differences (ESI)

Discriminant validity

Body Image Scale (BIS)+

Overall Version 0.56 0.95 1.67 (0.12)** p<0.001 English Version 0.51 0.90 1.96 (0.19)* NS Malay Version 0.54 0.96 1.96 (0.13)* p<0.001 Chinese Version 0.64 0.96 0.64 (0.04) P<0.01 Tamil Version 0.63 0.96 1.35 (0.09) P<0.01 Sexual Attractiveness-Body Esteem Scale (SA-BES) Overall Version 0.34 0.93 2.49 (0.14)** NS English Version 0.28 0.96 1.66 (0.16) NS Malay Version 0.42 0.93 1.96 (0.10) NS Chinese Version 0.22 0.93 2.78 (0.15) NS Tamil Version 0.31 0.88 4.10 (0.25) NS

*** p<0.001; ** p<0.01; *p<0.05 ICC = Intraclass Correlation Coefficient ESI = Effect Size Index + = Body Image subscale from QLQ-BR23 scale has four questions and Body Image Scale (BIS) has 10 questions. These four questions of Body Image sub-scale (QLQ-BR23) are similar to the four questions in the BIS

202

Table 6.8 depicts the construct validity of the Body Image Scale (BIS) and

Sexual Attractiveness-Body Esteem Scale (SA-BES), by examining the inter-

correlation of these scales with the European Organization for Research and Treatment

of Cancer Quality of Life Questionnaire (EORTC-QLQ C30), Breast Module (BR-23),

Hospital Anxiety and Depression Scale (HADS) and Blatt Menopausal Index (BMI).

It was pointed out that Body Image Scale (BIS) had a significant correlation

with a number of domains i.e. Global Health Status-EORTC-QLQ C30 (GH) (p<0.05),

Social Functioning-EORTC-QLQ C30 (SF) (p<0.05), Pain-EORTC-QLQ C30 (P)

(p<0.05), Body Image-BR23 (BI) (p<0.001), Future Perspective-BR23 (p<0.01), Breast

Symptoms-BR23 (BS) (p<0.05) and Arms Symptoms-BR23 (AS) (p<0.05). Likewise,

a number of domains exhibited a significant correlation with Sexual Attractiveness-

Body Esteem Scale (SA-BES). They were Global Health Status-EORTC-QLQ C30

(GH) (p<0.05), Emotional Functioning-EORTC-QLQ C30 (EF) (p<0.05), Social

Functioning-EORTC-QLQ C30 (SF) (p<0.05), Fatigue-EORTC-QLQ C30 (Ft)

(p<0.05), Body Image-BR23 (p<0.001), Anxiety-HADS (p<0.05) and Depression-

HADS (p<0.001). It was also exhibited that BIS had a significant correlation with SA-

BES, albeit a weak one (p<0.05).

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6.0.2 (c) Summary of the Results

Excellent internal consistencies were gathered for all the versions, as indicated

by the Cronbach’s alpha value of more than 0.75. However, the Body Image Scale

(BIS) for all the versions indicated quite a low agreement in the test-retest. Meanwhile,

Table 6.8: Construct Validity of the Sexuality Scales (Body Image Scale and Sexual Attractiveness-Body Esteem Scale): Inter-correlation (Pearson’s r) With the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ C30), Breast Module (BR-23), Hospital Anxiety and Depression Scale (HADS) and Blatt Menopausal Index (BMI).

BIS SA-BES GH -0.16a 0.18a

PF -0.16 0.11 RF -0.06 0.11 CF -0.13 0.12 EF -0.12 0.18a

SF -0.17a 0.18a

Ft 0.13 -0.19a

P 0.19a -0.13 NV -0.02 -0.07 Dys 0.06 -0.06 La -0.03 -0.12 I 0.08 -0.02 C 0.06 -0.02 Diar 0.13 -0.18 FD 0.13 -0.11 BI -0.50c 0.23b

Sex F -0.08 -0.10 Sex E 0.16 -0.01 FP -0.25b 0.10 STS 0.09 -0.09 BS 0.20a -0.20 AS 0.18a -0.24 HL 0.09 -0.09 A 0.13 -0.20a

D 0.14 -0.21b

BMI 0.02 -0.01 BIS - -0.18a

p<0.05a; p<0.01b; p<0.001c

BIS=Body Image Scale; SA-BES=Sexual Attractiveness-Body Esteem Scale; GH=Global Health Status (EORTC QLQ C-30); PF=Physical Functioning (EORTC QLQ C-30); RF=Role Functioning (EORTC QLQ C-30); CF=Cognitive Functioning (EORTC QLQ C-30); EF=Emotional Functioning (EORTC QLQ C-30); SF=Social Functioning (EORTC QLQ C-30); Ft=Fatigue (EORTC QLQ C-30); P=Pain (EORTC QLQ C-30); NV=Nausea and Vomiting (EORTC QLQ C-30); Dys=Dysponea (EORTC QLQ C-30); LA=Loss of Appetite (EORTC QLQ C-30); I=Insomnia (EORTC QLQ C-30); C=Constipation (EORTC QLQ C-30); Diar=Diarrhea (EORTC QLQ C-30); FD=Financial Difficulties (EORTC QLQ C-30); BI=Body Image (BR-23); SexF=Sexual Functioning (BR-23); SexE=Sexual Enjoyment (BR-23); FP=Future Perspective (BR-23); STS=Systemic Therapy Side Effect (BR-23); BS=Breast Symptoms (BR-23); AS=Arms Symptoms (BR-23); HL=Upset by Hair Loss (BR-23); A=Anxiety (Hospital Anxiety and Depression Scale-HADS); D=Depression (Hospital Anxiety and Depression Scale-HADS); BMI=Blatt Menopausal Index

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the Sexual Attractiveness-Body Esteem Scale (SA-BES) showed a moderate level of

the test-retest agreement for all the versions. These scales (all versions) also exhibited

a small sensitivity to change after the re-test. In the discriminant validity analysis, the

insignificant results for the differences in the sexual attractiveness between the

mastectomy and lumpectomy groups were pointed out by SA-BES. Nonetheless, with

an exception of the English version, the BIS was able to discriminate the difference of

the women’s body image between the mastectomy and lumpectomy groups. In terms

of construct validity of the scales, a number of domains from EORTC QLQ C-30 (e.g.

Global Health Status, Social Functioning) and BR-23 (e.g. Body Image) indicated a

significant correlation with BIS and SA-BES. Meanwhile, the Anxiety-HADS (A) and

Depression-HADS (D) exhibited a significant correlation with SA-BES, which contrast

to BIS.

6.0.3 The Measurement of the Women’s Interpersonal Relationship

As for the women’s interpersonal relationship aspect, a measurement was

carried out using the scales such as the Inventory of Socially Supportive Behavior

(ISSB), Level of Disclosure, Dyadic Satisfaction-Dyadic Adjustment Scale (DS-DAS),

Empathy-Revised Barret-Lennard Relationship Inventory (E-RBLRI), and Helpfulness

of Disclosure, Holding Back, Criticism and Withdrawal.

6.0.3 (a) The Inventory of Socially Supportive Behavior (ISSB)

The overall ISSB showed a high Cronbach’s alpha value (0.96) which indicated

an excellent internal consistency of the inventory, as shown in Table 6.9. Similarly,

excellent Cronbach’s alpha values could also be observed in the English version (0.97)

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(Table 6.10), Malay version (0.96) (Table 6.11), Chinese version (0.96) (Table 6.12)

and Tamil version (0.97) (Table 6.13). For this scale, the test-retest values of the

Intraclass Correlation Coefficient (ICC) were consistent among all the versions

[English (0.46) (Table 6.10), Chinese (0.37) (Table 6.12), Tamil (0.37) (Table 6.13)]

and the overall Cronbach’s alpha value (0.25) (Table 6.9), except for the Malay version

(0.03) (Table 6.11).

The overall sensitivity was found to be highly significant with the effect size

below the moderate level (ESI = 0.15; p<0.01), as given in Table 6.9. The English

version (ESI = 0.13; ns) (Table 6.10), Malay version (ESI = 0.18; ns) (Table 6.11),

Chinese version (ESI = 0.15; ns) (Table 6.12) and Tamil version (ESI = 0.04; ns)

(Table 6.13) also indicated the mean differences with a small effect size, which was not

significant.

The analysis carried out for the discriminant validity (for all versions) did not

yield any significant differences between the mastectomy and lumpectomy groups

(Tables 6.9, 6.10, 6.11, 6.12, and 6.13).

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6.0.3 (b) The Level of Disclosure

The overall Cronbach’s alpha value was high for this scale, i.e. at 0.74, as given

in Table 6.9. Acceptable values were also gathered for the versions in Chinese and

Tamil, with 0.65 and 0.59, respectively (Table 6.12 and Table 6.13). However, the

versions in English (Table 6.10) and Malay (Table 6.11) indicated low values, with

0.24 and 0.18, respectively. On the contrary, the test-retest values for the Intraclass

Correlation Coefficient were high for the overall ICC (0.90), as shown in Table 6.9,

and for the English Version (0.88) (Table 6.10), Malay Version (0.97) (Table 6.11),

Chinese Version (0.92) (Table 6.12) and Tamil Version (0.88) (Table 6.13), revealing

that there were changes after the re-test.

The mean difference was significantly indicated by all the versions [the overall

(ESI = 0.18; p<0.001) (see Table 6.9), English version (ESI = 0.21; p<0.001) (see

Table 6.10), Malay version (ESI = 0.17; p<0.001) (see Table 6.11), Chinese version

(ESI = 0.16; p<0.001) (see Table 6.12), Tamil version (ESI = 0.21; p<0.001) (see Table

6.13), with the effect size below the moderate level, indicating the small sensitivity of

the scale.

For this scale, the analysis carried out for the discriminant validity (for all

versions) did not demonstrate any significant difference between the mastectomy and

lumpectomy groups (Tables 6.9, 6.10, 6.11, 6.12, and 6.13).

6.0.3 (c) The Empathy-Revised Barret-Lennard Relationship Inventory

(E-RBLRI)

As presented respectively in Tables 6.9, 6.10, 6.11, 6.12 and 6.13, the

acceptable Cronbach’s alpha values were observed for the overall value (0.76), English

212

version (0.78), Malay version (0.70), Chinese version (0.85) and Tamil version (0.61).

The test-retest values of the Intraclass Correlation Coefficient were consistent in most

of the versions [the overall ICC (0.35), English (0.39), Malay (0.25) and Tamil (0.38)]

(respectively shown in Tables 6.9, 6.10, 6.11 and 6.13), except for the Chinese version

(0.59) (Table 6.12), which indicated the changes after the re-test.

All these versions indicated a small effect size, with some of the versions

showing the significant differences in the test-retest measurement [the overall value

(ESI = 0.14; p<0.01) (Table 6.9), English Version (ESI = 0.05; ns) (Table 6.10), Malay

Version (ESI = 0.24; p<0.01) (Table 6.11), Chinese Version (ESI = 0.15; p<0.05)

(Table 6.12) and Tamil Version (ESI = 0.05; ns) (Table 6.13)], confirming the small

sensitivity of the scales.

However, no significant differences were found between the mastectomy and

lumpectomy groups, as shown by the analysis of discriminant validity in all the

versions (Tables 6.9, 6.10, 6.11, 6.12, and 6.13).

6.0.3 (d) The Dyadic Satisfaction-Dyadic Adjustment Scale (DS-DAS)

Acceptable Cronbach’s alpha values were gathered for the overall value (0.65)

(Table 6.9), and the versions in English (0.49) (Table 6.10), Malay (0.66) (Table 6.11),

Chinese (0.61) (Table 6.12) and Tamil (0.76) (Table 6.13). The values collected in the

test-retest for the Intraclass Correlation Coefficient (ICC) were low for the overall

value (0.25) (Table 6.9), English version (0.10) (Table 6.10), Malay version (0.20)

(Table 6.11) and Tamil version (0.17) (Table 6.13). This was with an exception for the

Chinese version with the value of 0.51, as shown in Table 6.12.

All the versions indicated the effect size values below the moderate level, with

the overall value, English and Chinese versions showing significant differences in the

213

test-retest measurements [Overall (ESI = 0.13; p<0.01) (see Table 6.9), English version

(ESI = 0.24; p<0.05) (see Table 6.10), Malay version (ESI = 0.01; ns) (see Table 6.11),

Chinese version (ESI = 0.27; p<0.01) (see Table 6.12), and Tamil version (ESI = 0.20;

ns) (see Table 6.13)].

The analysis carried out to measure the discriminant validity (for all the

versions) did not reveal any significant difference between the mastectomy and

lumpectomy groups, as given in Tables 6.9, 6.10, 6.11, 6.12, and 6.13.

6.0.3 (e) The Helpfulness of Disclosure

The test-retest values for the Intraclass Correlation Coefficient (ICC) were

consistent and low for the versions in English (0.29), Chinese (0.28) and Tamil (0.22),

as shown in Tables 6.10, 6.12 and 6.13). Similarly, the ICC for the overall value

(Table 6.9) and the Malay version (Table 6.11) were low (0.16 and 0.06 respectively),

indicating the difference between the two measurements.

In this study, all versions were observed to have a small effect size, which

indicated the sensitivity of the scale [Overall (ESI = 0.00; ns) (see Table 6.9), English

version (ESI = 0.12; ns) (see Table 6.10), Malay version (ESI = 0.01; ns) (see Table

6.11), Chinese version (ESI = 0.03; ns) (see Table 6.12), Tamil version (ESI = 0.17; ns)

(see Table 6.13)].

The discriminant validity analysis, carried out for the all versions, did not show

any significant difference between the mastectomy and lumpectomy groups (Tables

6.9, 6.10, 6.11, 6.12, and 6.13).

214

6.0.3 (f) The Holding Back

All the versions (including the overall value for this scale) showed low

Intraclass Correlation Coefficient (ICC) [Overall ICC = <0.00 (see Table 6.9); Malay

version = <0.00 (see Table 6.11); Chinese version = 0.09 (Table 6.12); Tamil version =

<0.00 (see Table 6.13)], except for the English version which indicated a moderate ICC

value of 0.32, as shown in Table 6.10.

At the same time, all versions were discovered to have a small effect size,

showing that the scales possessed a small sensitivity to change [Overall value (ESI =

0.25; p<0.01) (see Table 6.9), English version (ESI = 0.38; p<0.001) (see Table 6.10),

Malay version (ESI = 0.26; p<0.01) (see Table 6.11), Chinese version (ESI = 0.19; ns)

(see Table 6.12), Tamil version (ESI = 0.14; ns) (see Table 6.13)].

The discriminate validity analysis carried out for all the versions (except for the

overall and the Malay version) did not indicate any significant differences between the

mastectomy and lumpectomy groups (see Tables 6.9, 6.10, 6.11, 6.12, and 6.13).

6.0.3 (g) The Criticism

All the versions demonstrated low Intraclass Correlation Coefficient (ICC)

values [Overall ICC = 0.13 (see Table 6.9); Malay version = 0.08 (see Table 6.11);

Chinese version = <0.00 (see Table 6.12); Tamil version = 0.09 (see Table 6.13)], with

an exception for the English version with a moderate ICC value of 0.30, as indicated in

Table 6.10, confirming the changes after the re-test.

For this aspect, all the versions revealed a small effect size which indicated the

small sensitivity of the scale [Overall value (ESI = 0.07; ns), English version (ESI =

215

0.02; ns), Malay version (ESI = 0.06; ns), Chinese version (ESI = 0.12; ns), and Tamil

version (ESI = 0.19; ns)], as shown respectively in Tables 6.9 to 6.13.

However, all these versions demonstrated insignificant differences between the

mastectomy and lumpectomy groups, based on the analysis of discriminant validity

conducted (see Tables 6.9, 6.10, 6.11, 6.12, and 6.13).

6.0.3 (h) The Withdrawal

The collected values of the Intraclass Correlation Coefficient (ICC) for the

English and Tamil versions were 0.52 and 0.39, respectively (Tables 6.10 and 6.13),

but these values were quite low for the overall ICC (0.18), the Malay and Chinese

versions (0.01 and <0.00, respectively) as shown in Tables 6.11 and 6.12.

Therefore, a small sensitivity of the scales was indicated by all the versions, with

small values of the effect size [English version (ESI = 0.05; ns) (see Table 6.10), Malay

version (ESI = 0.15; ns) (see Table 6.11), Chinese version (ESI = 0.11; ns) (see Table

6.12), Tamil version (ESI = 0.12; ns) (see Table 6.13)]. Nevertheless, the overall value

indicated a small effect size with significant differences (ESI = 0.11; p<0.05) as

depicted in Table 6.9.

For this, the discriminant validity analysis carried out for all the versions

(except for the Chinese version) indicated the insignificant differences between the

mastectomy and lumpectomy groups, as illustrated in Tables 6.9, 6.10, 6.11, 6.12, and

6.13.

Table 6.14 presents the construct validity of the various interpersonal

relationship scales used in this study i.e. Inventory of Socially Supportive Behavior

(ISSB), Level of Disclosure (LD), Empathy (Revised Barret-Lennard Relationship

216

Inventory) (E), Dyadic Satisfaction (Dyadic Adjustment Scale) (DS), Helpfulness of

Disclosure (HD), Holding back (H), Criticism (C) and Withdrawal (W).

The Inventory of Socially Supportive Behavior (ISSB) indicated the strong

correlation with Empathy-Revised Barret-Lennard Relationship Inventory (E)

(p<0.001), Dyadic Satisfaction-Dyadic Adjustment Scale (DS) (p<0.001) and

Helpfulness of Disclosure (HD) (p<0.001). However, the Inventory of Socially

Supportive Behavior (ISSB) indicated a weak correlation with Level of Disclosure

(LD) (p<0.05). Only a number of scales exhibited the significant correlation with

Level of Disclosure (LD) i.e. Inventory of Socially Supportive Behavior (ISSB)

(p<0.05) and Helpfulness of Disclosure (HD) (p<0.05). The Empathy (Revised Barret-

Lennard Relationship Inventory) (E) demonstrated the strong correlation (p<0.001)

with Inventory of Socially Supportive Behavior (ISSB), Empathy (Revised Barret-

Lennard Relationship Inventory) (E) and Helpfulness of Disclosure (HD).

Nonetheless, the Dyadic Satisfaction (Dyadic Adjustment Scale) (DS) indicated the

significant correlation with most of the scales used in this study i.e. Inventory of

Socially Supportive Behavior (ISSB) (p<0.001), Empathy (Revised Barret-Lennard

Relationship Inventory) (E) (p<0.001), Helpfulness of Disclosure (HD) (p<0.001),

Holding back (H) (p<0.05) and Criticism (C) (p<0.05). Similar to Holding Back (HD),

Table 6.14: Construct Validity of the Interpersonal Relationship Scales: Inter-correlation (Pearson’s r) Among the Scales ISSB LD E DS HD H C W ISSB - 0.18a 0.42c 0.32c 0.49c 0.10 0.14 0.16a

LD 0.18a - 0.11 0.06 0.17a 0.02 0.09 0.00 E 0.43c 0.11 - 0.33c 0.31c 0.01 -0.05 -0.10 DS 0.32c 0.06 0.33c - 0.43c -0.17a -0.10 -0.18a

HD 0.49c 0.17a 0.31c 0.43c - 0.02 0.05 0.05 H 0.10 0.12 0.01 -0.17a 0.02 - 0.22b 0.33c

C 0.14 0.09 -0.50 -0.10 0.05 0.22b - 0.07 W 0.16a 0.00 -0.10 -0.18a 0.05 0.33c 0.07 -

ap<0.05; bp<0.01; cp<0.001 ISSB=Inventory of Socially Supportive Behavior; LD=Level of Disclosure; E=Empathy (Revised Barret-Lennard Relationship Inventory); DS=Dyadic Satisfaction (Dyadic Adjustment Scale); HD=Helpfulness of Disclosure; H=Holding back; C=Criticism; W=Withdrawal

217

this scale showed a significant correlation with the Inventory of Socially Supportive

Behavior (ISSB) (p<0.001), Level of Disclosure (LD) (p<0.05), Empathy (Revised

Barret-Lennard Relationship Inventory) (E) (p<0.001) and Dyadic Satisfaction (Dyadic

Adjustment Scale) (DS) (p<0.001). However, only a number of scales were correlated

with Holding back (HD), Criticism (C) and Withdrawal (W), as indicated in Table 6.14.

6.0.3 (i) The Summary of the Results

Among the scales used in measuring the interpersonal relationship aspect of the

breast cancer patients (women), the ISSB from all the versions indicated an excellent

internal consistency, with the Cronbach’s alpha value of more than 0.75. Overall, the

internal consistency of the E-RBLRI scale was excellent as well as in the English and

Chinese versions (more than 0.75). In addition, excellent test-retest agreement was also

observed for the Level of Disclosure scale in all the versions, as compared to the other

scales. A small sensitivity to change was detected in all the scales from all versions

after the re-test. Some scales indicated high mean differences in the test-retest, such as

the Level of Disclosure [the overall mean (p<0.001), English version (p<0.001), Malay

version (p<0.001), Chinese version (p<0.001) and Tamil version (p<0.001)], Holding

Back [the overall mean (p<0.001), English version (p<0.001) and Malay version

(p<0.001)], Inventory of Socially Supportive Behavior [the overall mean (p<0.01)],

Empathy [the overall mean (p<0.01) and Malay version (p<0.01)], DS-DAS [the

overall mean (p<0.01) and Chinese version (p<0.01)]. In the discriminant validity

analysis, nearly all the scales revealed insignificant results, indicating that the

indifference existed between the mastectomy and lumpectomy groups. The construct

validity of the scales were proven by the inter-correlation existed among the

relationship scales.

218

6.0.4 The Measurement of the Women’s Coping Strategies

In this study, the brief COPE scale was used to measure the women’s coping

strategies with breast cancer.

6.0.4 (a) The Brief COPE Scale

Acceptable Cronbach’s alpha values were observed for the overall values,

ranging from 0.86 to 0.57. Meanwhile, the test-retest of the Intraclass Correlation

Coefficient was found to range from 0.09 to 0.99, indicating the changes after the re-

test, as depicted in Table 6.15. Specifically, the English version indicated the internal

consistency ranging from 0.25 to 1.00, with the ICC values ranging from 0.05 to 1.00

(Table 6.16). As for the Malay Version, the Cronbach’s alpha values ranged from 0.51

to 0.99, with the ICC ranged from <0.00 to 0.97 (Table 6.17). As shown in Table 6.18,

the Chinese version also showed the Cronbach’s alpha values from low to high (0.29 to

0.87), with the ICC values ranging from 0.06 to 1.00. Similarly, the Tamil version was

also observed to have the Cronbach’s alpha values which ranged from 0.21 to 0.92.

However, the sub-scale of Acceptable indicated a very low Cronbach’s alpha value in

the Tamil version; whereas, the sub-scale of Substance Use was not calculated due to

zero variance. The ICC value ranged from <0.00 to 1.00, with the exemption of the

Substance Use sub-scale (Table 6.19).

Some sub-scales indicated high significant differences, with the effect size

value below the moderate level, as observed in the overall value (ESI ranged from 0.00

to 0.48) (see Table 6.15), English version (ESI ranged from 0 to 0.53) (see Table 6.16),

Malay version (ESI ranged from 0.01 to 0.49) (see Table 6.17), Chinese version (ESI

219

ranged from 0 to 0.57) (see Table 6.18) and Tamil version (ESI ranged from 0 to 0.55)

(see Table 6.19).

The discriminant validity analysis showed that most of the sub-scales (all the

versions) indicated no significant differences between the mastectomy and lumpectomy

groups (Tables 6.15, 6.16, 6.17, 6.18, and 6.19).

Table 6.15: The Overall Reliability and Validity of the Brief COPE Scale of Women’s Version

Test-

retest (ICC)

Internal consistency

(Cronbach’s alpha)

Sensitivity to change Mean differences

(ESI)

Discriminant Validity

Brief COPE: Active coping 0.13 0.67 1.51 (0.48)*** NS Planning 0.24 0.71 0.66 (0.20)*** NS Positive reframing 0.09 0.68 1.37 (0.45)*** NS Acceptance 0.99 0.61 0.01 (0.00) NS Humour 0.11 0.72 0.18 (0.05) NS Religion 0.33 0.86 0.70 (0.23)*** NS Using emotional support 0.25 0.63 0.73 (0.22)*** NS Using instrumental support 0.19 0.71 0.87 (0.26)*** NS

Self-distraction 0.29 0.74 0.37 (0.11)*** NS Denial 0.97 0.60 0.06 (0.02) NS Venting 0.95 0.64 0.11 (0.04)*** NS Substance use 0.35 0.90 0.08 (0.04) NS Behavioural disengagement 0.99 0.70 0.00 (0.00) NS

Self-blame 0.94 0.57 0.13 (0.05)*** NS Problem-focused strategy 0.20 #1 0.21 (0.02) NS Emotion-focused strategy 0.33 #2 0.93 (0.10)*** NS

***p<0.001; **p<0.01; *p<0.05 ICC = Intraclass Correlation Coefficient ESI = Effect Size Index

# 1 = Problem-focused strategy consists of a combination of the sub-scales of active coping, planning and using instrumental support; therefore, the Cronbach’s alpha value is not provided. # 2 = Emotion-focused strategy is a combination of the sub-scales of positive reframing, acceptance, religion, using emotional support and denial; therefore, the Cronbach’s alpha value is not provided.

220

Table 6.16: The Reliability and Validity of the English Version of the Brief COPE Scale (Women’s Version)

Test-

retest (ICC)

Internal consistency

(Cronbach’s alpha)

Sensitivity to change Mean differences (ESI)

Discriminant Validity

Brief COPE: Active coping 0.44 0.50 1.00 (0.34)*** p<0.01 Planning 0.42 0.83 0.34 (0.09) p<0.01 Positive reframing <0.00 0.60 1.66 (0.53)*** NS Acceptance 0.99 0.80 0.06 (0.02) p<0.05 Humour 0.32 0.81 1.00 (0.26)** NS Religion 0.45 0.92 0.29 (0.10) NS Using emotional support 0.33 0.72 0.40 (0.14) NS Using instrumental support 0.36 0.83 0.77 (0.23)* NS Self-distraction 0.50 0.57 0.06 (0.02) NS Denial 0.97 0.58 0.03 (0.01) NS Venting 0.92 0.54 0.17 (0.06) NS Substance use 0.03 1.00 0.00 (0) NS Behavioural disengagement 1.00 0.74 0.00 (0) NS

Self-blame 0.94 0.25 0.06 (0.03) NS Problem-focused strategy 0.48 #1 1.03 (0.11) p<0.01 Emotion-focused strategy 0.34 #2 0.49 (0.05) NS

***p<0.001; **p<0.01; *p<0.05 ICC = Intraclass Correlation Coefficient ESI = Effect Size Index

# 1 = Problem-focused strategy is a combination of the sub-scales of active coping, planning and using instrumental support; therefore, the Cronbach’s alpha value is not provided.

# 2 = Emotion-focused strategy is a combination of the sub-scales of positive reframing, acceptance, religion, using emotional support and denial; therefore, the Cronbach’s alpha value is not provided.

221

Table 6.137: The Reliability and Validity of the Malay Version of the Brief COPE Scale (Women’s Version)

Test-retest (ICC)

Internal consistency (Cronbach’s

alpha)

Sensitivity to change

Mean differences (ESI)

Discriminant Validity

Brief COPE: Active coping <0.00 0.71 1.46 (0.49)*** p<0.01 Planning 0.06 0.60 0.54 (0.19)* p<0.01 Positive reframing 0.10 0.67 1.46 (0.48)*** p<0.05 Acceptance 0.98 0.69 0.01 (0.01) NS Humour <0.00 0.61 0.03 (0.01) NS Religion 0.11 0.68 0.45 (0.21)** p<0.05 Using emotional support 0.18 0.57 0.69 (0.21)** NS Using instrumental support 0.27 0.69 0.74 (0.22)** NS

Self-distraction 0.06 0.72 0.25 (0.09) p<0.05 Denial 0.96 0.57 0.12 (0.04)* NS Venting 0.95 0.63 0.12 (0.04)* NS Substance use 0.59 0.99 0.01 (0.01) NS Behavioural Disengagement 0.96 0.54 0.01 (0.01) NS

Self-blame 0.93 0.51 0.18 (0.06)** NS Problem-focused strategy <0.00 #1 0.12 (0.02) p<0.05 Emotion-focused strategy 0.17 #2 0.73 (0.10) p<0.05

***p<0.001; **p<0.01; *p<0.05 ICC = Intraclass Correlation Coefficient ESI = Effect Size Index

# 1 = Problem-focused strategy is a combination of the sub-scales of active coping, planning and using instrumental support; therefore, the Cronbach’s alpha value is not provided.

# 2 = Emotion-focused strategy is a combination of the sub-scales of positive reframing, acceptance, religion, using emotional support and denial; therefore, the Cronbach’s alpha value is not provided.

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Table 6.18: The Reliability and Validity of the Chinese Version of the Brief COPE Scale (Women’s Version)

Test-

retest (ICC)

Internal consistency (Cronbach’s alpha)

Sensitivity to change Mean differences (ESI)

Discriminant validity

Brief COPE: Active coping 0.18 0.73 2.03 (0.57)*** NS Planning 0.22 0.74 1.00 (0.27)** NS Positive reframing 0.06 0.77 1.03 (0.35)** NS Acceptance 1.00 0.43 0.00 (0) NS Humour 0.22 0.85 0.08 (0.03) NS Religion 0.31 0.87 1.53 (0.40)*** NS Using emotional support 0.25 0.70 1.03 (0.28)** NS Using instrumental support 0.06 0.62 1.39 (0.39)** NS

Self-distraction 0.31 0.46 0.78 (0.22)* NS Denial 0.96 0.29 0.03 (0.01) NS Venting 0.92 0.58 0.11 (0.04) NS Substance use 0.17 0.72 0.03 (0.01) p<0.01 Behavioural disengagement 1.00 0.77 0.00 (0) NS

Self-blame 0.99 0.74 0.03 (0.01) NS Problem focus strategy 0.17 #1 1.78 (0.17) NS Emotion focus strategy 0.32 #2 2.50 (0.25)** NS

***p<0.001; **p<0.01; *p<0.05 ICC = Intraclass Correlation Coefficient ESI = Effect Size Index

# 1 = Problem-focused strategy is a combination of the sub-scales of active coping, planning and using instrumental support; therefore, the Cronbach’s alpha value is not provided.

# 2 = Emotion-focused strategy is a combination of the sub-scales of positive reframing, acceptance, religion, using emotional support and denial; therefore, the Cronbach’s alpha value is not provided.

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Table 6.19: The Reliability and Validity of the Tamil Version of the Brief COPE Scale (Women’s Version)

Test-

retest (ICC)

Internal consistency

(Cronbach’s alpha)

Sensitivity to change Mean differences

(ESI)

Discriminant validity

Brief COPE: Active coping 0.18 0.83 1.65 (0.55)*** NS Planning 0.24 0.63 1.00 (0.30)* NS Positive reframing 0.04 0.21 1.20 (0.43)** NS Acceptance 1.00 <0.00 0.00 (0) NS Humour 0.47 0.43 0.10 (0.03) NS Religion 0.17 0.89 0.75 (0.29)* NS Using emotional support 0.30 0.38 0.90 (0.31)* NS Using instrumental support <0.00 0.61 0.55 (0.18) NS

Self-distraction 0.24 0.71 0.60 (0.18) NS Denial 0.99 0.92 0.05 (0.01) NS Venting 1.00 0.57 0.00 (0) NS Substance use @ @ 0.05 (0.22) NS Behavioural disengagement 0.99 0.86 0.05 (0.02) NS

Self-blame 0.92 0.72 0.25 (0.07) NS Problem-focused strategy 0.10 #1 0.65 (0.08) NS Emotion-focused strategy 0.18 #2 1.25 (0.13) NS

***p<0.001; **p<0.01; *p<0.05 ICC = Intraclass Correlation Coefficient ESI = Effect Size Index # 1 = Problem-focused strategy is a combination of the subscales of active coping, planning and using instrumental support; therefore, the Cronbach’s alpha value is not provided. # 2 = Emotion-focused strategy is a combination of the subscales of positive reframing, acceptance, religion, using emotional support and denial; therefore, the Cronbach’s alpha value is not provided.

The construct validity of the Brief COPE Scale was presented by the inter-

correlation among domains (see Table 6.20). The domain of Active indicated a strong

correlation with most of the Brief COPE Scale i.e. Planning (Pl) (p<0.001), Acceptance

(Acc) (p<0.001), Humor (Hum) (p<0.01), Religion (Rel) (p<0.001), Using Emotional

Support (ES) (p<0.001), Using Instrumental Support (IS) (p<0.001), Self-distraction

(Dis) (p<0.001), Denial (Den) (p<0.001) and Venting (Ven) (p<0.001). Similarly, most

domains of Brief COPE Scale demonstrated the significant correlation with Planning

(Pl). They were Active (Ac) (p<0.001), Acceptance (Acc) (p<0.001), Humor (Hum)

(p<0.01), Religion (Rel) (p<0.001), Using Emotional Support (ES) (p<0.001), Using

Instrumental Support (IS) (p<0.001), Self-distraction (Dis) (p<0.001), Denial (Den)

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(p<0.001) and Venting (Ven) (p<0.001). For the Positive Reframing (Pos), a number

of domains showed the significant correlation with this domain such as Planning (Pl)

(p<0.01), Acceptance (Acc) (p<0.05), Religion (Rel) (p<0.05), Self-distraction (Dis)

(p<0.01), Denial (Den) (p<0.001), Venting (Ven) (p<0.05), Behavioral Disengagement

(Beh) (p<0.05) and Self-blame (Bla) (p<0.001). Acceptance (Acc) indicated a strong

correlation (p<0.001) with Active (Ac), Planning (Pl), Religion (Rel), Using Emotional

Support (ES), Using Instrumental Support (IS) and Self-distraction (Dis). However, a

weak correlation was observed for Positive Reframing (Pos) (p<0.05), Denial (Den)

(p<0.05) and Venting (Ven) (p<0.05). Humor (Hum) demonstrated a significant

correlation with Active (Ac) (p<0.01), Planning (p<0.01) and Using Instrumental

Support (IS) (p<0.05). Most domains of Brief COPE Scale demonstrated a significant

correlation with Religion (Rel) such as Active (Ac) (p<0.01), Planning (Pl) (p<0.001),

Positive Reframing (p<0.05), Acceptance (p<0.001), Using Emotional Support

(p<0.001), Using Instrumental Support (p<0.001), Self-distraction (p<0.001), Denial

(p<0.05) and Venting (p<0.001). The same situation was observed for Using

Emotional Support (ES), whereby, most of the Brief COPE domains indicated a

significant correlation with this domain i.e. Active (Ac) (p<0.001), Planning (Pl)

(p<0.001), Acceptance (Acc) (p<0.001), Religion (Rel) (p<0.001), Using Instrumental

Support (IS) (p<0.001), Self-distraction (Dis) (p<0.01), Denial (Den) (p<0.05), Venting

(Ven) (p<0.001). For the Using Instrumental Support (IS), nearly all the domains from

Brief COPE Scale showed the significant correlation with this domain, such as Active

(Ac) (p<0.001), Planning (Pl) (p<0.001), Acceptance (Acc) (p<0.001), Humor

(p<0.05), Religion (p<0.001), Using Emotional Support (p<0.001), Self-distraction

(p<0.001), Denial (p<0.01), Venting (p<0.001) and Self-blame (p<0.01). Likewise,

majority of the Brief COPE domains exhibited a significant correlation with the Self-

distraction (Dis) i.e. Active (Ac) (p<0.001), Planning (Pl) (p<0.001), Positive

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Reframing (Pos) (p<0.01), Acceptance (Acc) (p<0.001), Religion (Rel) (p<0.001),

Using Emotional Support (ES) (p<0.001), Using Instrumental Support (IS) (p<0.001),

Denial (Den) (p<0.001) and Venting (Ven) (p<0.001). Denial (Den) showed a strong

correlation with Active Coping (Ac) (p<0.001), Planning (p<0.001), Positive

Reframing (p<0.001), Using Instrumental Support (p<0.01), Self-distraction (p<0.001),

Venting (p<0.001), Behavioral Disengagement (p<0.001) and Self-blame (p<0.001).

However a weak correlation (p<0.05) was discovered between Denial (Den) and other

domains i.e. Acceptance (Acc), Religion (Rel) and Using Emotional Support (ES).

Almost all the domains of Brief COPE Scale indicated the significant correlation with

Venting (Ven). They were Active (Ac) (p<0.001), Planning (Pl) (p<0.001), Positive

Reframing (Pos) (p<0.05), Acceptance (Acc) (p<0.05), Religion (Rel) (p<0.001), Using

Emotional Support (ES) (p<0.001), Using Instrumental Support (IS) (p<0.001), Self-

distraction (Dis) (p<0.001), Denial (Den) (p<0.001) and Self-blame (Bla) (p<0.001).

Substance Use (Sub) exhibited the significant correlation with Denial (Den) (p<0.01)

and Self-Blame (Bla) (p<0.05), however, did not exhibit the significant correlation with

other Brief COPE domains. A number of domains revealed the strong correlation

(p<0.001) with Behavioral Disengagement (Beh) such as Denial (Den) and Self-blame

(Bla), nonetheless, showed a weak correlation (p<0.05) with Active (Ac), Positive

Reframing (Pos) and Substance Use (Sub). Similarly, a number of domains revealed

the strong correlation with Self-blame (Bla) i.e. Positive Reframing (Pos) (p<0.001),

Using Instrumental Support (IS) (p<0.01), Denial (Den) (p<0.001), Venting (Ven)

(p<0.001) and Behavioral Disengagement (Beh) (p<0.001).

227

6.0.4 (b) Summary of the Results

Most of the sub-scales from all the versions indicated fair internal consistency.

This could be accepted as most of the subscales in the original Brief COPE scale

(Carver, 1997), indicated by the Cronbach’s alpha value which was less than 0.75.

Nevertheless, a high agreement was observed for some sub-scales in the overall

Interclass Correlation Coefficients, such as Acceptance (0.99), Denial (0.97), Venting

(0.95), Behavioral Disengagement (0.99) and Self-blame (0.94). In the English

version, the high agreement was noticed for Acceptance (0.99), Denial (0.97), Venting

(0.92), Behavioral Disengagement (1.00) and Self-blame (0.94). Almost similar

situation was observed in the Malay version, whereby excellent Intraclass Correlation

Coefficient was revealed by Acceptance (0.98), Denial (0.96), Venting (0.95),

Behavioral Disengagement (0.96) and Self-blame (0.93). Likewise, Acceptance (1.00),

Denial (0.96), Venting (0.92), Behavioral Disengagement (1.00) and Self-blame (0.99)

in the Chinese version showed excellent Intraclass Correlation Coefficient, indicating

the high agreement in the test-retest. The similar condition was also gathered in the

Tamil version, in which Acceptance (0.92), Denial (0.99), Venting (1.00), Behavioral

Disengagement (0.99) and Self-blame (0.92) exhibited a high agreement in the test-

retest. Almost all the subscales, from all the versions, revealed a small effect size,

revealing the small sensitivity of the scale. However, most of the sub-scales indicated

the high significant differences in the test-retest. These could be noticed in the overall

mean differences such as Active Coping (p<0.001), Planning (p<0.001), Positive

Reframing (p<0.001), Religion (p<0.001), Using Emotional Support (p<0.001), Using

Instrumental Support (p<0.001), Self-distraction (p<0.001), Venting (p<0.001), Self-

blame (p<0.001) and Emotion-focused Strategy (p<0.001). In the English version, high

mean differences were observed in Active Coping (p<0.001) and Positive Reframing

228

(p<0.001). The Active Coping (p<0.001), Positive Reframing (p<0.001), Religion

(p<0.01), Using Emotional Support (p<0.01), Using Instrumental Support (p<0.01)

were among the sub-scales, which were found to exhibit the significant differences in

the test-retest in the Malay version. As for the Chinese version, Active Coping

(p<0.001), Planning (p<0.01), Positive Reframing (p<0.01), Religion (p<0.001), Using

Emotional Support (p<0.01) and Emotion-focused Strategies (p<0.01) indicated

significant mean differences. The situation was a little bit different for the Tamil

version, as significant mean differences were only observed for the Active Coping

(p<0.001) and Positive Reframing (p<0.01). The discriminant validity analysis carried

out indicated insignificant results in the coping strategies employed by the patients in

the mastectomy and lumpectomy groups. In term of construct validity, the significant

inter-correlation among the domains was observed.

6.1 The Questionnaires and Inventories for the Husbands

The scales used for measuring the husbands’ related aspects were also further

categorized into four sub-groups. These were the measurement of their psychological

well-being, sexuality, interpersonal relationship and coping strategies.

6.1.1 The Measurement of the Husbands’ Psychological Well-being

The Hospital Anxiety and Depression Scale (HADS) was used to measure the

patients’ husbands’ psychological well-being. The HADS consists of two sub-scales,

which were known as Anxiety and Depression. This scale is similar to the scale used to

measure anxiety and depression among the breast cancer patients (women).

229

6.1.1 (a) The Hospital Anxiety and Depression Scale (HADS)

The overall internal consistency for both the Anxiety and Depression sub-scales

was excellent with the Cronbach’s alpha values of 0.81 and 0.76, respectively.

Nevertheless, low Intraclass Correlation Coefficients (ICC) were observed for Anxiety

(0.19) and Depression (0.30). The internal consistencies were also excellent in the

English version (0.82 for Anxiety and 0.85 for Depression) with low ICC, indicating

the changes between the two conditions. Similarly, the Malay version indicated high

Cronbach’s alpha values; these were 0.88 for anxiety and 0.79 for depression, with fair

ICC values (0.35 for Anxiety and 0.42 for Depression). However, the sub-scales

indicated acceptable Cronbach’s alpha values for the Chinese version (0.60 for Anxiety

and 0.73 for Depression) and the Tamil version (0.65 for Anxiety and 0.45 for

Depression), with moderate values of ICC (Chinese version: 0.35 for Anxiety and 0.42

for Depression; Tamil Version: 0.41 for Anxiety and 0.26 for Depression), as presented

in Table 6.21.

The sensitivity of the anxiety and depression sub-scales was indicated by the

mean differences existed, with a small effect size in the test-retest measurements

[Overall value (ESI = 0.16; p<0.01 for anxiety and ESI = 0.15; p<0.01 for depression),

English version (ESI = 0.12; ns for anxiety and ESI = 0.13; ns for anxiety), Malay

version (ESI = 0.21; p<0.01 for anxiety and ESI = 0.19; p<0.01 for depression),

Chinese version (ESI = 0.04; ns for anxiety and ESI = 0.04; ns for depression), Tamil

version (ESI = 0.37; p<0.01 for anxiety and ESI = 0.26; ns for depression)], as shown

in Table 6.21.

The discriminant validity analysis exhibited that the sub-scales (all the versions)

yielded insignificant differences between the husbands of the patients in the

mastectomy and lumpectomy groups (Table 6.21).

230

Table 6.21: The Reliability and Validity of the Hospital Anxiety and Depression Scale (HADS) of the Husband’s Version

Test-retest

(ICC) Internal consistency (Cronbach’s alpha)

Sensitivity to change Mean differences (ESI)

Discriminant validity

Anxiety Sub-scale:

Overall Value 0.19 0.81 1.03 (0.16)** NS English Version <0.00 0.82 0.83 (0.12) NS Malay Version 0.35 0.88 1.50 (0.21)** NS Chinese Version 0.35 0.60 0.25 (0.04) NS Tamil Version 0.41 0.65 2.10 (0.37)** NS Depression Sub-scale: Overall Value 0.30 0.76 0.99 (0.15)** NS English Version 0.10 0.85 0.91 (0.13) NS Malay Version 0.42 0.79 1.26 (0.19)** NS Chinese Version 0.42 0.73 0.25 (0.04) NS Tamil Version 0.26 0.45 1.60 (0.26) NS

***p<0.001; **p<0.01; *p<0.05 ICC = Intraclass Correlation Coefficient; ESI = Effect Size Index

6.1.1 (b) Summary of the Results

Excellent internal consistencies were observed for the Anxiety and Depression

sub-scales of the HADS in the overall, English and Chinese versions, with the

Cronbach’s alpha value of more than 0.75. Nonetheless, low agreement was exhibited

by all the versions in the test-retest. All the sub-scales showed a small effect size

which indicated a small sensitivity of the scale. In the discriminant validity analysis,

the Anxiety and Depression sub-scales were not able to differentiate the husbands’

psychological effects between the mastectomy and lumpectomy groups.

6.1.2 The Measurement of the Husband’s Sexuality

The Body Image Scale (BIS) and Sexual Attractiveness-Body Esteem Scale

(SA-BES) were used to measure the husband’s view on their wives’ body image and

sexual attractiveness, respectively. The scales were modified from the original version

to suit the patients’ husbands.

231

6.1.2 (a) The Body Image Scale (BIS) (Modified)

The Cronbach’s alpha values were excellent for the overall value (0.95), English

version (0.95), Malay version (0.94), Chinese version (0.97) and Tamil version (0.95).

The test-retest values of the Intraclass Correlation Coefficient (ICC) were consistent for

the overall ICC (0.42), English version (0.40) and Tamil version (0.41). However, the

ICC for the Chinese version was slightly higher (0.63), and this was a bit lower for the

Malay version (0.26), as demonstrated in Table 6.22.

Table 6.22: The Reliability and Validity of the Body Image Scale (BIS) and the Sexual Attractiveness-Body Esteem Scale (SA-BES) (the Husband’s version)

Test-retest

(ICC) Internal consistency (Cronbach’s alpha)

Sensitivity to change Mean differences (ESI)

Discriminant Validity

Body Image Scale (BIS): Overall Version 0.42 0.95 3.55 (0.24)*** NS English Version 0.40 0.98 2.57 (0.20)* NS Malay Version 0.26 0.94 2.58 (0.19)* NS Chinese Version 0.63 0.97 4.58 (0.27)*** p<0.05 Tamil Version 0.41 0.95 6.65 (0.36)** NS Sexual Attractiveness-Body Esteem Scale (SA-BES):

Overall Version 0.19 0.96 1.19 (0.06) NS English Version <0.00 0.95 0.60 (0.03) NS Malay Version 0.34 0.95 2.47 (0.13) NS Chinese Version 0.38 0.93 0.25 (0.02) NS Tamil Version 0.25 0.95 0.30 (0.02) NS

***p<0.001; **p<0.01; *p<0.05 ICC = Intraclass Correlation Coefficient ESI = Effect Size Index

The high significant mean differences with a small effect size were observed for

all the versions, indicating the sensitivity of the scales [Overall value (ESI = 0.16;

p<0.01), English version (ESI = 0.20; p<0.05), Malay version (ESI = 0.19; p<0.05),

Chinese version (ESI = 0.27; p<0.001), Tamil version (ESI = 0.36; p<0.01)], as

presented in Table 6.22.

232

The discriminant validity analysis showed that there was no significant

difference between the patients’ husbands in the mastectomy and lumpectomy groups,

in all versions, except for the Chinese version (p<0.05) (Table 6.22).

6.1.2 (b) The Sexual Attractiveness-Body Esteem Scale (SA-BES) (Modified)

The Cronbach’s alpha values were excellent for the overall value (0.96), English

version (0.98), Malay version (0.95), Chinese version (0.93) and Tamil version (0.95).

The low test-retest values of the Intraclass Correlation Coefficient were observed for

the overall ICC and the English version, as compared to the Malay (0.34), Chinese

(0.38) and Tamil (0.25) versions, as demonstrated in Table 6.22.

All the versions indicated the sensitivity of the scale with small mean

differences and effect size [Overall value (ESI = 0.06; ns), English Version (ESI =

0.03; ns), Malay Version (ESI = 0.13; ns), Chinese Version (ESI = 0.02; ns), Tamil

Version (ESI = 0.02; ns], as given in Table 6.22. For this, the discriminant validity

analysis indicated that there was no significant difference between the patients’

husbands in the mastectomy and lumpectomy groups, as shown in Table 6.22.

The construct validity of the modified version of the sexuality scales (from

husband’s perspective) (i.e. Body Image Scale (Modified) (BIS-M) and Sexual

Attractiveness-Body Esteem Scale (Modified) (SA-BES-M), by examining the inter-

correlation among the sexuality scales used in this study, were carried out (see Table

6.23). The BIS-M indicated a strong correlation with the original Body Image Scale

(BIS) (p<0.001). Similarly, the SA-BES-M exhibited the strong correlation with the

original Sexual Attractiveness-Body Esteem Scale (SA-BES) (p<0.001). This scale

also showed the significant correlation with the original Body Image Scale (BIS), albeit

a weak one (p<0.05).

233

6.1.2 (c) Summary of the Results

The modified Body Image Scale (BIS) and the Sexual Attractiveness-Body

Esteem Scale (SA-BES) for all the versions indicated excellent internal consistencies

with the Cronbach’s alpha value of more than 0.75. Low agreement in the test-retest

was observed in all the versions. A small sensitivity of the scale was indicated by the

small effect size. Nonetheless, the high mean differences in the test-retest were

observed in the BIS [Overall (p<0.001), Chinese version (p<0.001), Tamil version

(p<0.01)]. With the exception of the BIS (Chinese version), insignificant differences

between the patients’ husbands in the mastectomy and lumpectomy groups were

indicated by all scales (BIS and SA-BES) in the discriminant validity analysis. The

construct validity of the modified version of the sexuality scales was proven by the

significant inter-correlation existed between the BIS (M) and BIS; SA-BES (M) and

BIS; SA-BES (M) and SA-BES.

6.1.3 The Measurement of the Husband’s Interpersonal Relationship

The measurement of the husbands’ interpersonal relationship was carried out

using several scales - the Inventory of Socially Supportive Behavior (ISSB), Level of

Table 6.23: Construct Validity of the Modified Sexuality Scales (Body Image Scale and Sexual Attractiveness-Body Esteem Scale): Inter-correlation (Pearson’s r) Among the Scales

BIS (M) SA-BES (M) BI S(M) - -0.15 SA-BES (M) -0.15 - BIS 0.35c -0.19a

SA-BES -0.05 0.31c

p<0.05a; p<0.01b; p<0.001c

BIS=Body Image Scale; BIS (M)=Body Image Scale (Modified); SA-BES=Sexual Attractiveness-Body Esteem Scale; SA-BES (M)=Sexual Attractiveness-Body Esteem Scale (Modified)

234

Disclosure, Dyadic Satisfaction-Dyadic Adjustment Scale (DS-DAS), Empathy-

Revised Barret-Lennard Relationship Inventory (E-RBLRI), Helpfulness of Disclosure,

Holding Back, Criticism and Withdrawal. All these scales were modified from the

original scales to suit the patients’ husbands participating in this study, except for the

DS-DAS and E-RBLRI.

6.1.3 (a) The Inventory of Socially Supportive Behavior (ISSB) (Modified)

The internal consistency was found to be excellent for all the versions including

the overall Cronbach’s alpha value [the overall value (0.95) (see Table 6.24), English

version (0.95) (see Table 6.25), Malay version (0.95) (see Table 6.26), Chinese version

(0.95) (see Table 6.27) and Tamil version (0.97) (see Table 6.28)]. The test-retest

values of the Intraclass Correlation Coefficient were consistent among the versions, as

well as the overall ICC: Overall ICC (0.31) (see Table 6.24), English version (0.23)

(see Table 6.25), Malay version (0.31) (see Table 6.26), Chinese version (0.37) (see

Table 6.27) and Tamil Version (0.36) (see Table 6.28).

All the versions showed mean differences with the effect size below the

moderate level, indicating a small sensitivity of the scale [Overall value (ESI = 0.08;

ns), English version (ESI = 0.07; ns), Malay version (ESI = 0.04; ns), Chinese version

(ESI = 0.24; p<0.01), and Tamil version (ESI = 0.11; ns)], as demonstrated in Tables

6.24, 6.25, 6.26, 6.27, and 6.28.

Based on the discriminant validity analysis, with the exception of the ISSB in

the English Version (p<0.05), all the versions did not indicate any significance

differences between the husbands in mastectomy group and the husbands in the

lumpectomy groups (see Tables 6.24, 6.25, 6.26, 6.27, and 6.28).

.

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6.1.3 (b) The Level of Disclosure (Modified)

Acceptable Cronbach’s alpha values were observed for all the versions and the

overall value: English version (0.71), Malay version (0.51), Chinese version (0.70) and

Tamil version (0.49), as shown in Tables 6.25 to 6.28, and the overall value (0.63)

indicated in Table 6.24. The test-retest values of the Intraclass Correlation Coefficient

(ICC) were high for the overall ICC (0.91) (see Table 6.24), English version (0.90) (see

Table 6.25), Malay version (0.91) (see Table 6.26), Chinese version (0.94) (see Table

6.27) and Tamil version (0.85) (see Table 6.28).

All the versions indicated high significant mean differences in the test-retest

measurements, with the effect size value below the moderate level [Overall value (ESI

= 0.18; p<0.001, English version (ESI = 0.19; p<0.001), Malay version (ESI = 0.19;

p<0.001), Chinese version (ESI = 0.15; p<0.001), Tamil version (ESI = 0.23;

p<0.001)], as respectively shown in Tables 6.24 - 6.28).

The discriminant validity analysis (all versions) showed that there was no

significant difference between the husbands in the mastectomy and lumpectomy

groups, as indicated in Tables 6.24, 6.25, 6.26, 6.27, and 6.28.

6.1.3 (c) The Dyadic Satisfaction-Dyadic Adjustment Scale (DS-DAS)

The Cronbach’s alpha values were acceptable for the overall value (0.62),

English version (0.66) and Malay version (0.74), as shown in Tables 6.24, 6.25 and

6.26. Meanwhile, based on Tables 6.27 and 6.28, the Chinese and Tamil versions

indicated lower Cronbach’s alpha values, with 0.43 and 0.56, respectively. The overall

value of the Intraclass Correlation Coefficient (ICC) was fair at 0.41 (Table 6.24). This

241

value was similar to the English and Tamil versions with ICC values of 0.49 and 0.42

respectively (Tables 6.25 and 6.28). However, the ICC was lower for the Malay and

Chinese versions with 0.27 and 0.27, respectively (Tables 6.26 and 6.27), indicating the

change at re-test.

The mean differences were observed for the overall value (ESI = 0.06; ns) (see

Table 6.24), English version (ESI = 0.06; ns) (see Table 6.25), Malay version (ESI =

0.07; ns) (see Table 6.26), Chinese version (ESI = 0.13; ns) (see Table 6.27) and Tamil

version (ESI = 0.13; ns) (see Table 6.28), with a small effect size which confirmed the

small sensitivity of the scale.

All versions of the scales indicated no significant differences between the

husbands in the mastectomy and lumpectomy groups, based on the discriminant

validity analysis, presented in Tables 6.24, 6.25, 6.26, 6.27, and 6.28.

6.1.3 (d) The Empathy-Revised Barret-Lennard Relationship Inventory

(E-RBLRI)

For this inventory, acceptable Cronbach’s alpha values were gathered for the

overall value (0.74), English version (0.76), Malay version (0.66), Chinese version

(0.84) and Tamil version (0.75), as shown in Tables 6.24 - 6.28. Based on the data

presented in Tables 6.24, 6.27 and 6.28, the test-retest values of the Intraclass

Correlation Coefficient (ICC) were low for the overall ICC, Chinese version and Tamil

version. On the contrary, the ICC values were high for the English and Malay versions

with 0.27 and 0.41, respectively (Tables 6.25 and 6.26).

The significant mean difference of the measurement with a small effect size was

observed for the overall value (ESI = 0.19; p<0.001) (see Table 6.24), Malay version

(ESI = 0.16; p<0.01) (see Table 6.26) and Chinese version (ESI = 0.31; p<0.01) (see

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Table 6.27). Similarly, the English version (ESI = 0.09; ns) and Tamil version (ESI =

0.21; ns) (Tables 6.25 and 6.28) showed the mean differences with the effect size below

the moderate level, indicating the small sensitivity of the scales.

For this inventory, the discriminant validity analysis, conducted to observe the

difference between the husbands in the mastectomy and lumpectomy groups, revealed

insignificant differences between these groups (Tables 6.24, 6.25, 6.26, 6.27, and 6.28).

6.1.3 (e) Helpfulness of Disclosure (Modified)

As shown respectively in Tables 6.24, 6.25, 6.26 and 6.28, the test-retest values of

the Intraclass Correlation Coefficient (ICC) were low as indicated by the overall ICC

(0.17), English version (0.08), Malay version (0.11) and Tamil version (0.14), except

for the Chinese version which had the ICC value of 0.45 (Table 6.27).

The overall value (ESI = 0.10; p<0.05) (see Table 6.24) and Chinese version (ESI

= 0.32; p<0.001) (see Table 6.27) indicated the sensitivity of the scale, with significant

differences and a small effect size, as compared to the English version (ESI = 0.17; ns)

(see Table 6.25), Malay version (ESI = 0.01; ns) (see Table 6.26) and Tamil version

(ESI = 0.07; ns) (see Table 6.28).

The discriminant validity analysis, done to observe the differences between the

patients’ husbands in the mastectomy and lumpectomy groups, exhibited insignificant

differences between the two groups (Tables 6.24, 6.25, 6.26, 6.27, and 6.28).

6.1.3 (f) Holding Back (Modified)

The overall Intraclass Correlation Coefficient (ICC) for the English and Chinese

versions indicated very low ICC values [Overall ICC = 0.11 (see Table 6.24); English

243

version = 0.02 (see Table 6.25); Chinese version = <0.00 (see Table 6.27)], except for

the Malay and Tamil versions with the values of 0.28 and 0.32, respectively (see Tables

6.26 and 6.28).

All the versions indicated the sensitivity of the scale, with small differences and

small effect size [Overall value (ESI = 0.12; p<0.05) (see Table 6.24), English version

(ESI = 0.17; ns) (see Table 6.25), Malay version (ESI = 0.13; ns) (see Table 6.26),

Chinese version (ESI = 0.14; ns) (see Table 6.27), and Tamil version (ESI = 0.06; ns)

(see Table 6.28)].

The discriminant validity, conducted to investigate the differences between the

husbands in the mastectomy group and the husbands in the lumpectomy group,

indicated insignificant differences between the two groups in all the versions (see Table

6.24 to 6.28).

6.1.3 (g) Criticism (Modified)

The Intraclass Correlation Coefficient (ICC) values were very low for all the

versions, including the overall value (Overall ICC = 0.02, English version = <0.00,

Malay version = <0.00, Chinese version = 0.18 and Tamil version = 0.09) as

demonstrated in Tables 6.24 - 6.28.

Almost all versions (except for English) showed significant mean differences with

the effect size value below the moderate level, indicating that the scales had a small

sensitivity to change in the test-retest measurement [Overall value (ESI = 0.28;

p<0.001) (see Table 6.24); English version (ESI = 0.11; ns) (see Table 6.25), Malay

version (ESI = 0.40; p<0.001) (see Table 6.26), Chinese version (ESI = 0.23; p<0.05)

(see Table 6.27), and Tamil version (ESI = 0.30; p<0.05) (see Table 6.28)].

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No significant differences of the scales were found between the husbands in the

mastectomy and lumpectomy groups for all the versions, according to the data gauged

in the discriminant validity analysis (see Tables 6.24, 6.25, 6.26, 6.27, and 6.28).

6.1.3 (h) Withdrawal (Modified)

As for withdrawal, the Tamil version indicated a high value for the Intraclass

Correlation Coefficient (ICC) (0.83) shown in Table 6.28; on the other hand, the other

versions and the overall value indicated very low values (Overall ICC = 0.24, English

version = <0.00, Malay version = 0.23, and Chinese version = 0.18), as presented in

Tables 6.24, 6.25, 6.26 and 6.27.

The English version (ESI = 0.15; ns) (see Table 6.25), Malay version (ESI = 0.31;

p<0.001) (see Table 6.26), Chinese version (ESI = 0.09; ns) (see Table 6.27) and Tamil

version (ESI = 0.11; ns) (see Table 6.28) indicated sensitivity of the scale with

insignificant differences and small effect size. However, the overall value (ESI = 0.14;

p<0.01) showed significant mean differences with a small effect size, as given in Table

6.24.

Nevertheless, no significant mean differences were found between the husbands

of the patients in the Mastectomy and Lumpectomy groups (in all versions, except for

the English version) in the data derived from the discriminant validity analysis

presented in Tables 6.24, 6.25, 6.26, 6.27, and 6.28.

Table 6.29 presents the construct validity of the modified version of the

relationship scales used in this study i.e. Inventory of Socially Supportive Behavior

(Modified-ISSB), Level of Disclosure (Modified-LD), Helpfulness of Disclosure

245

(Modified-HD), Holding back (Modified-H), Criticism (Modified-C) and Withdrawal

(Modified-W). The analysis was carried out by examining the inter-correlation

between the modified scales and other relationship scales i.e. Empathy-Revised Barret-

Lennard Relationship Inventory (E) and Dyadic Satisfaction-Dyadic Adjustment Scale

(DS).

Modified-ISSB indicated a significant correlation with Empathy-Revised

Barret-Lennard Relationship Inventory (E) (p<0.01) and Dyadic Satisfaction-Dyadic

Adjustment Scale (DS) (p<0.001), Modified-HD (p<0.001) and Modified-W (p<0.05).

A number of scales such as Empathy-Revised Barret-Lennard Relationship Inventory

(E) and Modified-W exhibited a significant correlation with Modified-LD (p<0.05 and

p<0.001 respectively). Similarly, a number of scales showed a strong correlation with

Modified-HD such as Modified-ISSB (p<0.001) and Dyadic Satisfaction-Dyadic

Adjustment Scale (DS) (p<0.01). Similar to Modified-M, this scale showed the

significant correlation (p<0.01) with Empathy-Revised Barret-Lennard Relationship

Inventory (E) and Modified-C. A number of scales demonstrated significant

correlation with Modified-W i.e. Modified-ISSB (p<0.05), Modified LD (p<0.001) and

Empathy-Revised Barret-Lennard Relationship Inventory (E) (p<0.01). However, the

Table 6.29: Construct Validity of the Modified Interpersonal Relationship Scales: Inter-correlation (Pearson’s r) Among the Scales

ISSB (M) LD (M) HD (M) H (M) C (M) W (M)

ISSB (M) - 0.11 0.31c 0.13 0.13 -0.19a

LD (M) 0.11 - 0.04 0.04 0.06 0.33c

E 0.27b -0.18a 0.12 0.21b 0.06 -0.26b

DS 0.30c -0.04 0.26b -0.13 0.02 -0.18 HD (M) 0.31c 0.04 - 0.04 0.00 -0.11 H (M) 0.13 0.04 0.04 - 0.22b 0.07 C (M) 0.13 0.06 0.00 0.22b - 0.04 W (M) -0.19a 0.33c -0.11 0.07 0.04 -

p<0.05a; p<0.01b; p<0.001c

ISSB (M)=Inventory of Socially Supportive Behavior (Modified); LD=Level of Disclosure (Modified); E=Empathy (Revised Barret-Lennard Relationship Inventory); DS=Dyadic Satisfaction (Dyadic Adjustment Scale); HD=Helpfulness of Disclosure (Modified); H=Holding back (Modified); C=Criticism (Modified); W=Withdrawal (Modified)

246

Modified-C indicated the significant correlation (p<0.01) with the Modified-H,

however, did not show any correlation with other relationship scales.

6.1.3 (i) Summary of the Results

The modified scale of the ISSB revealed the Cronbach’s alpha value of more

than 0.75, indicating the excellent internal consistency of the scales. As for the E-

RBLRI, a good internal consistency was observed in the overall, English, Chinese and

Tamil versions. The internal consistency in the DS-DAS was quite good in the Malay

version. A small effect size was exhibited by all the scales used to measure the

interpersonal relationship of the patients’ husbands, suggesting that the scales had small

sensitivity to change after the re-test. Nevertheless, a number of scales showed high

significant differences. These could be seen in the overall mean differences [Level of

Disclosure (p<0.001), E-RBLRI (p<0.001), Criticism (p<0.001) and Withdrawal

(p<0.01)], English version [Level of Disclosure (p<0.001), Malay version [Level of

Disclosure (p<0.001), E-RBLRI (p<0.01), Criticism (p<0.001), Withdrawal (p<0.001)],

Chinese version [ISSB (p<0.01), Level of Disclosure (p<0.001), E-RBLRI (p<0.01),

Helpfulness of Disclosure (p<0.001)] and Tamil version [Level of Disclosure

(p<0.001)]. Based on the discriminant validity analysis, almost all the scales revealed

insignificant results when comparisons were made between the husbands of the patients

in the mastectomy and lumpectomy groups. The construct validity of the modified

version of interpersonal relationship scales was proven by the inter-correlation existed

among the scales.

247

6.1.4 The Measurement of the Husband’s Coping Strategies

The Brief COPE scale was used to measure the coping strategies employed by

the patients’ husbands, in which this scale is similar to the one used to measure the

coping strategies of the women with breast cancer.

6.1.4 (a) Brief COPE

Most sub-scales indicated acceptable values with the overall Cronbach’s alpha

values ranging from 0.44 to 0.97 (Table 6.30). The range was almost similar to ones

for the English version, with the Cronbach’s alpha values ranging from 0.54 to 0.96

(Table 6.31). As for the Malay version, most of the sub-scales were at acceptable

values (0.5 to 0.95), with the two sub-scales indicating lower values (0.24 for Positive

Reframing and 0.42 for Venting), as given in Table 6.32. Similarly, the Chinese

version indicated a high internal consistency for most of the sub-scales with the

Cronbach’s alpha values ranging from 0.31 to 1.00 (Table 6.33). The Tamil version

was also observed to have excellent internal consistency for most of its sub-scales,

ranging from 0.37 to 0.94 (Table 6.34). The overall Intraclass Correlation Coefficient

(ICC) gathered ranged from 0.06 to 0.80, showing the changes after the re-test (Table

6.30). The same situation was also detected for the English version (0.00 to 0.83)

(Table 6.31), Malay version (0.00 to 0.98) (Table 6.32), Chinese version (0.00 to 1.00)

(Table 6.33) and Tamil version (0.00 to 1.00) (Table 6.34), confirming the ICC values

which indicated the changes among the sub-scales after the re-test.

The values of the overall effect size (ESI = 0.00 to 0.39) (Table 6.30), English

version (ESI = 0 to 0.36) (Table 6.31), Malay version (ESI = 0 to 0.42) (Table 6.32),

248

Chinese version (ESI = 0 to 0.43) (Table 6.33) and Tamil version (ESI = 0 to 0.42)

(Table 6.34) indicated that the scales used in the study were indeed sensitive.

For this, the discriminant validity analysis showed that most of the sub-scales

produced no significant differences between the husbands of the patients in the

mastectomy and lumpectomy groups in all versions, as presented by the data in Tables

6.30, 6.31, 6.32, 6.33, and 6.34.

Table 6.30: The Overall Reliability and Validity of the Brief COPE Scale for the Husband’s Version

Test-retest (ICC)

Internal consistency (Cronbach’s

alpha)

Sensitivity to change Mean differences (ESI)

Discriminant validity

Brief COPE:

Active coping 0.30 0.60 1.16 (0.37)*** NS Planning 0.80 0.64 1.00 (0.34) NS Positive reframing 0.34 0.57 0.49 (0.17)*** NS Acceptance 0.06 0.63 0.01 (0.00) NS

Humour 0.32 0.77 0.09 (0.04) NS Religion 0.39 0.80 1.17 (0.39)*** NS Using emotional support 0.34 0.66 0.08 (0.03) NS Using instrumental support 0.47 0.66 0.08 (0.02) NS Self-distraction 0.30 0.44 0.81 (0.27)*** NS Denial 0.99 0.63 0.03 (0.01) NS Venting 0.38 0.52 0.27 (0.10)*** NS Substance use 0.25 0.97 0.13 (0.07) NS Behavioural disengagement 0.27 0.66 0.03 (0.01) NS Self-blame 0.98 0.86 0.01 (0.01) NS Problem-focused strategy 0.41 #1 1.37 (0.19)*** NS Emotion-focused strategy 0.67 #2 1.85 (0.09)* NS

***p<0.001; **p<0.01; *p<0.05 ICC = Intraclass Correlation Coefficient ESI = Effect Size Index # 1 = Problem-focused strategy is a combination of the sub-scales of active coping, planning and using instrumental support; therefore, the Cronbach’s alpha value is not provided. # 2 = Emotion-focused strategy is a combination of the subscales of positive reframing, acceptance, religion, using emotional support and denial; therefore, the Cronbach’s alpha value is not provided.

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Table 6.31: The Reliability and Validity of the English Version of Brief COPE Scale (the Husband’s Version)

Test-retest (ICC)

Internal consistency (Cronbach’s

alpha)

Sensitivity to change Mean differences (ESI)

Discriminant validity

Brief COPE:

Active coping 0.43 0.65 1.22 (0.36)*** NS Planning 0.83 0.76 1.00 (0.30) NS Positive reframing 0.40 0.68 0.17 (0.06) NS Acceptance 0.01 0.73 0.29 (0.09) p<0.05

Humour 0.14 0.54 0.29 (0.14) NS Religion 0.46 0.85 1.06 (0.35)*** p<0.01 Using emotional support 0.37 0.76 0.09 (0.03) p<0.05 Using instrumental support 0.62 0.67 0.08 (0.01) NS Self-distraction 0.18 0.52 1.00 (0.32)** NS Denial 1.00 0.62 0 (0) NS Venting 0.39 0.58 0.17 (0.06) NS Substance use <0.00 0.91 0.03 (0.02) NS Behavioural disengagement 0.40 0.82 0.03 (0.01) NS Self-blame 0.18 0.96 0 (0) NS Problem-focused strategy 0.40 #1 1.37 (0.17)** NS Emotion-focused strategy 0.78 #2 1.51 (0.20) NS

***p<0.001; **p<0.01; *p<0.05 ICC = Intraclass Correlation Coefficient ESI = Effect Size Index # 1 = Problem-focused strategy is a combination of the sub-scales of active coping, planning and using instrumental support; therefore, the Cronbach’s alpha value is not provided. # 2 = Emotion-focused strategy is a combination of the sub-scales of positive reframing, acceptance, religion, using emotional support and denial; therefore, the Cronbach’s alpha value is not provided.

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Table 6.32: The Reliability and Validity of the Malay Version of Brief COPE Scale (the Husband’s Version)

Test-retest (ICC)

Internal consistency (Cronbach’s

alpha)

Sensitivity to change Mean differences (ESI)

Discriminant validity

Brief COPE:

Active coping 0.26 0.58 1.14 (0.38)*** NS Planning 0.79 0.62 1.00 (0.35) NS Positive reframing 0.26 0.24 0.55 (0.20)** NS Acceptance <0.00 0.58 0.38 (0.13) NS

Humour 0.30 0.78 0.02 (0.01) NS Religion 0.33 0.56 1.12 (0.42)*** NS Using emotional support 0.38 0.63 0.06 (0.02) NS Using instrumental support 0.49 0.70 0.14 (0.04) NS Self-distraction 0.39 0.40 0.91 (0.31)*** NS Denial 0.98 0.50 0.03 (0.01) NS Venting 0.50 0.42 0.36 (0.13)* NS Substance use <0.00 0.95 0.20 (0.11) NS Behavioural disengagement 0.25 0.56 0.09 (0.06) NS Self-blame 0.40 0.72 0 (0) NS Problem-focused strategy 0.40 #1 1.14 (0.15)** NS Emotion-focused strategy 0.69 #2 1.39 (0.16)* NS

***p<0.001; **p<0.01; *p<0.05 ICC = Intraclass Correlation Coefficient ESI = Effect Size Index # 1 = Problem-focused strategy is a combination of the sub-scales of active coping, planning and using instrumental support; therefore, the Cronbach’s alpha value is not provided. # 2 = Emotion-focused strategy is a combination of the sub-scales of positive reframing, acceptance, religion, using emotional support and denial; therefore, the Cronbach’s alpha value is not provided.

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Table 6.33: The Reliability and Validity of the Chinese Version of Brief COPE Scale (the Husband’s Version)

Test-retest

(ICC) Internal

consistency (Cronbach’s

alpha)

Sensitivity to change Mean differences (ESI)

Discriminant validity

Brief COPE:

Active coping 0.26 0.31 1.11 (0.37)*** NS Planning 0.79 0.17 1.00 (0.41) NS Positive reframing 0.26 0.79 0.56 (0.19) NS Acceptance <0.00 0.40 0.69 (0.23)* NS

Humour 0.30 0.89 0.00 (0) NS Religion 0.33 0.88 1.36 (0.43)*** NS Using emotional support 0.38 0.65 0.03 (0.01) NS Using instrumental support 0.49 0.70 0.17 (0.06) NS Self-distraction 0.39 0.40 0.75 (0.24)* NS Denial 0.98 0.79 0.06 (0.02) NS Venting 0.50 0.73 0.28 (0.13) NS Substance use <0.00 1.00 0.28 (0.11) NS Behavioural disengagement 0.25 0.59 0.14 (0.09) NS Self-blame 1.00 1.00 0 (0) NS Problem-focused strategy 0.21 #1 1.42 (0.23)** NS Emotion-focused strategy 0.39 #2 0.08 (0.01) NS

***p<0.001; **p<0.01; *p<0.05 ICC = Intraclass Correlation Coefficient ESI = Effect Size Index # 1 = Problem-focused strategy is a combination of the sub-scales of active coping, planning and using instrumental support; therefore, the Cronbach’s alpha value is not provided. # 2 = Emotion-focused strategy is a combination of the sub-scales of positive reframing, acceptance, religion, using emotional support and denial; therefore, the Cronbach’s alpha value is not provided.

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Table 6.34: The Reliability and Validity of the Tamil Version of Brief COPE Scale (the Husband’s Version)

Test-retest (ICC)

Internal consistency (Cronbach’s

alpha)

Sensitivity to change Mean differences (ESI)

Discriminant validity

Brief COPE:

Active coping 0.20 0.82 1.20 (0.35)* NS Planning 0.85 0.87 1.00 (0.28) NS Positive reframing 0.35 0.43 0.75 (0.27)* p<0.05 Acceptance 0.42 0.80 0.60 (0.23) NS

Humour 0.44 0.87 0.25 (0.09) NS Religion 0.38 0.91 1.20 (0.42)*** NS Using emotional support 0.61 0.61 0.20 (0.07) NS Using instrumental support 0.45 0.44 0.70 (0.27)* NS Self-distraction 0.57 0.61 0.25 (0.01) NS Denial 1.00 0.84 0 (0) NS Venting 0.35 0.56 0.15 (0.05) NS Substance use 0.62 0.80 0.15 (0.10) NS Behavioural disengagement 0.19 0.37 0.20 (0.14) NS Self-blame 0.90 0.94 0.10 (0.05) NS Problem-focused strategy 0.54 #1 2.05 (0.28)** NS Emotion-focused strategy 0.59 #2 0.45 (0.05) NS

***p<0.001; **p<0.01; *p<0.05 ICC = Intraclass Correlation Coefficient ESI = Effect Size Index # 1 = Problem focus strategy is a combination of the sub-scales of active coping, planning and using instrumental support; therefore, the Cronbach’s alpha value is not provided. # 2 = Emotion focus strategy is a combination of the sub-scales of positive reframing, acceptance, religion, using emotional support and denial; therefore, the Cronbach’s alpha value is not provided. 6.1.4 (b) Summary of the Results

Most scales from all the versions indicated moderate internal consistencies,

except for a number of scales which showed the Cronbach’s alpha value of more than

0.75. These could be seen in the overall Cronbach’s alpha (Humour, Religion,

Substance Use, Self-blame), English version (Planning, Religion, Using Emotional

Support, Substance Use, Self-blame), Malay version (Humour, Using Instrumental

Support, Substance Use), Chinese version (Positive Reframing, Humour, Religion,

Denial, Self-blame) and Tamil version (Active Coping, Planning, Acceptance, Humour,

Religion, Denial, Substance Use, Self-blame). Most of the scales indicated low

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agreement in the test-retest. Nevertheless, a number of scales showed high agreement

such as Planning, Denial and Self-blame in the overall Intraclass Correlation

Coefficient, as well as the Chinese and Tamil versions. In the English version,

Planning, Denial and Emotion-focused Strategies revealed a high agreement in the test-

retest. Therefore, only the sub-scale of Planning and Denial from the Malay version

demonstrated a high agreement in the test-retest. All the sub-scales from all versions

showed a small sensitivity to change when the test-retest was carried out. Nonetheless,

the high mean significant differences were observed in certain sub-scales. These were

the overall Active Coping (p<0.001), Positive Reframing (p<0.001), Religion

(p<0.001), Self-distraction (p<0.001), Venting (p<0.001) and Problem-focused Strategy

(p<0.001). This situation could also be observed in the other versions, such as in the

English version [Active Coping (p<0.001), Self-distraction (p<0.001), Problem-focused

Strategy (p<0.01)], the Malay version [Active Coping (p<0.001), Positive Reframing

(p<0.01), Religion (p<0.001), Self-distraction (p<0.001) and Problem-focused Strategy

(p<0.01)], the Chinese version [Active Coping (p<0.001), Religion (p<0.001),

Problem-focused Strategy (p<0.01)] and the Tamil version [Religion (p<0.001) and

Problem-focused Strategy (p<0.01)]. The discriminant validity analysis did not reveal

any significant differences for most of the coping strategies employed by the husbands

of the patients in the mastectomy group and those husbands in the lumpectomy group.

Based on the results of the reliability and validity of the scales presented in this

chapter, the justifications and discussion of the appropriateness of the scales as a

research tools, will be presented in the next chapter.

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CHAPTER SEVEN

DISCUSSION: PART ONE

RELIABILITY AND VALIDITY OF THE SCALES

In this chapter, the discussion is focused on the reliability and the validity of the

scales that had been used to measure the various psychosocial aspects of the women with

breast cancer and their husbands. In this discussion, the scales have been ordered in the

following sequence: the measurement of quality of life [European Organization for

Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30),

Breast Module (QLQ BR-23), Hospital Anxiety and Depression Scale (HADS), Blatt

Menopausal Index (BMI)], Sexuality [Body Image Scale (BIS), Sexual Attractiveness:

Body Esteem Scale (SA-BES)], Interpersonal Relationship [Inventory of Socially

Supportive Behaviour (ISSB), Level of Disclosure, Helpfulness of Disclosure, Criticism,

Withdrawal, Empathy (Revised Barrett-Lennard Relationship Inventory (E-RBLRI) and

Dyadic Satisfaction: Dyadic Adjustment Scale (DS-DAS)]) and coping strategies (Brief

COPE). For this, both the women’s and the husbands’ versions are discussed in this

section.

7.0 The Reliability and Validity of the Scale of Quality of Life, Sexuality,

Interpersonal Relationship and Coping Strategies: The Women’s Version.

In general, most of the domains from the European Organization for Research and

Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), Breast Module

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(QLQ BR-23), Hospital Anxiety and Depression Scale (HADS) and Blatt Menopausal

Index (BMI) showed acceptable internal consistencies. All these quality of life scales are

almost parallel to the Cronbach’s alpha value obtained from the previous studies, such as

the EORTC QLQ C-30, which indicated the Cronbach’s alpha of more than 0.75 in almost

all domains except for the Role Functioning (Aaronson et al., 1993). Similar to QLQ-

BR23, the Cronbach’s alpha coefficients were found to range from 0.7 to 0.91 and from

0.46 to 0.94 among the breast cancer patients in the United States and Spain, respectively

(Sprangers et al., 1996). This is in line with Moorey et al (1991), who reported the

Cronbach’s alpha of 0.93 and 0.90 for the Anxiety and Depression sub-scales of HADS,

respectively. Meanwhile, Carpenter and Andrykowski (1999) indicated the Cronbach’s

alpha of 0.84 for the BMI.

In this study, the Intraclass Correlation Coefficient (ICC) of EORTC QLQ C-30

were found to have a range from a high to a low ICC. Domains such as Social and

Physical Functioning were revealed to show a relatively low ICC value, in all versions.

This might be caused by the effects of the different phases of the treatment (pre-

chemotherapy and during chemotherapy) on the women’s social and physical functioning.

The domains of Fatigue, Appetite Loss and Nausea and Vomiting also showed low ICC

values, which might probably also be caused by the effect of the different phases of the

treatment. The symptomatology domains of the English Version of the QLQ-BR23 scale

were found to yield very low ICC values (Systemic Therapy Side Effects = 0.21, Breast

Symptoms = 0.13, Arm Symptoms = 0.02 and Upset by Hair Loss = <0.00) as compared to

the ICC values from the other versions as well as the overall value. It was speculated that

this might probably be due to the socio-demographic background of the respondents who

answered the English Version of the questionnaire. The respondents who answered the

English Version indicated to have higher levels of education compared to the respondents

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who answered in other languages [As many as 43% (n=16) of the respondents who

answered the English Version attended tertiary education (up to university degree)

compared to the respondents who answered the Malay Version (1.5%, n=1), the Chinese

Version (0%) and the Tamil Version (0%)]. Thus, it was suggested that educational level

might affect the respondents’ appraisal on cancer symptomatology (QLQ-BR23), prior-to

and during the chemotherapy treatment. However, the appraisal on the menopausal

symptoms was found to be nearly similar for all the versions, with low ICC value (as well

as the overall values). This shows that the scores of the menopausal symptoms, obtained

between prior-to and during-chemotherapy phases, are different (the symptomatology

items of BMI is different from the symtomatology items of QLQ-BR23, as the BMI

incorporates both the psychological items in the scale as compared to QLQ-BR23 which

only has physical items). The ICC value for the HADS sub-scales of Anxiety and

Depression were found to be low in all versions (as well as the overall value). This could

be caused by the lack of agreement between prior-to and during-chemotherapy phases.

This could also be influenced by the different scores between the two phases.

Nevertheless, this situation was found to be slightly different for some of the EORTC QLQ

C-30 domains and the Functional scale of QLQ-BR23 where the ICC values produced

were high (as well as the overall value), indicating the agreement between the two

measurements as carried out in both, prior-to and the during-chemotherapy phases.

Meanwhile, the Body Image domain of QLQ-BR23 from all versions (as well as the

overall ICC) showed relatively low ICC values, ranging from poor to moderate. This

might also be caused by the lack of agreement between the measurements in prior-to and

during-chemotherapy phases. The lack of agreement between these two phases might be

caused by the women’s tolerance on their body image over a period of time.

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Most of the domains in the measurement of quality of life indicated a small effect

size which probably signalled a low sensitivity of the scale to detect change. However, the

treatment situations in this study (prior-to and during chemotherapy) are suggested to have

contributed to this small effect size, and not because of the low sensitivity of the scale.

Meanwhile, the analysis of the discriminant validity, to evaluate the differences

between the mastectomy and lumpectomy groups (the choice of groups to be compared

was based on the previous studies), showed that all versions did not have any differences

in quality of life (except for Sexual Enjoyment in the English Version and the overall

value; and Nauseas and Vomiting for the overall value). These findings are in line with the

previous studies which concluded that the quality of life between the mastectomy and the

lumpectomy groups were not different (e.g. Bleiker et al., 2000; Cohen et al., 2000; Ganz

et al., 1992). Unexpectedly, the domain of Body Image QLQ-BR23 did not yield any

difference between the mastectomy and the lumpectomy groups. This is in contrast to the

Body Image Scale (Hopwood et al., 2001) which differentiated the appraisal of the body

image between the mastectomy and lumpectomy groups (the differences between these

two scales are discussed in the next paragraph).

The measurement of the women’s sexuality, using the Body Image Scale (BIS) and

Sexual Attractiveness-Body Esteem Scale (SA-BES), showed an excellent internal

consistency in all versions (as well as the overall version). This is almost similar to the

finding by Hopwood et al. (2001), where a Cronbach’s alpha of 0.93 was found for BIS,

and 0.78 for SA-BES by Franzoi and Sheilds (1984).

The ICC value for the Sexual Attractiveness-Body Esteem Scale (SA-BES) was

found to be quite low compared to the Body Image Scale (BIS). This might possibly be

due to the drastic effects of the chemotherapy treatment on the patients’ overall sexual

attractiveness (as measured by SA-BES), rather than the loss of the breast alone (as

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measured by BIS) (the Sexual Attractiveness-Body Esteem Scale is used not only to

evaluate the aspect of sexuality, from the changes of the breast alone, but also the other

organs such as the private parts, hair, face, nose, etc.).

Both the sexuality scales (BIS and SA-BES) showed a small sensitivity to change

from prior-to to during-chemotherapy phases, as indicated by the small values of the effect

size. The discriminant analysis showed that there were differences in the body image

between the mastectomy and lumpectomy groups (in all versions, except for the English

Version and the overall value). This is similar to the findings of some previous studies

which found the importance of body image issue, following breast cancer surgery (e.g.

Bukovic et al., 2005; Hartl et al., 2003). The English Version did not indicate any

difference in the body image for the mastectomy and lumpectomy groups, and this could

be caused by the higher education level among the respondents who answered the

questionnaire in English [43% (n=16) of the respondents of the English version were

highly educated and had received tertiary education (first degree/ master/ PhD)], compared

to the respondents from other versions. Their education level seemed to influence their

tolerance on the body image change via the enhancement in their ability to understand a

situation and use the information efficiently (this particular finding in line with Ben-zur et

al., 2001).

The current study also discovered a major finding i.e., BIS is able to differentiate

body image change between the mastectomy and the lumpectomy groups, but the Body

Image-QLQ BR23 is not. This could be due to the higher number of items in the BIS (ten

items) compared to the Body Image-QLQ BR23 (four items only). Moreover, the BIS

consist of six more items which are able to capture the psychosexual aspect of the

respondents, as compared to the Body Image-QLQ BR23. Meanwhile, SA-BES was found

to be unable to differentiate the sexual situation between the mastectomy and the

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lumpectomy groups (in all versions and the overall value). This could be caused by the

fact that the SA-BES measures the sexual concept in a broad sense and does not only focus

on the loss of the breast alone, which is in line with Wilmoth (2001) stated, i.e. sexuality is

“..more than the act of sex, that it concluded championship, touching and affection and

that women’s sexuality was the gestalt of feelings towards another and their partner’s

feelings towards them”. It is also likely that women, who had undergone different types of

breast cancer surgery, are most concerned about the aspect of their body image related to

the loss of the breast, rather than their sexual attractiveness in general.

Meanwhile, for the measurement of the women’s interpersonal relationship, the

internal consistencies of the scales were acceptable. The internal consistency obtained

from the ISSB in this study is similar to the previous studies which suggested the

Cronbach’s alpha consistently above 0.9 (Barrera, 1981; Barrera et al., 1981; Cohen et al.,

1984; Cohen & Hoberman, 1983; Stokes & Wilson, 1984). The Cronbach’s alpha for the

E-RBLRI is also nearly similar to Pistrang and Barker (1995; 1992) who also indicated the

Cronbach’s alpha of 0.84 and 0.83, respectively. As for the Dyadic Satisfaction-Dyadic

Adjustment Scale, the Cronbach’s alpha was found a bit lower as compared to Spanier

(1976) who indicated the Cronbach’s alpha of 0.94 in his study.

The ISSB, E-RBLRI, DS-DAS, Helpfulness of Disclosure, Holding Back,

Criticism and Withdrawal showed low ICC values. This situation was different for the

Level of Disclosure which showed high ICC values. This is probably related to item

number five in the scale of Level of Disclosure (Pistrang and Barker, 1995), i.e.

“uncertainty about whether the cancer will recur or spread in the future” and item number

six in the scale of Level of Disclosure (Pistrang and Barker, 1995), i.e. “thoughts about

death and dying”. Both questions led the patients towards a tendency to have the feeling

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of “death” and “cancer spread/recurrence,” which do not really differ after surgery for up

to a three month’s period.

All the scales, used to measure the aspect of interpersonal relationship, showed

small effect size, which perhaps indicated a small sensitivity of the scales to detect any

changes. However, it is suggested that the treatment situation itself (prior-to and during

chemotherapy) contributed to the small effect size, and not due to the small sensitivity or

undetectable of the scale used in the current study.

For the analysis of discriminant validity, almost all the scales (all versions and the

overall value) showed no differences between the mastectomy and lumpectomy groups.

This is similar to the previous studies which found the insignificance issue of the type of

breast cancer surgery on women’s interpersonal relationship (e.g. Onen-Sertoz et al., 2004)

[However, besides the possibility of the cultural influence, the Malay Version of the

Holding Back scale showed a difference in the score between the mastectomy and

lumpectomy groups, which might be caused by the percentage of the pre-menopausal

women at 62% (n=42) compared to the post-menopausal women at 31% (n=21). In

addition, the discriminant validity of the Malay Version might also be influenced by the

overall validity which found differences in the ‘holding back’ of the mastectomy and

lumpectomy groups].

In the aspect of coping behaviour, most of the domains from Brief COPE scale

showed Cronbach’s alpha values ranging from acceptable to excellent. This internal

consistency could be accepted as Carver (1997) also indicated the Cronbach’s alpha of at

least 0.6 in most of the domains of Brief COPE in his study.

Meanwhile, the ICC values were found to range from a low value to a high value

for all versions and the overall value. Domains such as Active coping, Positive Reframing,

Humour, Religion, Using Emotional Support, Using Instrumental Support, Self-distraction

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and Substance Use showed poor ICC values, suggesting a poor agreement as compared to

Acceptance, Denial, Venting, Behavioural Disengagement and Self-blame which showed

excellent agreement. This could probably be due to the fact that the coping strategies

which were based on the element of “action” were influenced by the phases of the

treatment (pre- and during chemotherapy), while the coping strategies which were based

on the element of “psychology” were found to be the opposite.

All versions and the overall value showed a range of effect size, from trivial to

moderate, with most of the action-based coping strategies (such as Active, Positive

Reframing, Using Emotional and Instrumental Support) showed high mean differences

compared to the domains which were based on the psychological element. A range of the

sensitivity of the scales was perhaps due to the treatment situation as measured at prior-to

and during chemotherapy phases.

The English and Malay versions of the Brief COPE scale showed that the

discriminant validity was quite different from the Chinese and Tamil Versions. This

difference (between the mastectomy and lumpectomy groups) could be seen in the domains

of Active, Planning and Acceptance (for the English Version) and the domains of Active,

Planning, Positive Reframing, Religion and Using Instrumental Support (for the Malay

Version). This condition might be influenced by the level of education of the respondents

for the English and Malay Versions, who were highly educated compared to respondents

for the Chinese and Tamil Versions [89% (n=33) of the respondents from the English

Version and 56% (n=38) of the respondents from the Malay Version have education levels

to at least that of high secondary school]. Meanwhile, there were no differences between

the mastectomy and lumpectomy groups in most domains (for all versions and the overall

results); these findings are almost in line with the results of some previous studies (e.g.

Buddeberg et al., 1990; Jackish et al., 1997). In term of the construct validity of the scales

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used in this study, the validity of all the scales to measure quality of life, sexuality,

interpersonal relationship and coping strategies is satisfactory as there was a significant

inter-correlation among the scales and their domains.

7.1 The Reliability and Validity of the Scales of Psychological Well-being,

Sexuality, Interpersonal Relationship and Coping Strategies: The Husband’s

Version

The English, Malay, Chinese and Tamil versions of the Hospital Anxiety and

Depression Scale (HADS) showed an internal consistency of at least at an acceptable level,

when evaluated on the husbands. Nevertheless, this value is a bit lower to the values

obtained by Moorey et al. (1991), which were 0.93 and 9.0 for Anxiety and Depression,

respectively. The Intraclass Correlation Coefficient (ICC) was found to be low in all

versions, indicating that there was less agreement between the scores for prior-to and

during-chemotherapy. All versions showed sensitivity to change with a small effect size.

This small sensitivity is suggested to be related to the treatment situation itself, and not

because of the inability of the scales to measure. In the analysis of the discriminant

validity, the Anxiety-HADS did not differentiate the husbands’ anxiety between the

mastectomy and lumpectomy groups. Similarly, the husbands’ depression between the two

groups also could not be differentiated by the Depression-HADS. This is in line with the

patient’s version and the studies surrounding breast cancer (e.g. Bleiker et al., 2000; Ganz

et al., 1992).

In the sexuality measurement from the husbands’ perspectives, the modified

version of the Body Image Scale (BIS) and the Sexual Attractiveness-Body Esteem Scale

(SA-BES) showed excellent internal consistencies.

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With the exception for the Malay Version, the ICC value for the SA-BES was

found to be low compared to the BIS for all versions and the overall ICC values. This

might be caused by the situations during the chemotherapy treatment which imposed

effects on the husbands’ view on their wives’ (the patients of breast cancer) sexual

attraction. The decline in the sexual attraction might be less experienced prior-to

chemotherapy. In this study, the SA-BES scale was also found to measure the concept of

sexual attraction in a broader scope (encompassing attractions to other parts of the body

such as nose, private parts, chin, etc.) as compared to the BIS. This might be precisely the

reason why the value of ICC in the BIS was higher than the SA-BES scale. All the scales

from all versions and the overall value showed a small effect size which signalled a small

sensitivity of the scale from prior-to to during-chemotherapy phases. Nonetheless, it is

suggested that the small effect size of the scale is greatly due to the treatment situation

itself, rather than the low ability of the scales to detect changes.

Both scales (BIS and SA-BES) did not differentiate between the view of the

husbands in the mastectomy and lumpectomy groups on their wives’ body image and

sexual attractiveness. This finding is acceptable with two conditions; the husbands

perceived the issue of “cancer treatment” as a priority compared to the issue of “sexuality”;

otherwise, the husbands perceived the treatment on their wives’ breast cancer (whether it is

a treatment on the whole breast or only a portion) influenced their view on their wives’

body image and sexual attractiveness.

The scales (all versions) which had been used in the measurement of the husbands’

interpersonal relationship also showed internal consistencies ranging from an acceptable

value to an excellent value. The internal consistency of DS-DAS in the study is slightly

lower than the value indicated by Spanier (1976) in his study, i.e. the Cronbach’s alpha

value of 0.94.

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The ICC value for all the interpersonal relationship scales for all versions and the

overall version were found to be low, indicating a poor agreement in the test-retest.

However, the situation was different for the Modified-Level of Disclosure, which indicated

an excellent agreement in the test-retest which shows a high ICC value (indicate excellent

agreement). This finding is similar to the ICC value obtained in the interpersonal

relationship scales of the women’s version. It is also suggested that item number five,

which is “uncertainty about whether the cancer will recur or spread in the future” and

item number six, which is “thoughts about death and dying” from the Modified-Level of

Disclosure had influenced the scores obtained in the test-retest of this study. This also

explained the significant difference in the ICC values of the Modified-Level of Disclosure

and the other scales. All the scales (for all versions and the overall value) showed a small

effect size which indicated a small sensitivity of the scale after the retest. Nonetheless, the

small effect size is mainly due to the treatment situation, rather than the low detectable of

the scales themselves.

The discriminant validity did not show any difference in the husbands’

interpersonal relationship between the mastectomy and the lumpectomy groups. This

could be seen in all versions (and the overall validity), except for the English Version

which showed a different score for the M-ISSB and Modified-Withdrawal scales. This

difference might probably be caused by the respondents’ education level for the English

Version which was comparatively higher than the respondents from the other versions

[60% (n=22) of the respondents from the English Version had at least a Form Six or

diploma qualification as compared to the respondents from other versions].

For the measurement of the coping strategies among the husbands, the internal

consistencies for the Brief COPE scale domains (for all versions and the overall result

Cronbach’s alpha) ranged from acceptable to excellent. The low Cronbach’s alpha values

265

for some domains could be accepted as Carver (1997) had also observed the Cronbach’s

alpha of at least 0.6 in almost all the Brief COPE domains in his study.

The ICC values of all versions and the overall ICC were low on most of the

domains; these indicated a poor agreement in the test-retest, except for the domain of

Planning which showed excellent agreement. The differences of the three domains are

acceptable because their situations were influenced by the minimal change between the

scores obtained from prior-to and during chemotherapy.

Most of the domains from all versions and the overall sensitivity showed the

sensitivity of the scale with small values of effect size. The domains of Self-blame, Denial

and Humour, which did not show any sensitivity to detect change, are accepted because the

feelings such as blaming oneself, denying the breast cancer and the element of humour did

not change from prior-to to during-chemotherapy phases.

As for the husbands’ coping strategies, no differences were found between the

mastectomy and lumpectomy groups. This finding is similar for all versions and the

overall discriminant validity. However, the results from the English Version showed a

difference between the mastectomy and the lumpectomy groups in the domains of

Acceptance, Religion and Using Emotional Support. This situation is probably related to

the higher educational level of the respondents from the English Version [60% (n=22) of

the respondents from the English version had at least a higher secondary education as

compared to the respondents for other versions. The modified versions indicated a

satisfactory construct validity through the inter-correlation existed with other scales.

Generally, the scales used in this research were found to be reliable and valid for

the Malaysian population, based on the acceptable internal consistency, the ability of the

scales to detect the changes (indicated by the mean differences and the effect size values)

and the satisfactory of the construct validity of the scales. However, several justifications

266

need to be given to the domains which show low ICC values and a small sensitivity, which

might be due to the different treatment phases. This is also applicable to the discriminant

validity, which was influenced by the various socio-economic backgrounds of the

respondents participating in this study. Beside that, the findings of the previous studies

have also been shown to support the results obtained in the current study.

Thus, the major findings of the study, which were based on the various hypotheses

postulated, will be reported in the next chapter.

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CHAPTER EIGHT

RESULTS: PART TWO

QUALITY OF LIFE, INTERPERSONAL RELATIONSHIP AND

COPING STRATEGIES OF THE WOMEN WITH BREAST CANCER A ND

THEIR HUSBANDS

In this chapter, the results of the study are divided into five parts: 1. Bio/Socio-

demographic and Medical Characteristics of the Women with Breast Cancer and their

Husbands; 2. Breast Cancer: From the Couples’ Perspective; 3. Breast Cancer: From

the Women’s Perspective; 4. Breast Cancer: From the Husbands’ Perspective; and 5.

Factors Predictive of the Women’s Global Health Status, Sexuality, Relationship

Satisfaction and Coping Strategies.

8.0 Bio/Socio-demographic and Medical Characteristics of the Women with

Breast Cancer and Their Husbands

Table 8.0 presents the bio/socio-demographic and medical characteristics of

women with breast cancer and their husbands. In this study, the mean age of the

women was 48.29 (sd±8.85) years old, with the ages ranging from 29 to 71 years old.

Meanwhile, the mean age of their husbands was 52.21 (sd±9.01) years old, with the

ages ranging from 32 to 74 years old. Their ages were found to be significantly

different [t (317) = 3.92; p<0.001]. The mean duration of the marriages was 23.10

(sd±9.83) years. A majority of the women had undergone mastectomy (79.4%, n=127),

as compared to lumpectomy (20.6%, n=33), with most of them diagnosed with

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Table 8.0: Bio/socio-demographic and Medical Characteristics of the Women with Breast Cancer and their Husbands

Women Husbands Age (mean ± sd)

48.29 ± 8.85 years (Range: 29 to 71 years old)

52.21 ± 9.01 years (Range: 32 to 74 years old)

Duration of Marriage (mean ± sd) 23.10 ± 9.83 years NA Ethnicity: Malay 78 (48.8%) 77 (48.1%) Chinese 51 (31.9%) 53 (33.1%) Indian 30 (18.8%) 29 (18.1%) Others 1 (0.6%) 0 (0%) Education Levels: Primary school 36 (22.5%) 32 (20.0%) Lower secondary 50 (31.3%) 34 (21.3%) Upper secondary 40 (25.0%) 54 (33.8%) Form 6/Diploma/Certificate 17 (10.6%) 17 (10.6%) Tertiary 17 (10.6%) 22 (13.8%) Household Monthly Income (RM3.80=USD1): Less than RM1000 32 (20.0%) NA RM1001 to RM3000 87 (54.4%) RM3001 to RM5000 24 (15.0%) More than RM5000 17 (10.6%) Occupation: Professionals 19 (11.9%) 26 (16.4%) Technicians and associate

professionals 9 (5.6%) 14 (8.8%)

Clerical workers 17 (10.6%) 17 (10.7%) Service workers/shop market sales

workers 9 (5.6%) 28 (17.6%)

Skilled agricultural and fishery workers

1 (0.6%) 2 (1.3%)

Plant and machine-operators 3 (1.9%) 6 (3.8%) Elementary occupations 2 (1.3%) 19 (11.9%) Armed forces 0 (0%) 4 (2.5%) Housewife 80 (50.0%) NA Pensioner/Retiree 20 (12.5%) 43 (27.0%) Family/ relative/ close friends diagnosed with breast cancer

43 (26.9%) NA

Types of Breast Cancer Surgery: Mastectomy 127 (79.4%) NA Lumpectomy 33 (20.6%)

Table 8.0, Continued.

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Women Husbands Menopausal Status: Pre-menopausal 83 (51.9%) NA Peri-menopausal 13 (8.1%) Post-menopausal 64 (40.0%) Stages of Breast Cancer: Stage 1 13 (8.1%) NA Stage 2a 55 (34.4%) Stage 2b 36 (22.5%) Stage 3a 33 (20.6%) Stage 3b 17 (10.6%) Stage 3c 6 (3.8%)

Duration of Breast Cancer (mean ± sd) (From diagnosis to the participation in the study)

51.68 ± 2.50 days NA

NA: Not Applicable

stage two of breast cancer (56.9%, n=91), followed by stage three (35%; n=56) and

stage one (8.1%, n=13). From the point of diagnosis to the participation in the study, it

was estimated that these women had been suffering from breast cancer for a mean

duration of 51.68 (sd±2.50) days.

The bio/socio-demographic pattern of the women also indicated the pre-

menopausal group consisted of the largest proportion (51.9%, n=83), followed by the

post-menopausal (40.0%, n=64) and peri-menopausal (8.1%, n=13). In terms of

ethnicity, Malays formed the largest proportion of the study (women: 48.8%, n=78;

husbands: 49.1%, n=78), followed by Chinese (women: 31.9%, n=51; husbands:

32.7%, n=52) and Indians (women: 18.8%, n=30; husbands: 18.1%, n=29). These

women and their husbands had at least a secondary education (women: 56.3%, n=90;

husbands: 55.1%, n=88), with a household monthly income of at least RM3000 or

USD854.94 (74.4%, n=119). Most of the women were unemployed (62.5%, n=80), as

compared to their husbands, with only 27.0% (n=43) of those who were no longer

270

working or had retired. One quarter of the women indicated that a family member or

relative or a close friend had experienced breast cancer (26.9%, n=43).

In the next main sections, the results from the section on “Breast Cancer: From

the Couples’ Perspective” is presented, followed by the section of “Breast Cancer:

From the Women’s Perspective” and “Breast Cancer: From the Husband’s

Perspective”.

8.1 Breast Cancer: From the Couples’ Perspective

In this section, the reporting of the results was limited only to the data which

was gathered from both the women and their husbands who answered on the similar

scales - anxiety and depression (Hospital Anxiety and Depression Scale), relationship

satisfaction (Dyadic Relationship: Dyadic Adjustment Scale) and coping strategies

(Brief COPE Scale).

The section is further divided into three sub-sections: psychological well-being,

relationship satisfaction and coping strategies. Thus, the results in every sub-section

are presented in the following sequence:

(1) First level of analysis i.e. Two Ways Repeated Measure ANOVA, to examine

the differences of the psychological well-being, relationship satisfaction and coping

strategies at different phases of treatment (prior-to, during and post-chemotherapy),

between the women with breast cancer and their husbands. This analysis was carried

out based on the whole sample size as described in Table 8.1 below:

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Table 8.1: The Sample Size Distribution of the Study

Respondents Phase One:

Prior to Chemotherapy

Phase Two: During

Chemotherapy

Phase Three: After

Chemotherapy

Women with Breast Cancer N=160 N=158 N=157

Husbands N=159 N=157 N=157

Note: Three women (Two women at Phase Two and one woman at Phase Three) were excluded from the study because they did not complete the chemotherapy treatment. However, for the husbands, one refused to participate as stated at the initial stage of the study and two refused to participate at Phases Two and Three.

[The section was further elaborated by the analysis carried out separately at the

individual’s level i.e. the women’s level and husbands’ level. The analyses of One-way

Repeated Measure ANOVA (for the parametric test) and Friedman analysis (for the

non-parametric test) were conducted to examine the differences in terms of

psychological well-being, relationship satisfaction and coping strategies at different

phases of treatment i.e. prior-to, during and post-chemotherapy. The whole sample size

was used in this analysis, as described in Table 8.1]

(2) Second level of analysis i.e. the Three Factors Mixed Repeated Measure

ANOVA (two within the subjects’ factors and one between the subjects’ factor) to

examine the differences in the psychological well-being, relationship satisfaction and

coping strategies at different phases of treatment (prior-to, during and post-

chemotherapy), between the women and their husbands, by looking at the effects of the

types of surgery, stages of breast cancer, menopausal status and ethnicity. These

analyses were carried out based on the various sample size of independent factors as

presented in detail in Table 8.2.

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Table 8.2: Sample Size Proportion for the Analysis of Split Plot Repeated Measure ANOVA and Three Factors Mixed Repeated Measure ANOVA

Independent Factors Sample Size Proportions

Types of Surgery

Mastectomy, N=124 Lumpectomy, N=33 Final sample size for data analysis =157

Breast Cancer Stages

Stage one, N=13 (excluded) Stage two, N=89 Stage three, N=55 Final sample size for data analysis =144

Menopausal Status

Pre-Menopausal, N=81 Peri-Menopausal, N=13 (excluded) Post-Menopausal, N=63 Final sample size for data analysis =144

Ethnicity

Malay, N=76 Chinese, N=51 Indian, N=30 Final sample size for data analysis =157

Note: Stage one and peri-menopausal groups were excluded from the analysis, due to the small numbers which could cause statistical errors.

In this section, only the results of Between Subjects Effect are highlighted

because the other results, such as the main effects for the groups, main effects of the

time and the interaction effect (from the whole sample) have already been reported and

described in the first level of the analysis. Therefore, all these results will not be

reported again in this second level of the analysis, however, are cited as an appendix

(see Appendix 4). In addition, only the results of Between Subject Effect are

highlighted in the second level of analysis as the different sample size of independent

factors (types of surgery, breast cancer stages, menopausal status and ethnicity)

revealed the different results of the group effect, time effect and interaction effects for

each independent factor. Thus, the results of the group effect, time effect and

interaction effects from the whole sample were reported in the present study.

273

The medical records of the breast cancer patients were investigated to gather the

medical-related information, such as the types of surgery undergone and the stages of

the patients’ breast cancer. This was also done in order to classify the patients and their

husbands into the right groups for the analysis. Meanwhile, the classification for the

patients’ menopausal status was done by referring to the Massachusetts Women’s

Health Study (Brambilla et al., 1994), as the definition can be easily used in large

epidemiologic investigations, as well as having been used by many researchers (e.g.

Bastian et al., 2003; Dudley et al., 1998). Thus, pre-menopausal is defined as having

had a menstrual period in the last three months. In this study, women who had

experienced three to 11 months of amenorrhea or increased menstrual irregularity (if

still cycling), were categorized as peri-menopausal. Post-menopausal is defined as

having 12 or more months of amenorrhea. The sample size distribution for this

analysis is presented in Table 8.2, as below:

[The section was further elaborated by the analysis carried out separately at the

individual’s level i.e. the women’s level and husbands’ level. The analyses of the Split

Plot Repeated Measure ANOVA (one’s within subjects’ factors and one between the

subjects’ factor) were conducted to examine the differences of psychological aspect,

relationship satisfaction and coping strategies at different phases of treatment (prior-

to, during and post-chemotherapy), by observing at the effects imposed by the types of

surgery, breast cancer stages, menopausal status and ethnicity. Similar to the analysis

of Three Factors Mixed Repeated Measure ANOVA, different sample size was also used

for this analysis, Split Plot Repeated Measure ANOVA (see Table 8.2). Only the results

of Between Subjects Effect are highlighted here as the results obtained for the effect of

time have already been reported in first level of analysis which was based on the whole

sample. Moreover, the different results of time effect and interaction effect were

274

gathered from each independent factor (types of surgery, breast cancer surgery,

menopausal status and ethnicity) due to the different sample size. Thus, only the results

of the time effect obtained from the whole sample are focused in this presentation. The

classification of the independent factors for various analyses was similar to the

analysis of the Three Factors Mixed Repeated Measure ANOVA, as described in the

earlier paragraph].

Hence, these results were presented in such a sequence so as to answer the

general and specific hypotheses postulated in this study, as below:

General Hypothesis:

• Treatment phases (prior-to, during and post-chemotherapy) have different

effects on the couples’ psychological aspects (anxiety and depression),

relationship satisfaction and coping strategies.

Specific Hypotheses:

(a) There are similarities in the patterns of the psychological aspects (anxiety

and depression), relationship satisfaction and coping strategies, between

the women and their husbands over time (prior-to, during and post-

chemotherapy); however, these women were found to indicate a higher level

of psychological problems (anxiety and depression), better relationship

satisfaction and the greater use of coping strategies, as compared to their

husbands in all occasions (prior-to, during and post-chemotherapy).

(b) Medical (surgery types and stages of breast cancer) and selected bio/socio-

demographic aspects (ethnicity and menopausal status) have significant

effects on the couples’ psychological aspects (anxiety and depression),

relationship satisfaction and coping strategies.

275

Hence, in accordance to the above hypotheses, the results of the couples’

psychological well-being, relationship satisfaction and coping strategies will be

presented in the next section.

8.1.1 The Couples’ Psychological Well-being

An analysis of the Two-ways Repeated Measure ANOVA showed that there

was a significant difference between the patients and their husbands on anxiety [F (1,

156) = 17.84; p<0.001] [women experienced more anxiety at prior-to (11.52 ±3.15),

during (12.64±3.34) and post-chemotherapy (10.71±2.86), as compared to their

husbands (prior-to=10.54±3.18, during=11.57±3.27 and post-

chemotherapy=10.38±2.55)], and the main effects of time [F (2, 312) = 21.93;

p<0.001] [women and their husbands’ anxiety increased from prior-to to during and

decreased post-chemotherapy]. However, no significant interaction was found between

the groups and time [F (2, 312) = 1.99; ns] [Table 8.3 (a); Figure 8.0 (a)].

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Figure 8.0 (a): Couples' Anxiety

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es

Women

Husbands

Groups: F (1, 156) = 17.84; p<0.001 Time: F (2, 312) = 21.93; p<0.001 Interaction Effect: F (2, 312) = 1.99; ns (8.0 a)

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Table 8.3 (a): Two-way Repeated Measure ANOVA: Psychological Aspect of the Couples with Breast Cancer

Source of Variation ss df ms f sign

Anxiety Within Subjects Effect: Couples with Breast Cancer (Groups)

148.488 1 148.488 17.844 p<0.001

Anxiety (Time) 399.327 2 199.663 21.930 p<0.001 Groups x time 25.663 2 12.816 1.990 ns

Depression Within Subjects Effect: Couples with Breast Cancer (Groups)

42.463 1 42.463 4.398 p<0.05

Depression (Time) 723.008 2 361.504 48.588 p<0.001 Groups x time 114.155 2 57.077 11.284 p<0.001

The similar analysis also indicated a significant difference between the women

and their husbands on depression [F (1, 156) = 4.40; p<0.05] [women experienced more

depression prior-to (12.32±3.26) and during chemotherapy (13.74±2.98), as compared

to their husbands (prior=11.63±3.12; during=12.62±3.32). However, the depression

level post-chemotherapy was higher in husband’s group (11.31±2.46) than women’s

group (10.78±2.76)], a significant effect of time [F (2, 312) = 48.59; p<0.001] [Both

women’s and their husbands’ depression increased from prior-to to during and

declined post-chemotherapy] and a significant interaction effect between the groups

and time [F (2, 312) = 11.28; p<0.001] [Table 8.3 (a); Figure 8.0 (b)].

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Figure 8.0 (b): Couples' Depression

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Women

Husbands

Groups: F (1, 156) = 4.40; p<0.05 Time: F (2, 312) = 48.59; p<0.001 Interaction Effect: F (2, 312) = 11.28; p<0.001 (8.0 b)

277

The results of Between Subjects Effect of the Three Factors Mixed Repeated

Measure ANOVA indicated that the couples’ anxiety was unaffected by all factors: the

types of surgery [F (1, 155) = 0.40; ns], stages of breast cancer [F (1, 155) = 1.04; ns],

menopausal status [F (1, 142) = 0.28; ns] and ethnicity [F (2, 154) = 0.46; ns].

Likewise, all factors did not affect the couples’ depression: the types of surgery [F (1,

155) = 0.40; ns], stages of breast cancer [F (1, 155) = 0.83; ns], menopausal status [F

(1, 142) = 0.06; ns] and ethnicity [F (2, 154) = 0.24; ns] [Appendix D: Tables 1 (a), (b),

(c), and (d)].

The analyses for the women and the husbands were carried out separately, at an

individual level to observe the psychological pattern over time and the effect of the

independent factors (types of surgery, stages of breast cancer, menopausal status and

ethnicity) on the psychological aspect.

The result of the One-way Repeated Measure ANOVA indicated a significant

effect of time on women’s anxiety [F (1.91, 297.56 = 16.91; p<0.001] [Women’s

anxiety increased from prior-to (11.52±3.15) to during (12.64±3.34), and declined at

post-chemotherapy (10.71±2.86)] and husbands’ anxiety [F (1.93, 301.51) = 9.52;

p<0.001] [Husbands’ anxiety increased from prior-to (10.54±3.18) to during

(11.57±3.27) and diminished at post-chemotherapy (10.38±2.55)] [Table 8.3 (b)].

Similarly, a significant effect was observed for the women’s depression [F (2, 312) =

53.79; p<0.001] [Women’s depression rose from prior-to (12.32±3.26) to during

(13.74±2.98) and it later decreased at post-chemotherapy (10.78±2.76)], and

husbands’ depression [F (2, 312) = 12.16; p<0.001] [Husbands’ depression rose from

prior-to (11.63±3.12) to during (12.62±3.32) and declined at post-chemotherapy

(11.31±2.46)] [Table 8.3 (b)].

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Table 8.3 (b): One-way Repeated Measure ANOVA: The Psychological Aspect of the Women with Breast Cancer and Their Husbands

Source of Variation ss df ms f sign

Women with Breast Cancer:

Anxiety 295.146 1.907 154.736 16.910 p<0.001 Depression 688.998 2 344.499 53.787 p<0.001 Husbands:

Anxiety 129.813 1.933 67.164 9.519 p<0.001 Depression 148.166 2 74.083 12.158 p<0.001

The results from the Split Plot Repeated Measure ANOVA indicated the non-

significant effects of all the independent factors on the women’s anxiety: types of

surgery [F (1, 55) = 0.92; ns], stages of breast cancer [F (1, 142) = 1.29; ns],

menopausal status [F (1, 142) = 0.12; ns] and ethnicity [F (2, 154) = 0.10; ns] [Tables

8.3 (c), (d), (e), (f); Figures 8.0 (c), (d), (e), (f)].

Table 8.3 (c): Split Plot Repeated Measure ANOVA: The Effect of the Types of Surgery on the Psychological Aspect of the Women with Breast Cancer

Source of Variation ss df ms f sign

Anxiety Within Subjects Effect: Anxiety (Time) 268.13 1.923 139.438 15.376 p<0.001 Time x Surgery Types 19.867 1.923 10.332 1.139 ns Between Subjects Effect: 10.907 1 10.907 0.922 ns (Effect of Types of Surgery)

Depression Within Subjects Effect: Depression (Time) 622.34 2 311.169 49.199 p<0.001 Time x Types of Surgery 37.685 2 18.842 2.979 ns Between Subjects Effect: 0.392 1 0.392 0.027 ns (Effect of Types of Surgery)

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Figure 8.0 (c): The Effect of Types of Surgery on Women's Anxiety

Mea

n sc

ore

s

Mastectomy (N=124)

Lumpectomy (N=33)

Table 8.3 (d): Split Plot Repeated Measure ANOVA: The Effect of the Breast Cancer Stages on the Psychological Aspect of Women with Breast Cancer

Source of Variation ss df ms f sign

Anxiety Within Subjects Effect: Anxiety (Time) 268.105 1.932 148.124 16.215 p<0.001 Time x Breast Cancer Stages 7.669 1.932 3.971 0.435 ns Between Subjects Effect: 14.540 1 14.540 1.293 ns (Effect of Breast Cancer Stages) Depression Within Subjects Effect: Depression (Time) 651.348 2 325.674 50.608 p<0.001 Time x breast cancer stages 13.154 2 6.577 1.022 ns Between Subjects Effect: 1.617 1 1.617 0.114 ns (Effect of Breast Cancer Stages)

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Figure 8.0 (d): The Effect of Breast Cancer Stages on Women's Anxiety

Mea

n sc

ores Stage Two (N=89)

Stage Three (N=55)

Time: F (1.923, 298.06) = 15.376; p<0.001 Interaction Effect: F (1.923, 298.06) = 1.139; ns Between Subjects Effect: F (1, 155) = 0.922; ns (8.0 c)

Time: F (1.932, 274.277) = 16.215; p<0.001 Interaction Effects: F (1.932, 274.277) = 0.435; ns Between Subjects Effect: F (1, 142) = 1.293; ns (8.0 d)

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Table 8.3 (e): Split Plot Repeated Measure ANOVA: The Effect of Menopausal Status on the Psychological Aspect of the Women with Breast Cancer

Source of Variation ss df ms f sign

Anxiety Within Subjects Effect: Anxiety (Time) 319.005 1.901 167.833 17.607 p<0.001 Time x Menopausal Status 14.524 1.901 7.641 0.802 ns Between Subjects Effect: 1.514 1 1.514 0.124 ns (Effect of Menopausal Status ) Depression Within Subjects Effect: Depression (Time) 638.720 2 319.360 49.025 p<0.001 Time x Menopausal Status 1.943 2 0.971 0.149 ns Between Subjects Effect: 5.938 1 5.938 0.397 ns (Effect of Menopausal Status)

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Figure 8.0 (e): The Effect of Menopausal Status on Women's Anxiety

Me

an

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es Pre-menopausal(N=81)

Post-menopausal(N=63)

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Figure 8.0 (f): The Effect of Ethnicity on Women's Anxiety

Me

an s

core

s Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (1.901, 269.903) = 17.607; p<0.001 Interaction Effect: F (1.901, 269.903) = 0.802; ns Between Subjects Effect: F (1, 142) = 0.124; ns (8.0 e)

Time: F (1.942, 299.051) = 18.677; p<0.01 Interaction Effect: F (3.884, 299.051) = 1.187; ns Between Subjects Effect: F (2, 154) = 0.100; ns (8.0 f)

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Table 8.3 (f): Split Plot Repeated Measure ANOVA: The Effect of Ethnicity on the Psychological Aspect of the Women with Breast Cancer

Source of Variation ss df ms f sign

Anxiety Within Subjects Effect: Anxiety (Time) 325.206 1.942 167.469 18.677 p<0.01 Time x Ethnicity 41.339 3.884 10.644 1.187 ns Between Subjects Effect: 2.383 2 1.192 0.100 ns (Effects of Ethnicity)

Depression Within Subjects Effect: Depression (Time) 690.719 2 345.360 54.721 p<0.001 Time x Ethnicity 54.460 4 13.615 2.157 ns Between Subjects Effect: 14.781 2 7.391 0.513 ns (Effects of Ethnicity)

Similarly, all the independent factors did not influence the women’s depression:

types of surgery [F (1, 155) = 0.03; ns], stages of breast cancer [F (1, 142) = 0.11; ns],

menopausal status [F (1, 142) = 0.40; ns] and ethnicity [F (2, 154) = 0.51; ns] [Tables

8.3 (c), (d), (e), (f); Figures 8.0 (g), (h), (i), (j)].

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Figure 8.0 (g): The Effect of Types of Surgery on Women's Depression

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core

s

Mastectomy (N=124)

Lumpectomy (N=33)

Time: F (2, 310) = 49.199; p<0.001 Interaction Effect: F (2, 310) = 2.979; ns Between Subjects Effect: F (1, 155) = 0.027; ns (8.0 g)

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Figure 8.0 (h): The Effect of Breast Cancer Stages on Women's Depression

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Stage Two (N=89)

Stage Three (N=55)

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Figure 8.0 (i): The Effect of Menopausal Status on Women's Depression

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Pre-menopausal(N=81)

Post-menopausal(N=63)

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Figure 8.0 (j): The Effect of Ethnicity on Women's Depression

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an s

core

s

Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (2, 284) = 49.025; p<0.001 Interaction Effect: F (2, 284) = 0.149; ns Between Subjects Effect: F (1, 142) = 0.397; ns (8.0 i)

Time: F (2, 308) = 54.721; p<0.001 Interaction Effect: F (4,308) = 2.157; ns Between Subjects Effect: F (2, 154) = 0.513; ns (8.0 j)

Time: F (2, 284) = 50.608; p<0.001 Interaction Effect: F (2, 284) = 1.022; ns Between Subjects Effect: F (1, 142) = 0.114; ns (8.0 h)

283

Likewise, the husbands’ anxiety was not affected by all the independent factors:

types of surgery [F (1, 155) = 0.01; ns], stages of breast cancer [F (1, 142) = 0.32; ns],

menopausal status [F (1, 142) = 0.27; ns], and ethnicity [F (2, 154) = 1.07; ns] [Tables

8.3 (g), (h), (i), (j); Figures 8.0 (k), (l), (m), (n)].

Figures 8.3 (g): Split Plot Repeated Measure ANOVA: The Effect of the Types of Surgery on the Husbands’ Psychological Aspect

Source of Variation ss df ms f sign

Anxiety Within Subjects Effect: Anxiety (Time) 164.748 1.955 84.266 12.238 p<0.001 Time x Types of Surgery 40.986 1.955 20.964 3.045 ns Between Subjects Effect: 0.186 1 0.186 0.014 ns (Effect of Types of Surgery)

Depression Within Subjects Effect: Depression (Time) 196.488 1.953 100.616 16.537 p<0.001 Time x Types of Surgery 59.536 1.953 30.487 5.011 P<0.01 Between Subjects Effect: 3.483 1 3.483 0.238 ns (Effect of Types of Surgery)

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Figure 8.0 (k): The Effect of Types of Surgery on Husbands' Anxiety

Mea

n s

core

s

Mastectomy(N=124)

Lumpectomy(N=33)

Time: F (1.955, 303.038) = 12.238; p<0.001 Interaction Effect: F (1.955, 303.038) = 3.045; ns Between Subjects Effect: F (1, 155) = 0.014; ns (8.0 k)

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Table 8.3 (h): Split Plot Repeated Measure ANOVA: The Effects of the Breast Cancer Stages on the Husbands’ Psychological Aspect

Source of Variation ss df ms f sign

Anxiety Within Subjects Effect: Anxiety (Time) 118.618 1.931 61.442 8.866 p<0.001 Time x Breast Cancer Stages 2.174 1.931 1.126 0.162 ns Between Subjects Effect: (Effect of Breast Cancer Stages) 4.633 1 4.633 0.324 ns

Depression Within Subjects Effect: Depression (Time) 114.148 2 57.074 9.548 p<0.001 Time x Breast Cancer Stages 6.565 2 3.282 0.551 ns Between Subjects Effect: 18.716 1 18.716 1.274 ns (Effect of Breast Cancer Stages)

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Figure 8.0 (l): The Effect of Breast Cancer Stages on Husbands' Anxiety

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Stage Two (N=89)

Stage Three (N=55)

Time: F (1.931, 274.141) = 8.866; p<0.001 Interaction Effect: F (1.931, 274.141) = 0.162; ns Between Subjects Effect: F (1, 142) = 0.324; ns (8.0 l)

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Table 8.3 (i): Split Plot Repeated Measure ANOVA: The Effect of Menopausal Status on the Husbands’ Psychological Aspect

Source of Variation ss df ms f sign

Anxiety Within Subjects Effect: Anxiety (Time) 84.875 2 42.437 6.217 p<0.001 Time x Menopausal Status 3.792 2 1.896 0.278 ns Between Subjects Effect: 3.786 1 3.786 0.270 ns (Effect of Menopausal Status )

Depression Within Subjects Effect: Depression (Time) 93.113 2 46.556 7.921 p<0.001 Time x Menopausal Status 19.057 2 9.529 1.621 ns Between Subjects Effect: 0.783 1 0.783 0.051 ns (Effect of Menopausal Status)

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Figure 8.0 (m): The Effect of Menopausal Status on Husbands' Anxiety

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Pre-menopausal(N=81)

Post-menopausal(N=63)

Time: F (2,284) = 6.217; p<0.01 Interaction Effect: F (2, 284) = 0.278; ns Between Subjects Effect: F (1, 142) = 0.270; ns (8.0 m)

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Table 8.3 (j): Split Plot Repeated Measure ANOVA: The Effect of Ethnicity on the Husbands’ Psychological Aspect

Source of Variation ss df ms f sign

Anxiety Within Subjects Effect: Anxiety (Time) 106.888 1.963 54.442 7.828 p<0.01 Time x Ethnicity 24.623 3.927 6.271 0.902 ns Between Subjects Effect: 29.357 2 14.678 1.072 ns (Effect of Ethnicity)

Depression Within Subjects Effect: Depression (Time) 143.699 2 71.850 11.845 p<0.001 Time x Ethnicity 32.899 4 8.225 1.356 ns Between Subjects Effect: 0.185 2 0.092 0.006 ns (Effect of Ethnicity)

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Figure 8.0 (n): The Effect of Ethnicity on Husbands' Anxiety

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (1.963, 302.356) = 7.828; p<0.01 Interaction Effect: F (3.927, 302.356) = 0.902; ns Between Subjects Effect: F (2, 154) = 1.072; ns (8.0 n)

287

Parallel to anxiety, the husbands’ depression was also unaffected by the types of

surgery [F (1, 155) = 0.01; ns], stages of breast cancer [F (1, 142) = 1.27; ns],

menopausal status [F (1, 142) = 0.05; ns] and ethnicity [F (2, 154) = 0.01; ns] [Tables

8.3 (g), (h), (i), (j); Figures 8.0 (o), (p), (q), (r)].

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Figure 8.0 (o): The Effect of Types of Surgery on Husbands' Depression

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Mastectomy(N=124)

Lumpectomy(N=33)

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Figure 8.0 (p): The Effect of Breast Cancer Stages on Husbands' Depression

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Stage Two (N=89)

Stage Three (N=55)

Time: F (1.953, 310) = 16.537; p<0.001 Interaction Effect: F (1.950, 310) = 5.011; p<0.01 Between Subjects Effect: F (1, 155) = 0.238; ns (8.0 o)

Time: F (2, 284) = 9.584; p<0.001 Interaction Effect: F (2, 284) = 0.551; ns Between Subjects Effect: F (1, 142) = 1.274; ns (8.0 p)

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Figure 8.0 (q): The Effect of Menopausal Status on Husbands' Depression

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Pre-menopausal(N=81)

Post-menopausal(N=63)

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Figure 8.0 (r): The Effect of Ethnicity on Husbands' Depression

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

7.1.1.1 Summary of the Results

The hypotheses of the study which state that the treatment phases (prior-to,

during and post-chemotherapy) have a significant effect on couples’ psychological

aspect (anxiety and depression); and there are similarities in the patterns of this

psychological aspect between women with breast cancer and their husbands, are

confirmed. This is indicated by the finding that couples’ anxiety and depression

Time: F (2, 284) = 7.921; p<0.001 Interaction Effect: F (2, 284) = 1.621; ns Between Subjects Effect: F (1, 142) = 0.051; ns (8.0 –q)

Time: F (2,308) = 11.845; p<0.001 Interaction Effect: F (4,308) = 1.356; ns Between Subjects Effect: F (2, 154) = 0.006; ns (8.0 –r)

289

increased from prior-to to during chemotherapy, but declined at post-chemotherapy.

Further, the specific hypothesis which postulated that women with breast cancer

experience higher psychological problems (anxiety and depression) than their husbands

is also proven, whereby it was demonstrated that women with breast cancer

experienced more anxiety and depression as compared to their husbands.

Similarly, a separate analysis carried out at an individual level for women and

their husbands, also indicated the significant effect of time on their feelings of anxiety

and depression, which confirm the hypotheses that are proposed at an individual’s level

i.e. treatment phases (prior-to, during and post-chemotherapy) have different effect on

the psychological aspect (anxiety and depression) of the women with breast cancer and

their husbands. All the independent factors (types of surgery, stages of breast cancer,

menopausal status, and ethnicity) did not affect the couples’ anxiety and depression (as

well as of the individual women and their husbands), which is not in line to the

proposed hypotheses that the independent factors (types of surgery, stages of breast

cancer, menopausal status, and ethnicity) have significant effects on the psychological

aspects (anxiety and depression), either at the couple’s level or individual’s level.

290

8.1.2 The Satisfaction of the Couples’ Relationship

An analysis of Two-Way Repeated Measure ANOVA indicated that there was a

significant difference detected in the relationship satisfaction between the groups of

women and their husbands [F (1.00, 156.00) = 33.96; p<0.001] [Women’s level of

relationship satisfaction was higher prior-to (35.90±5.81), during (37.41±5.88) and

post-chemotherapy (35.78±4.06), as compared to the husbands’ level of satisfaction in

the relationship (prior-to=38.32±5.04; during=38.92±4.50 and post-

chemotherapy=37.34±3.90)] and over the time [F (1.91, 297.28) = 11.75; p<0.001]

[Women’s and their husbands’ levels of relationship satisfaction increased from prior-

to to during and declined at post-chemotherapy]. However, no significant interaction

effect was found between the groups and time [F (1.80, 280.55) = 1.63; ns] [Table 8.4

(a); Figure 8.1 (a)].

Table 8.4 (a): Two-way Repeated Measure ANOVA: The Relationship Satisfaction of the Couples with Breast Cancer

Source of Variation ss df ms f sign

Within Subjects Effect:

Couples with Breast Cancer (Groups) 788.794 1.000 788.794 33.962 p<0.001

Relationship Satisfaction (Time) 723.008 1.906 218.290 11.746 p<0.001

Groups x time

40.270 1.798 22.392 1.627 ns

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Figure 8.1 (a): Couples' Relationship Satisfaction

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Husbands

Types of surgery [F (1, 155) = 0.44; ns], stages of breast cancer [F (1, 142) =

0.39; ns] and menopausal status [F (1, 142) = 0.48; ns] did not affect the couples’ level

of relationship satisfaction, except for the ethnicity [F (2, 154) = 4.00; p<0.05] [Malay

women indicated the highest level of relationship satisfaction at prior-to (37.17±5.70)

and post-chemotherapy (36.20±3.64), followed by Chinese women (prior-

to=35.39±5.06; post-chemotherapy=35.59±3.97) and Indian women (prior-

to=33.57±6.57; post-chemotherapy=35.03±5.11). However, during chemotherapy,

Chinese women indicated the highest level of relationship satisfaction (38.57±5.11),

followed by Malay women (37.16±6.00) and Indian women (36.07±6.59). Meanwhile,

among husbands, Malay men indicated the highest level of relationship satisfaction at

all occasions: prior-to (39.07±5.44), during (39.34±3.94) and post-chemotherapy

(37.72±3.75), followed by Chinese men (prior-to=38.22±4.46; during=39.18±4.23 and

post-chemotherapy=37.29±3.60) and Indian men (prior-to=36.60±4.63;

during=37.40±5.93 and post-chemotherapy=36.47±4.67)] [Appendix D: Tables (a),

(b), (c), and (d)].

The analyses for the women and their husbands were carried out separately at

an individual level, to observe the pattern of relationship satisfaction over time, and

Groups: F (1.00, 156.00) = 33.96; p<0.001 Time: F (1.91, 297.27) = 11.75; p<0.001 Interaction Effect: F (1.80, 280.55) = 1.63; ns (8.1 a)

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the effect of independent factors (types of surgery, stages of breast cancer, menopausal

status and ethnicity) on their relationship satisfaction. The results gathered from the

One-way Repeated Measure ANOVA pointed out the significant effect of time on the

relationship satisfaction for both women [F (1.79, 279.65) = 6.94; p<0.01] [Women’s

relationship satisfaction rose from prior-to (35.90±5.81) to during (37.41±5.88) and

decreased at post-chemotherapy (35.78±4.06)] and their husbands [F (1.94, 303.23) =

8.64; p<0.001] [Husbands’ relationship satisfaction slightly increased from prior-to

(38.32±5.04) to during (38.92±4.50) and declined at post-chemotherapy (37.34±3.90)]

[Table 8.4 (b); Figure 8.1 (b)].

Table 8.4 (b): One-way Repeated Measure ANOVA: The Relationship Satisfaction of the Women with Breast Cancer and their Husbands

Source of Variation ss df ms f sign Relationship Satisfaction (Women)

258.242

1.793

144.059

6.936

p<0.01

Relationship Satisfaction (Husbands) 197.992 1.944 101.860 8.636 p<0.001

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Figure 8.1 (b): Women and Husbands' Relationship Satisfaction

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Pre-chemotherapy

During Chemotherapy

Post-chemotherapy

F (1.79, 279.65) = 6.94; p<0.01 F (1.94, 303.23) = 8.64; p<0.001

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However, the results gathered from the Split Plot Repeated Measure ANOVA

revealed the non-significant effects of all the independent factors on these women’s

relationship satisfaction: types of surgery [F (1, 155) = 0.59; ns], stages of breast cancer

[F (1, 142) = 0.42; ns], menopausal status [F (1, 142) = 1.44; ns] and ethnicity [F (2,

154) = 2.70; ns] [Table 8.4 (c); Figures 8.1 (c), (d), (e), (f)].

Table 8.4 (c): Split Plot Repeated Measure ANOVA: The Effect of Type of Surgery, Breast Cancer Stages, Menopausal Status and Ethnicity on the Relationship

Satisfaction of the Women with Breast Cancer Source of Variation ss df ms f sign

Types of Surgery Within Subjects Effect: Relationship Satisfaction (Time) 398.122 1.827 212.946 10.735 p<0.001 Time x Types of Surgery 190.056 1.827 104.008 5.243 p<0.01 Between Subjects Effect: 28.320 1 28.320 0.594 ns (Effect of Types of Surgery)

Breast Cancer Stages Within Subjects Effects: Relationship Satisfaction (Time) 164.003 1.826 89.824 89.824 p<0.05 Time x Breast Cancer Stages 16.253 1.826 8.902 0.442 ns Between Subjects Effect: 19.558 1 19.558 0.420 ns (Effect of Breast Cancer Stages )

Menopausal Status Within Subjects Effect: Relationship Satisfaction (Time) 151.633 1.827 83.001 4.211 p<0.05 Time x Menopausal Status 43.420 1.827 23.767 1.206 ns

Between Subjects Effects: 14.956 1 14.956 0.311 ns (Effect of Menopausal Status )

Ethnicity Within Subjects Effect: Relationship Satisfaction (Time) 288.915 1.830 157.884 7.943 p<0.01 Time x Ethnicity 207.031 3.660 56.568 2.846 p<0.05

Between Subjects Effect: 251.503 2 251.503 2.701 ns (Effect of Ethnicity)

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Figure 8.1 (c): The Effect of Types of Surgery on Women's Relationship

Satisfaction

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Mastectomy (N=124)

Lumpectomy (N=33)

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Figure 8.1 (d): The Effect of Breast Cancer Stages on Women's Relationship Satisfaction

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Stage Two (N=89)

Stage Three (N=55)

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Figure 8.1 (e): The Effect of Menopausal Status on Women's

Relationship Satisfaction

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Pre-menopausal (N=81)

Post-menopausal (N=63)

Time: F (1.827, 283.236) = 10.735; p<0.001 Interaction Effect: F (1.827, 283.236) = 5.243; p<0.01 Between Subjects Effect: F (1, 155) = 0.594; ns (8.1 -c)

Time: F (1.826, 259.267) = 89.824; p<0.05 Interaction Effect: F (1.826, 259.267) = 0.442; ns Between Subjects Effect: F (1, 142) = 0.420; ns (8.1-d)

Time: F (1.827, 259.418) = 4.211; p<0.05 Interaction Effect: F (1.827, 259.418) = 1.206; ns Between Subjects Effect: F (1, 142) = 0.311; ns (8.1-e)

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Figure 8.1 (f): The Effect of Ethnicity on Women's Relationship Satisfaction

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Malay (N=76)Chinese (N=51)Indian (N=30)

Likewise, the husbands’ relationship satisfaction was not influenced by the

types of surgery [F (1, 155) = 0.12; ns], stages of breast cancer [F (1, 142) = 0.17; ns]

and menopausal status [F (1, 142) = 0.41; ns]. On the contrary, the ethnicity factor

indicated a significant effect on the husbands’ relationship satisfaction [F (2, 154) =

3.14; p<0.05] [Among the patients’ husbands, Malay men indicated the highest level of

relationship satisfaction in all occasions: prior-to (39.07±5.44), during (39.34±3.94)

and post-chemotherapy (37.72±3.75), followed by Chinese (prior-to=38.22±4.46;

during=39.18±4.23 and post-chemotherapy=37.29±3.60) and Indian (prior-

to=36.60±4.63; during=37.40±5.93 and post-chemotherapy=36.47±4.67)] [Table 8.4

(d); Figures 8.1 (g), (h), (i), (j)].

Time: F (1.830, 281.808) = 7.943; p<0.01 Interaction Effect: F (3.660, 281.808) = 2.846; p<0.05 Between Subjects Effect: F (2, 154) = 2.701; ns (8.1-f)

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Table 8.4 (d): Split Plot Repeated Measure ANOVA: The Effect of Types of Surgery, Breast Cancer Stages, Menopausal Status and Ethnicity on the Relationship

Satisfaction of the Husbands.

Source of Variation ss df ms f sign Types of Surgery

Within Subjects Effect: Relationship satisfaction (Time) 90.842 1.953 46.507 3.952 p<0.05 Time x Types of Surgery 13.577 1.953 6.951 0.591 ns Between subjects effect: 4.555 1 4.555 0.119 ns (Effect of Types of Surgery )

Breast Cancer Stages Within subjects effect: Relationship satisfaction (Time) 186.126 1.935 96.167 8.350 p<0.001

Time x Breast Cancer Stages 30.459 1.935 15.738 1.366 ns Between subjects effect: 6.425 1 6.425 0.165 ns (Effect of Breast Cancer Stages )

Menopausal Status Within subjects effect: Relationship satisfaction (Time) 145.004 1.946 74.533 6.263 p<0.01 Time x Menopausal Status 26.393 1.946 13.566 1.140 ns

Between subjects effect: 16.445 1 16.445 0.411 ns (Effect of Menopausal Status )

Ethnicity Within subjects effect: Relationship satisfaction (Time) 149.053 1.968 75.731 6.457 p<0.01 Time x Ethnicity 21.584 3.936 5.483 0.467 ns

Between subjects effect: 230.375 2 115.19 3.115 p<0.05 (Effect of Ethnicity)

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DuringChemotherapy

PostChemotherapy

Figure 8.1 (g): The Effect of Types of Surgery on Husbands' Relationship

Satisfaction

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Mastectomy (N=124)

Lumpectomy (N=33)

Time: F (1.953, 302.763) = 3.952; p<0.05 Interaction Effect: F (1.953, 302.763) = 0.591; ns Between Subjects Effect: F (1, 155) = 0.119; ns (7.1-g)

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Figure 8.1 (h): The Effect of Breast Cancer Stages on Husbands' Relationship

Satisfaction

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Stage Two (N=89)Stage Three (N=55)

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DuringChemotherapy

PostChemotherapy

Figure 8.1 (i): The Effect of Menopausal Status on Husbands'

Relationship Satisfaction

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Pre-menopausal(N=81)

Post-menopausal(N=63)

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Figure 8.1 (j): The Effect of Ethnicity on Husbands' Relationship Satisfaction

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Malay (N=76)Chinese (N=51)Indian (N=30)

Time: F (1.935, 274.832) = 8.350; p<0.001 Interaction Effect: F (1.935, 274.832) = 1.366; ns Between Subjects Effect: F (1, 142) = 0.165; ns (8.1-h)

Time: F (1.946, 276.261) = 6.263; p<0.01 Interaction Effect: F (1.946, 276.261) = 1.140; ns Between Subjects Effect: F (1, 142) = 0.411; ns (8.1-i)

Time: F (1.968, 293.648) = 6.457; p<0.01 Interaction Effect: F (3.936, 293.648) = 0.467; ns Within Subjects Effect: F (2, 154) = 3.115; p<0.05 (8.1-j)

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8.1.2.1 Summary of the Results

The main effect of time was observed for the couples’ relationship satisfaction,

whereby the level of relationship satisfaction was higher during chemotherapy as

compared to prior-to and post-chemotherapy. This finding proves the study’s

hypotheses that the treatment phases (prior-to, during and post-chemotherapy) have

different effect on couples’ relationship satisfaction, whereby the overtime patterns of

the relationship satisfaction is similar between the women and their husbands. The

significant difference in the relationship satisfaction between these women and their

husbands was also observed; for this, the level of relationship satisfaction was higher

among the women as compared to their husbands. This is parallel to the study’s

specific hypothesis which suggests that women with breast cancer indicate higher

relationship satisfaction compared to their husbands.

Similarly, when the analysis was done at an individual level, the result was

maintained, indicating that the women with breast cancer and their husbands showed

the significant effect of time which confirms the other two hypotheses i.e. treatment

phases (prior-to, during and post-chemotherapy) have different effects on the

relationship satisfaction of the women with breast cancer and their husbands. The

results relating to study’s hypotheses which states that medical (types of surgery and

breast cancer stages) and bio/socio-demographic factor have significant effect on the

relationship satisfaction, at both the couple’s level and individual level, were not

significant with one exception. Almost a similar finding was obtained at the individual

level, where all the independent factors were found to be failed to influence the

satisfaction of the women in their relationship. Likewise, with the exception of

ethnicity, all the independent factors also failed to influence the husbands’ relationship

satisfaction.

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8.1.3 The Couples’ Coping Strategies

The analysis of the Two-way Repeated Measure ANOVA indicated a

significant effect in the Active coping strategy between the women and their husbands

[F (1, 156) = 184.13; p<0.001] [Women used more of the Active Coping strategy, prior-

to (5.61±1.55), during (7.10±1.20) and post-chemotherapy (4.97±1.40), as compared to

their husbands (prior-to=4.29±1.29; during=5.45±1.40; post-

chemotherapy=4.84±1.27)], the significant effect of time [F (2, 312) = 117.74;

p<0.001] [Both women and their husbands used more of the Active Coping Strategy

during chemotherapy, as compared to prior-to and post-chemotherapy], and the

significant interaction effects between the groups and time [F (1.95, 304.09) = 34.57;

p<0.001] [Table 8.5 (a); Figure 8.2.0 (a)].

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Figure 8.2.0 (a): Couples' Coping Strategy (Active Coping)

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Women Husbands

Significant effects were also retrieved for the Planning strategy used by these women

and their husbands [F (1.00, 156.00) = 44.68; p<0.001] [Women used more of the

Planning strategy prior-to (5.48±1.68), during (6.13±1.57) and post-chemotherapy

(6.17±1.57), as compared to their husbands (prior-to=4.74±1.40; during=5.74±1.40;

Groups: F (1, 156) = 184.13; p<0.001 Time: F (2, 312) = 117.74; p<0.001 Interaction Effect: F (1.95, 304.09) = 34.57; p<0.001 (8.2.0 a)

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Table 8.5 (a): Two-way Repeated Measure ANOVA: The Coping Strategies Used by the Couples with Breast Cancer

Sources of Variation ss df ms f sign

Active coping Within Subjects Effect: Couples with Breast Cancer (Groups)

300.450 1 300.450 184.130 p<0.001

Active Coping (Time) 427.684 2 213.842 117.742 p<0.001 Groups x Time

64.754 1.949 33.219 34.565 p<0.001

Planning Within Subjects Effect: Couples with Breast Cancer (Groups)

158.990 1.000 158.990 44.675 p<0.001

Planning (Time) 106.907 1.091 97.949 79.255 p<0.001 Groups x Time

34.631 1.103 31.400 24.930 P<0.001

Positive Reframing Within Subjects Effect: Couples with Breast Cancer (Groups)

34.014 1.000 34.014 10.072 p<0.01

Positive Reframing (Time) 149.293 1.721 86.731 54.967 p<0.001 Groups x Time 32.575 1.781 18.289 12.545 p<0.001

Acceptance Within Subjects Effect: Couples with Breast Cancer (Groups)

21.708 1.000 21.708 12.537 p<0.01

Acceptance (Time) 15.174 1.513 10.030 4.372 p<0.05 Groups x time 44.333 1.935 22.907 20.441 p<0.001

Using Emotional Support Within Subjects Effect: Couples with Breast Cancer (Groups)

18.497 1 18.497 8.079 p<0.01

Using Emotional Support (Time) 84.448 1.926 43.843 18.428 p<0.001 Groups x Time 17.051 2 8.525 5.493 P<0.01

Using Instrumental Support Within Subjects Effect: Couples with Breast Cancer (Groups)

12.382 1 12.382 4.293 p<0.05

Using Instrumental Support (Time)

108.257 2 54.128 24.943 p<0.001

Groups x Time

24.669 1.794 13.747 7.289 p<0.01

Self-distraction Within Subjects Effect: Couples with Breast Cancer (Groups)

10.616 1 10.616 3.142 ns

Self-distraction (Time) 101.318 1.635 61.984 31.360 p<0.001 Groups x Time 23.467 1.855 12.648 10.117 p<0.001

Table 8.5 (a), Continued

301

ss df ms f sign Denial

Within Subjects Effect: Couples with Breast Cancer (Groups)

593.953 1 593.953 177.942 p<0.001

Denial (Time) 293.059 1.138 257.589 392.062 p<0.001 Groups x Time

307.658 1.134 271.393 404.421 p<0.001

Venting Within Subjects Effect: Couples with Breast Cancer (Groups)

233.504 1 233.504 55.276 p<0.001

Venting (Time) 206.682 2 103.341 181.833 p<0.001 Groups x Time

231.505 2 115.753 191.596 p<0.001

Behavioural Disengagement Within Subjects Effect: Couples with Breast Cancer (Groups)

404.128 1.000 404.128 160.130 p<0.001

Behavioural Disengagement (Time)

0.059 1.080 0.055 0.142 ns

Groups x Time

0.161 1.076 0.150 0.378 ns

Self-blame Within Subjects Effect: Couples with Breast Cancer (Groups)

189.946 1 189.946 63.877 p<0.001

Self-blame (Time) 0.688 1.588 0.433 6.716 p<0.01 Groups x Time 1.248 1.613 0.774 12.631 p<0.001

Problem-focused Strategy Within Subjects Effect: Couples with Breast Cancer (Groups)

548.791 1 548.791 32.436 p<0.001

Problem-focused Strategy (Time) 155.025 1.878 82.538 8.520 p<0.001 Groups x Time 71.938 1.767 40.722 6.039 p<0.01

Emotion-focused Strategy Within Subjects Effect: Couples with Breast Cancer (Groups)

4246.285 1 4246.285 213.222 p<0.001

Emotion-focused Strategy (Time) 112.996 2 56.498 3.524 p<0.05 Groups x Time

564.626 2 282.313 34.375 P<0.001

Note: The domains of Humour and Substance Use of Brief COPE were excluded from the analysis as the assumptions for the parametric test were not met

302

post-chemotherapy=4.84±1.27)]; the significant effect of time [F (1.09, 170.26) =

79.26; p<0.001] [Both women and their husbands used more of the Planning strategy

during chemotherapy, as compared to prior-to and post-chemotherapy] and the

interaction effect between the groups and time [F (1.10, 170.26) = 24.93; p<0.001)]

[Table 8.5 (a); Figure 8.2.0 (b)].

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Figure 8.2.0 (b): Couples' Coping Strategy (Planning)

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Similarly, Positive Reframing strategy indicated a significant difference between the

women and their husbands [F (1.00, 156.00) = 10.07; p<0.01] [Women used less

Positive Reframing strategy prior-to (5.03±1.31), but more of this strategy during

(6.43±1.39) and post-chemotherapy (5.93±1.65), as compared to their husbands (prior-

to=5.10±1.36; during=5.59±1.56; post-chemotherapy=5.56±1.55)], significant effect

of time [F (1.72, 268.53) = 54.97; p<0.001] [Both women and husbands used more

Positive Reframing Strategy during chemotherapy as compared to prior-to and post-

chemotherapy], and the interaction effect between the groups and time [F (1.78,

277.85) = 12.55; p<0.001] [Table 8.5 (a); Figure 8.2.0 (c)].

Groups: F (1.00, 156.00) = 44.68; p<0.001 Time: F (1.09, 170.27) = 79.26; p<0.001 Interaction Effect: F (1.10, 170.26) = 24.93; p<0.001 (8.2.0 b)

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PostChemotherapy

Figure 8.2.0 (c): Couples' Coping Strategy (Positive Reframing)

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Likewise, there was a significant effect of the Acceptance strategy on the women and

their husbands [F (1.00, 156.00) = 12.54; p<0.01] [Women were found to use less

Acceptance Strategy prior-to (6.43±1.48) and during (6.43±1.49), but more post-

chemotherapy (7.16±1.29) as compared to their husbands (prior=6.43±1.48;

during=6.44±1.51; post-chemotherapy=6.24±1.49], overtime effect [F (1.51, 236.00) =

4.37; p<0.05] [Women employed more Acceptance strategy post-chemotherapy as

compared to prior-to and during chemotherapy. However, their husbands were found

to use more Acceptance Strategy during chemotherapy, as compared to prior-to and

post-chemotherapy] and the interaction effect between the groups and time [F (1.94,

301.92) = 20.44; p<0.001] [Table 8.5 (a); Figure 8.2.0 (d)]. The Emotional Support

strategy was also showed to impose a significant effect on the women and their

husbands [F (1, 156) = 8.08; p<0.01] [Women used more Emotional Support during

(6.03±1.73) and post-chemotherapy (5.08±1.39) as compared to their husbands

(during=5.39±1.33; post-chemotherapy=4.88±1.88). However, couples were indicated

as having the same level of use for this particular strategy prior to chemotherapy

(women=5.31±1.43; husbands=5.31±1.44)], significant effect of time [F (1.93, 300.48)

= 18.43; p<0.001] [Women and husbands used more Emotional Support during

chemotherapy as compared to prior-to and post-chemotherapy] and the interaction

Groups: F (1.00, 156.00) = 10.07; p<0.01 Time: F (1.72, 268.53) = 54.97; p<0.001 Interaction Effect: F (1.78, 277.85) = 12.55; p<0.001 (8.2.0 c)

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between the groups and time [F (2, 312) = 5.49; p<0.01] [Table 8.5 (a); Figure 8.2.0

(e)].

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DuringChemotherapy

PostChemotherapy

Figure 8.2.0 (d): Couples' Coping Strategies (Acceptance)

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Figure 8.2.0 (e): Couples' Coping Strategy (Using Emotional Support)

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A similar analysis revealed the significant effect of the Instrumental Support strategy

on women with breast cancer and their husbands [F (1, 156) = 4.29; p<0.05] [Women

used more Instrumental Support during (6.38±1.60) and post-chemotherapy

(5.31±1.47) but less prior-to chemotherapy (5.52±1.68) as compared to their husbands

(prior-to=5.65±1.41; during=5.73±1.48; post-chemotherapy=5.15±1.74)], significant

time effect [F (2, 312) = 24.94; p<0.001] [Both women and husbands made use of more

Groups: F (1.00, 156.00) = 12.54; p<0.01 Time: F (1.51, 236.00) = 4.37; p<0.05 Interaction Effect: F (1.94, 301.92) = 20.44; p<0.001 (8.2.0 d)

Groups: F (1, 156) = 8.98; p<0.01 Time: F (1.93, 300.48) = 18.43; p<0.001 Interaction Effect: F (2, 312) = 5.49; p<0.01 (8.2.0 e)

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Instrumental Support during chemotherapy as compared to prior-to and post-chemotherapy]

and the significant interaction effect between the groups and time [F (1.79, 279.93) =

7.29; p<0.01] [Table 8.5 (a); Figure 8.2.0 (f)].

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Figure 8.2.0 (f): Couples' Coping Strategy (Using Instrumental Support)

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Similarly, a significant difference was found between the women participating in this

study and the husbands in terms of their use of Denial strategy [F (1, 156) = 177.94;

p<0.001] [Women used more Denial strategy prior-to (5.67±1.45), during (5.62±1.50)

and post-chemotherapy (5.67±1.46) as compared to their husbands (prior-

to=4.85±1.27; during=4.87±1.31; post-chemotherapy=2.47±1.14)], significant time

effect [F (1.14, 117.48) = 392.06; p<0.001] [Women’s Denial Strategy declined from

prior-to to during chemotherapy and increased post-chemotherapy as compared to the

husbands, where the use of this particular strategy was found to decline from prior-to

to during to post-chemotherapy] and the significant interaction between the groups and

time [F (1.134, 176.85) = 404.42; p<0.001] [Table 8.5 (a); Figure 8.2.0 (g)].

Groups: F (1, 156) = 4.29; p<0.05 Time: F (2, 312) = 24.94; p<0.001 Interaction Effect: F (1.79, 279.93) = 7.29; p<0.01 (8.2.0 f)

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PostChemotherapy

Figure 8.2.0 (g): Couples' Coping Strategy (Denial)

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A significant effect was also demonstrated for the Venting strategy on women and their

husbands [F (1, 156) = 55.276; p<0.001] [Women used more Venting strategy prior-to

(5.65±1.54), during (5.76±1.57) and post-chemotherapy (5.78±1.58) as compared to

their husbands (prior=5.27±1.27; during=5.55±1.34; post-chemotherapy=3.38±1.52)],

significant effect of time [F (2, 312) = 181.83; p<0.001] [Women’s use of Venting

strategy increased from prior-to to during and post-chemotherapy. However, the

husbands’ use of Venting strategy was found to increase from prior-to to during

chemotherapy, but it declined at post-chemotherapy] and the significant interaction

between the groups and time [F (2, 312) = 191.60; p<0.001] [Table 8.5 (a); Figure 8.2.0

(h)].

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Figure 8.2.0 (h): Couples' Coping Strategy (Venting)

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Groups: F (1, 156) = 177.94; p<0.001 Time: F (1.14, 177.48) = 392.06; p<0.001 Interaction Effect: F (1.134, 176.85) = 404.42; p<0.001 (8.2.0 g)

Groups: F (1, 156) = 55.28; p<0.001 Time: F (2, 312) = 181.83; p<0.001 Interaction Effect: F (2, 312) = 191.60; p<0.001 (8.2.0 h)

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Both these women and their husbands showed a significant effect from their use of

Self-blame strategy [F (1, 156) = 63.88; p<0.001] [Women used more of Self-blame

strategy prior-to (5.07±1.25), during (5.20±1.43) and post-chemotherapy (5.21±1.45)

as compared to their husbands (prior=4.27±0.77; during=4.26±0.79; post-

chemotherapy=4.25±0.75)], significant effect of time [F (1.59, 247.70) = 6.72;

p<0.001] [Women’s Self-blame strategy increased from prior-to, during and post-

chemotherapy. Nevertheless, husbands indicated a similar level of use for this

particular strategy at prior-to, during and post-chemotherapy], and the significant

interaction between the groups and time [F (1.61, 251.62) = 12.63; p<0.001] [Table 8.5

(a); Figure 8.2.0 (i)].

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Figure 8.2.0 (i): Couples' Coping Strategy (Self-blame)

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In this study, the Emotion-focused Strategy also exhibited a significant effect on the

women with breast cancer and their husbands [F (1, 156) = 213.22; p<0.001] [Women

used more of Emotion-focused strategy prior-to (28.98±4.87), during (28.90±4.39) and

post-chemotherapy (30.16±4.07), as compared to husbands (prior=26.59±4.20;

during=25.74±4.92; post-chemotherapy=23.97±4.35)], time effect [F (2, 312) = 3.52;

p<0.05] [Women’s Emotion-focused strategy declined from prior-to to during, but

increased at post-chemotherapy. On the contrary, their husbands showed a declining

Groups: F (1, 156) = 63.89; p<0.001 Time: F (1.59, 247.70) = 6.72; p<0.01 Interaction Effect: F (1.61, 251.62) = 12.63; p<0.001 (8.2.0 i)

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pattern from prior-to to during and post-chemotherapy] and the interaction between the

groups and time [F (2, 312) = 34.38; p<0.001] [Table 8.5 (a); Figure 8.2.0 (j)].

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Figure 8.2.0 (j): Couples' Coping Strategy (Emotion-focused Strategy)

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In the case of Problem-focused strategies, a main effect on the women with breast

cancer and their husbands was also observed [F (1, 156) = 32.44; p<0.001] [Women

used more Problem-focused Strategy prior-to (16.61±4.03), during (16.79±4.77) and

post-chemotherapy (16.44±3.17), as compared to their husbands (prior-

to=14.68±3.16; during=16.04±3.93; post-chemotherapy=14.54±2.99)]. A similar

result was also yielded on the effect of overtime [F (1.88, 293.01) = 8.52; p<0.001]

[Both women’s and husbands’ use of Problem-focused Strategy indicated an increment

from prior-to to during, but this declined at post-chemotherapy] and the interaction

between the groups and time [F (1.77, 275.59) = 6.04; p<0.001] [Table 8.5 (a); Figure

8.2.0 (k)].

Groups: F (1, 156) = 213.22; p<0.001 Time: F (2, 312) = 3.52; p<0.05 Interaction Effect: F (2, 312) = 34.38; p<0.001 (8.2.0 j)

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PostChemotherapy

Figure 8.2.0 (k): Couples' Coping Strategy (Problem-focused Strategy)

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However, no significant effect was gathered for the use of Self-distraction strategy on

these women and their husbands [F (1, 156) = 3.14; ns]. This was different for the

effect of time [F (1.64, 255.00) = 32.36; p<0.001] [Women and husbands used more

Self-distraction strategy during chemotherapy (women=5.83±1.66;

husbands=6.02±1.47), as compared to prior-to (women=5.46±1.62;

husbands=5.21±1.38) and post-chemotherapy

women=5.45±1.63;husbands=4.87±1.47)] and the interaction effect between the

groups and time [F (1.86, 289.45) = 10.18; p<0.001] [Table 8.5 (a); Figure 8.2.0 (l)],

whereby important effects were detected for both.

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Figure 8.2.0 (l): Couples' Coping Strategy (Self-distraction)

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Groups: F (1, 156) = 32.44; p<0.001 Time: F (1.88, 293.01) = 8.52; p<0.001 Interaction Effect: F (1.77, 275.59) = 6.04; p<0.001 (8.3.0 k)

Groups: F (1, 156) = 3.14; ns Time: F (1.64, 255) = 31.36; p<0.001 Interaction Effect: F (1.86, 289.45) = 10.18; p<0.001 (8.2.0 l)

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A different result was also obtained for the Behavioural Disengagement strategy, i.e. it

imposed a significant effect on the women and their husbands [F (1.00, 156.00) =

160.13; p<0.001)] [Women used more Behavioural Disengagement strategy prior-to

(4.65±1.14), during (4.65±1.17) and post-chemotherapy (4.66±1.19), as compared to

their husbands (prior-to=3.37±0.98; during=3.34±0.85; post-

chemotherapy=3.32±0.80)]. However, no significant effect of time [F (1.08, 168.43)

=0.14; ns] and the interaction effect between the groups and time [F (1.08, 167.92) =

0.39; ns] was observed [Table 8.5 (a); Figure 8.2.0 (m)].

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PostChemotherapy

Figure 8.2.0 (m): Couples' Coping Strategy (Behavioral Disengagement)

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The results gathered for Between Subjects Effect from the analysis of Three

Factor Mixed ANOVA (two within subjects factors and one between subjects factors)

indicated that the types of surgery was not important for all types of couples’ coping

strategies: Active Coping [F (1, 155) = 1.69; ns], Planning [F (1, 155) = 2.37; ns],

Positive Reframing [F (1, 155) = 3.21; ns], Acceptance [F (1, 155) = 0.99; ns], Using

Emotional Support [F (1, 155) = 1.90; ns], Using Instrumental Support [F (1, 155) =

1.95; ns], Self-distraction [F (1, 155) = 0.14; ns], Denial [F (1, 155) = 0.00; ns],

Groups: F (1.00, 156.00) = 160.13; p<0.001 Time: F (1.08, 168.43) = 0.14; ns Interaction Effect: F (1.08, 167.92) = 0.39; ns (8.2.0 m)

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Venting [F (1, 155) = 1.10; ns], Behavioural Disengagement [F (1, 155) = 0.18; ns],

Self-blame [F (1, 155) = 0.76; ns], Problem-focused Strategies [F (1, 155) = 2.41; ns]

and Emotion-focused Strategies [F (1, 155) = 1.81; ns] [Appendix D: Table 3 (a)].

Similarly, the same analysis failed to yield any significant effects of the breast

cancer stages on the couples’ coping strategies: Active Coping [F (1, 142) = 0.09; ns],

Planning [F (1, 142) = 1.09; ns], Positive Reframing [F (1, 142) = 0.22; ns], Acceptance

[F (1, 142) = 0.16; ns], Using Emotional Support [F (1, 142) = 2.50; ns], Using

Instrumental Support [F (1, 142) = 0.93; ns], Self-distraction [F (1, 142) = 0.44; ns],

Denial [F (1, 142) = 0.81; ns], Venting [F (1, 142) = 0.37; ns], Behavioural

Disengagement [F (1, 142) = 0.01; ns], Self-blame [F (1, 142) = 0.34; ns], Problem-

focused Strategies [F (1, 142) = 0.06; ns] and Emotion-focused Strategies [F (1, 142) =

0.38; ns] [Appendix D: Table 3.0 (b)].

Nonetheless, the menopausal status of the women was found to have a major

impact on the coping strategies of the couples, such as Planning [F (1, 142) = 17.13;

p<0.001] [Pre-menopausal women (prior-to=5.73±1.63; during=6.40±1.42; post-

chemotherapy=6.46±1.42) and their husbands (prior-to=5.02±1.41;

during=6.02±1.41; post-chemotherapy=5.12±1.25) were indicated to use more of the

Planning strategy, as compared to post-menopausal women (prior-to=5.24±1.78;

during=5.68±1.70; post-chemotherapy=5.68±1.69) and their husbands (prior-

to=4.25±1.26; during=5.25±1.26; post-chemotherapy=4.37±1.17)], Using Emotional

Support [F (1, 142) = 11.65; p<0.01] [Pre-menopausal women (prior-to=5.36±1.43;

during=6.35±1.67; post-chemotherapy=5.35±1.45) and their husbands (prior-

to=5.47±1.49; during=5.63±1.27; post-chemotherapy=5.09±1.89) employed more

Emotional Support as compared to post-menopausal women (prior-to=5.35±1.38;

during=5.52±1.79; post-chemotherapy=4.79±1.31) and their husbands (prior-

to=5.10±1.39; during=5.02±1.36; post-chemotherapy=4.57±1.79)], Using

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Instrumental Support [F (1, 142) = 10.225; p<0.01] [Pre-menopausal women (prior-

to=5.72±1.68; during=6.52±1.59; post-chemotherapy=5.48±1.57) and their husbands

(prior-to=5.75±1.46; during=5.98±1.33; post-chemotherapy=5.41±1.72) were

indicated as using more of the Instrumental Support as compared to post-menopausal

women (prior-to=5.29±1.74; during=6.06±1.65; post-chemotherapy=5.13±1.44) and

their husbands (prior-to=5.56±1.37; during=5.33±1.60; post-

chemotherapy=4.83±1.73)], Self-distraction [F (1, 142) = 13.67; p<0.001] [Pre-

menopausal women (prior-to=5.65±1.47; during=5.99±1.76; post-

chemotherapy=5.65±1.47) and their husbands (prior-to=5.30±1.33;

during=6.16±1.44; post-chemotherapy=5.25±1.46) indicated that they used more of

the Self-distraction strategy as compared to post-menopausal women (prior-

to=5.11±1.70; during=5.57±1.56; post-chemotherapy=5.08±1.71) and their husbands

(prior-to=5.06±1.47; during=5.65±1.46; post-chemotherapy=4.19±1.20)], Denial [F

(1, 142) = 20.76; p<0.001] [Pre-menopausal women (prior-to=6.00±1.47;

during=5.93±1.53; post-chemotherapy=6.02±1.49) and their husbands (prior-

to=5.11±1.40; during=5.16±1.46; post-chemotherapy=2.69±1.44) revealed that they

used more of the Denial strategy as compared to post-menopausal women (prior-

to=5.08±1.21; during=5.03±1.26; post-chemotherapy=5.05±1.18) and their husbands

(prior-to=4.56±1.06; during=4.56±1.06; post-chemotherapy=2.21±0.60)], Venting [F

(1, 142) = 13.721; p<0.001] [Pre-menopausal women (prior-to=5.99±1.52;

during=6.11±1.53; post-chemotherapy=6.14±1.55) and their husbands (prior-

to=5.51±1.28; during=5.70±1.42; post-chemotherapy=3.68±1.69) also indicated to

use more Venting strategy as compared to post-menopausal women (prior-

to=5.27±1.52; during=5.38±1.61; post-chemotherapy=5.38±1.61) and their husbands

(prior-to=5.08±1.20; during=5.30±1.28; post-chemotherapy=2.90±1.15)], Self-blame

[F (1, 142) = 6.06; p<0.05] [Pre-menopausal women (prior-to=5.28±1.33;

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during=5.43±1.52; post-chemotherapy=5.46±1.54) and their husbands

(prior=4.31±0.81; during=4.28±0.87; post-chemotherapy=4.31±0.83) were shown to

employ more Self-blame strategy as compared to post-menopausal women (prior-

to=4.78±1.17; during=4.87±1.34; post-chemotherapy=4.87±1.34) and their husbands

(prior-to=4.17±0.55; during=4.17±0.55; post-chemotherapy=4.11±0.44)], Problem-

focused Strategy [F (1, 142) = 25.11; p<0.001] [Pre-menopausal women (prior-

to=17.31±3.85; during=17.46±4.61; post-chemotherapy=17.33±3.27) and their

husbands (prior-to=15.36±3.10; during=17.07±3.51; post-chemotherapy=15.32±2.94)

were also found to use more Problem-focused Strategy than post-menopausal women

(prior-to=15.87±4.18; during=15.57±4.90; post-chemotherapy=15.29±2.93) and their

husbands (prior-to=13.60±3.12; during=14.37±3.84; post-

chemotherapy=13.43±2.87)], Emotion-focused Strategy [F (1, 142) = 19.92; p<0.001]

[Pre-menopausal women (prior-to=29.86±4.65; during=30.46±4.20; post-

chemotherapy=30.93±4.27) and their husbands (prior-to=27.63±3.81;

during=26.99±4.41; post-chemotherapy=25.23±4.61) were indicated to be using more

of Emotion-focused Strategy as compared to post-menopausal women (prior-

to=28±13; during=29.10; post-chemotherapy=29.37) and their husbands (prior-

to=25.46±4.32; during=24.14±5.13; post-chemotherapy=22.52±3.62)]. However, no

significant effects of these women’s menopausal status were found on Active Coping

[F (1, 142) = 17.14; ns], Positive Reframing [F (1, 142) = 17.98; ns], Acceptance [F (1,

142) = 0.22; ns] and Behavioural Disengagement [F (1, 142) = 0.95; ns] [Appendix D:

Table 3.0 (c)].

In terms of ethnicity, a significant effect was found on the couples’ coping

strategies, such as Active coping [F (2, 154) = 6.91; p<0.01] [Indian women used more

Active coping strategy prior to chemotherapy (5.97±1.50) followed by Malays

(5.87±1.42) and Chinese (5.00±1.61). However, Malay women indicated of using more

314

of the Active strategy during (7.30±1.08) and post-chemotherapy (5.22±1.37), followed

by Indians (during=7.27±1.11; post-chemotherapy=4.93±1.53) and Chinese

(during=6.71±1.33; post-chemotherapy=4.61±1.31). On the other hand, Malay

husbands used more of the Active strategy, prior to chemotherapy (4.50±1.20) as

compared to Indian (4.37±1.38) and Chinese husbands (3.92±1.16). During

chemotherapy, Malay (5.67±1.56) and Chinese husbands (5.67±1.56) showed the same

level of Active strategy use, followed by Indian husbands (5.04±1.65). At post-

chemotherapy, Malay husbands scored the highest in terms of the Active strategy

(4.61±1.39), followed by the Chinese (4.51±1.35) and Indian husbands (4.50±1.20)],

Planning [F (2, 154) = 7.10; p<0.01] [Malay women used more Planning strategy

prior-to (5.83±1.54), during (6.38±1.30) and post-chemotherapy (6.46±1.32), followed

by Indians (prior-to=5.67±1.79; during=6.30±1.56; post-chemotherapy=6.23±1.63)

and Chinese women (prior-to=4.86±1.67; during=5.67±1.84; post-

chemotherapy=5.69±1.77). Nonetheless, Indian husbands indicated the highest scores

in the Planning strategies, prior-to (4.93±1.57) and during chemotherapy (5.00±1.46);

this was followed by the Malay (prior=4.92±1.35; during chemotherapy=5.92±1.35)

and Chinese husbands (prior-to= 4.35±1.31; during chemotherapy=5.35±1.31). At

post-chemotherapy, Malay husbands were found to use more of the Planning strategies

(5.01±1.23), as compared to those of the Indians (5.00±1.46) and Chinese

(4.49±1.17)], Positive Reframing [F (2, 154) = 12.62; p<0.001] [Prior to

chemotherapy, Indian women (5.43±1.36) used more Positive Reframing strategy

followed by Malay (5.08±1.34) and Chinese (4.73±1.18) women. During and post-

chemotherapy, Malay women scored highest (during=6.72±1.27; post-

chemotherapy=6.18±1.45) in Positive Reframing followed by Indian

(during=6.70±1.12; post-chemotherapy=6.07±1.82) and Chinese women

(during=5.84±1.54; post-chemotherapy=5.47±1.75). In contrast, Malay husbands

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indicated highest scores of Positive Reframing in all occasions (prior-to=5.36±1.22;

during=5.92±1.59; post-chemotherapy=5.87±1.59) followed by Indian (prior-

to=5.20±1.16; during=5.60±1.57; post-chemotherapy=5.57±1.57) and Chinese

husbands (prior-to=4.67±1.58; during=5.10±1.39; post-chemotherapy=5.10±1.39)],

Acceptance [F (2, 154) = 9.26; p<0.001] [Malay women used Acceptance strategy more

prior-to (6.91±1.22) and during chemotherapy (6.89±1.25), as compared to Indian

(prior-to=6.37±1.16; during=5.78±1.74) and Chinese women (prior-to=5.75±1.72;

during=5.78±1.74). However, Indian women scored the highest for the use of

Acceptance strategy at post-chemotherapy (7.27±1.14), followed by Malay (7.21±1.15)

and Chinese women (7.02±1.56). Likewise for prior to chemotherapy, Malay husbands

indicated the highest scores in the Acceptance strategy (6.91±1.22), as compared to

Indian (6.37±1.16) and Chinese husbands (5.75±1.72). On the other hand, Indian

husbands were found to use more of this particular strategy during (6.83±1.34) and at

post-chemotherapy (6.67±1.21), followed by Malay (during=6.50±1.52; post-

chemotherapy=6.18±1.64) and Chinese husbands (during=6.12±1.54; post-

chemotherapy=6.08±1.37)], Using Emotional Support [F (2, 154) = 6.45; p<0.01]

[Indian women used more Emotional Support in all occasions (prior-to=5.77±1.10;

during=6.50±1.53; post-chemotherapy=5.27±1.41), in comparison to the Malay

women (prior-to=5.45±1.35; during=6.04±5.75; post-chemotherapy=5.22±1.36) and

Chinese women (prior-to=4.84±1.59; during=5.75±1.83; post-

chemotherapy=4.75±1.40). Similarly, Indian husbands were found to have the highest

scores for the use of Emotional Support prior-to (5.60±1.28), during (5.70±1.29) and

post-chemotherapy (5.10±1.99), followed by Malay (prior-to=5.37±1.53;

during=5.45±1.38; post-chemotherapy=4.99±1.94) and Chinese husbands (prior-

to=5.06±1.39; during=5.12±1.26; post-chemotherapy=4.59±1.70)], Using

Instrumental Support [F (2, 154) = 5.47; p<0.01] [Malay women indicated the highest

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scores of Using Instrumental Support prior-to (5.72±1.68) and post-chemotherapy

(5.43±1.44), followed by Indian (prior-to=6.13±1.53; post-chemotherapy=5.27±1.72)

and Chinese (prior-to=4.86±1.59; post-chemotherapy=5.14±1.39). However, Malay

(6.50±1.56) and Indian (6.50±1.48) women scored the same level for the use of

Instrumental Support during chemotherapy, and this was followed by Chinese women

(6.14±1.73). Nonetheless, Indian husbands demonstrated the highest use of

Instrumental Support prior-to (5.87±1.28), during (6.23±1.45) and post-chemotherapy

(5.43±1.87), followed by Malay (prior-to=5.74±1.53; during=5.71±1.52; post-

chemotherapy=5.12±1.71) and Chinese husbands (prior-to=5.39±1.30;

during=5.45±1.38; post-chemotherapy=5.02±1.70)], Self-distraction [F (2, 154) =

10.03; p<0.001] [Malay women indicated the highest scores for Self-distraction prior-

to (5.93±1.56), during (6.16±1.38) and post-chemotherapy (5.91±1.58). This was

followed by Indian (prior-to=5.63±1.52; during=6.03±1.69; post-

menopausal=5.63±1.52) and Chinese (prior-to=4.65±1.48; during=5.22±1.89; post-

chemotherapy=4.65±1.48). Similarly, Malay husbands indicated to use more of the

Self-distraction strategy during (6.14±1.36) and post-chemotherapy (5.03±1.58),

followed by Indian (during=6.00±1.31; post-chemotherapy=4.77±1.33) and Chinese

husbands (during=5.84±1.70; post-chemotherapy=4.69±1.38). On the contrary,

Indian husbands scored the highest in Self-distraction strategy prior-to chemotherapy

(5.47±1.43), compared to Malay (5.21±1.37) and Chinese women (5.06±1.38)], Denial

[F (2, 154) = 3.48; p<0.05] [Indian women used more Denial strategy prior-to

(6.03±1.63) during (6.00±1.64) and post-chemotherapy (6.03±1.63) followed by Malay

(prior-to=5.76±1.49; during=5.66±1.52; post-chemotherapy=5.72±1.49) and Chinese

women (prior-to=5.31±1.22; during=5.31±1.33; post-chemotherapy=5.37±1.26). In

contrast, Indian husbands indicated the highest scores for the use Denial strategy in all

the treatment phases (prior-to=5.13±1.55; during=5.13±1.55; post-

317

chemotherapy=2.63±1.43), as compared to Malay (prior-to=4.92±1.31;

during=4.95±1.36; post-chemotherapy=2.51±1.27) and Chinese (prior-to=4.57±0.96;

during=4.61±1.06; post-chemotherapy=2.29±0.61)], Venting [F (2, 154) = 10.77;

p<0.001] [Indian women exhibited more Venting strategy in all the treatment phases

(prior-to=6.23±1.45; during=6.23±1.45; post-chemotherapy=6.30±1.49), followed by

Malay (prior-to=5.87±1.53; during=6.04±1.57; post-chemotherapy=6.04±1.57) and

Chinese women (prior-to=4.98; during=5.08±1.44; post-chemotherapy=5.08±1.44).

This was in comparison to the Malay husbands who exhibited more use of the Venting

strategy prior-to (5.43±1.27), during (5.79±1.36) and post-chemotherapy (3.72±1.53),

followed by the Indian (prior-to=5.27±1.46; during=5.70±1.49; post-

chemotherapy=3.20±1.85) and Chinese husbands (prior-to=5.04±1.13;

during=5.10±1.10; post-chemotherapy=2.98±1.18], Behavioural Disengagement [F (2,

154) = 3.53; p<0.05] [Indian women engaged themselves more in the Behavioural

Disengagement strategy prior-to (4.97±1.40), during (5.00±1.46) and post-

chemotherapy (5.00±1.46), followed by Chinese (prior-to=4.73±1.13;

during=4.73±1.13; post-chemotherapy=4.73±1.13) and Malay women (prior-

to=4.47±1.00; during=4.46±1.03; post-chemotherapy=4.49±1.09). Likewise, Indian

husbands were found to engage more in the Behavioural Disengagement in all

occasions (prior-to=3.50±1.07; during=3.60±1.30; post-chemotherapy=3.53±1.17) as

compared to the Malay (prior-to=3.22±0.84; during=3.30±0.77; post-

chemotherapy=3.28±0.74) and Chinese husbands (prior-to=3.51±1.10;

during=3.25±0.59; post-chemotherapy=3.25±0.59)], Problem-Focused Strategy [F (2,

154) = 13.12; p<0.001] [Indian women engaged more in the Problem-focused Strategy

prior-to (17.77±4.11) and during chemotherapy (17.60±5.00), followed by Malay

(prior-to=17.42±3.52; during=17.26±3.79) and Chinese women (prior-to=14.73±4.10;

during=15.61±5.72). Nonetheless, Malay women demonstrated to use more of such

318

strategies at post-chemotherapy (17.12±2.75), followed by Indian (16.43±3.30) and

Chinese women (15.43±3.45). Among the patients’ husbands, the Indians were

indicated to engage in more Problem-focused Strategy in all occasions (prior-

to=15.17±2.87; during=16.83±4.00; post-chemotherapy=14.93±3.07), followed by the

Malay (prior-to=15.16±3.44; during=16.45±3.95; post-chemotherapy=14.74±3.18)

and Chinese husbands (prior-to=13.67±2.66; during=14.98±3.71; post-

chemotherapy=14.02±2.63)], Emotion-focused Strategy [F (2, 154) = 25.31; p<0.001]

[Indian women demonstrated to use more of the Emotion-focused Strategy prior-to

(30.67±4.68), during (31.30±4.68) and post-chemotherapy (30.80±4.32), as compared

to Malay (prior-to=30.30±3.67; during=30.75±3.43; post-chemotherapy=30.97±3.67)

and Chinese women (prior-to=26.02±5.27; during=27.80±4.80; post-

chemotherapy=28.57±4.11). Among the husbands, Malays indicated the highest scores

for this particular strategy prior to chemotherapy (27.95±3.64), as compared to other

races (Indian=27.57±3.71; Chinese=23.98±4.11). Nonetheless, Indian husbands were

found to display more Emotion-focused Strategy during (27.83±4.57) and post-

chemotherapy (24.90±4.23), followed by the Malay (during=26.39±4.71; post-

chemotherapy=24.83±4.77) and Chinese husbands (during=23.53±4.68; post-

chemotherapy=22.16±3.07)]. However, patients’ ethnicity had no significant effect on

the Self-blame strategy [F (2, 154) = 1.189; ns] [Appendix D: Table 3.0 (d)].

A separate analysis at an individual level was carried out for the women and

their husbands to observe at the effect of time and independent factors (types of

surgery, breast cancer stages, menopausal status and ethnicity) on the women’s and

their husbands’ coping strategies. The results of the One-way Repeated Measure

ANOVA indicated that there was a significant effect of time for most of the women’s

coping strategies. These were Active Coping [F (2, 312) = 137.13; p<0.001] [The use

of Active Coping was increased from prior-to (5.61±1.55) to during (7.10±1.20)

319

chemotherapy, but it declined at post-chemotherapy (4.97±1.40)], Planning [F (1.06,

165.742) = 17.35; p<0.001] [Planning strategy rose from prior-to (5.48±1.68) to

during chemotherapy (6.13±1.57), and this increment continued to slightly increase at

post-chemotherapy (6.17±1.57)], Positive Reframing [F (2.00, 312.00) = 45.84;

p<0.001] [Positive Reframing strategy was heightened from prior-to (5.03±1.31) to

during chemotherapy (6.43±1.39), but it decreased at post-chemotherapy (5.93±1.65)],

Acceptance [F (1.03, 159.83) = 29.64; p<0.001] [A similar level of Acceptance was

observed both prior-to (6.43±1.48) and during chemotherapy (6.43±1.49); however,

this was increased at post-chemotherapy (7.16±1.29)] , Religion [F (1.90, 295.80) =

26.06; p<0.001] [The use of the religion strategy was raised from prior-to (6.54±1.83)

to during chemotherapy (7.25±0.96), but it dropped at post-chemotherapy

(6.32±1.56)], Using Emotional Support [F (2, 312) = 23.27; p<0.001] [Using

Emotional Support was found to enhance from prior-to (5.31±1.43) to during the

treatment (6.03±1.73), but it was shown to diminish at post-chemotherapy

(5.08±1.39)], Using Instrumental Support [F (2, 312) = 25.66; p<0.001] [Using

Instrumental Support boosted from prior-to (5.52±1.68) to during chemotherapy

(6.38±1.60), but decreased at post-chemotherapy (5.31±1.47)], Self-distraction [F

(1.01, 157.57) = 5.77; p<0.05] [Self-distraction increased from prior-to (5.46±1.62) to

during (5.83±1.66), but declined at post-chemotherapy (5.45±1.63)], Venting [F (1.15,

179.81) = 8.68; p<0.01] [Venting strategy slightly increased from prior-to (5.65±1.54)

to during (5.76±1.57) and diminished post-chemotherapy (5.78±1.58)], Self-blaming [F

(1.18, 184.43) = 12.54; p<0.001] [Self-blaming enhanced from prior-to (5.07±1.25) to

during (5.20±1.43) and slightly decreased post-chemotherapy (5.21±1.45)] and

Emotion-focused Strategy [F (1.94, 302.08) = 5.03; p<0.01] [Almost the similar levels

were observed for the use of Emotion-focused Strategy prior-to (28.98±4.87) and

during (28.90±4.39), and this was slightly increased at post-chemotherapy

320

(30.16±4.07)]. Similarly, the Friedman analysis also indicated the significant effect of

time for humour (χ2 = 23.59; df = 2; p<0.001) [A slight decrease was observed for the

use of Humour strategy from prior-to (3.38±1.68) to during (3.21±1.73), and the use

was somewhat increased at post-chemotherapy (3.44±0.96)] [Table 8.5 (b), (c); Figure

8.2.1 (a), (b)]. Nonetheless, a number of these women’s coping strategies did not have

the significant effect of time such as Denial [F (1.80, 280.82) = 12.54; ns], Behavioural

Disengagement [F (1.57, 245.59) = 0.40; ns], Problem-focused Strategy [F (1.63,

254.54) = 0.45; ns] [Table 7.5 (b); Figure 7.2.1 (a), (b)] and Substance Use (χ2 = 0.36;

df = 2; ns) [Table 8.5 (c); Figure 8.2.1 (a)].

Table 8.5 (b): One-way Repeated Measure ANOVA: Coping Strategies of the Women with Breast Cancer

Sources of Variation ss df ms f sign Active 376.752 2 188.376 137.134 p<0.001 Planning 46.450 1.062 43.720 17.354 p<0.001 Positive Reframing 158.221 2.000 79.110 45.840 p<0.001 Acceptance 55.673 1.025 54.340 29.642 p<0.001 Humour* (Non-Parametric Table) Religion 74.344 1.896 39.208 26.063 p<0.001 Using Emotional Support 77.788 2 38.894 23.267 p<0.001 Using Instrumental Support 101.788 2 50.894 25.657 p<0.001 Self-distraction 14.794 1.010 14.647 5.772 p<0.05 Denial 0.344 1.800 0.191 2.556 ns Venting 1.546 1.153 1.341 8.677 p<0.01 Substance Use* (Non-Parametric Table) Behavioural Disengagement 0.017 1.574 0.011 0.398 ns Self-blaming 1.885 1.182 1.595 12.543 p<0.001 Problem-focused Strategy 9.635 1.632 5.905 0.450 ns Emotion-focused Strategy 120.259 1.936 62.105 5.033 p<0.01

*The non-parametric analysis was used as the assumptions for parametric analysis were not met

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Table 8.5 (c): Non-parametric Analysis (Friedman Test): Coping Strategies of the Women with Breast Cancer

χ

2 df sign Humour 23.59 2 p<0.001 Substance Use 0.364 2 ns

Note: The non-parametric analysis was used as the assumptions for parametric analysis were not met

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30

40

Problem-focused Strategy Emotion-focused Strategy

Figure 8.2.1 (b): Women's Problem- and Emotion-focused Strategies

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core

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Pre-chemotherapy

During Chemotherapy

Post-chemotherapy

An analysis of the Split Plot Repeated Measure ANOVA was carried out for

this; it indicated the significant effect of the types of surgery on certain coping

strategies used by the women with breast cancer, such as Planning [F (1, 155) = 5.31;

p<0.05] [The women in the lumpectomy group indicated to use more of Planning

strategy in all occasions (prior-to=5.52±1.72; during=6.85±1.12; post-

chemotherapy=6.79±1.24), as compared to those in the mastectomy group (prior-

to=5.48±1.67; during=5.94±1.61; post-chemotherapy=6.00±1.61)] [Table 8.5 (d);

Figure 8.2.2 (a)],

F (1.63, 254.54) = 0.45; ns

F (1.94, 302.08) = 5.03; p<0.01

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Pre-Chemotherapy

DuringChemotherapy

PostChemotherapy

Figure 8.2.2 (a): The Effect of Types of surgery on Women's Coping Strategy (Planning)

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an s

core

sMastectomy (N=124)

Lumpectomy (N=33)

Using Instrumental Support [F (1, 155) = 4.20; p<0.05] [The women in the lumpectomy

group claimed to use Instrumental Support prior-to (5.79±1.54), during (6.97±1.29)

and post-chemotherapy (5.48±1.58) more often than the women in the mastectomy

group (prior-to=5.45±1.72; during=6.23±1.65; post-chemotherapy=5.26±1.45)]

[Table 8.5 (d); Figure 8.2.2 (b)]

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Pre-Chemotherapy DuringChemotherapy

PostChemotherapy

Figure 8.2.2 (b): The Effect of Types of Surgery on Women's Coping Strategies (Using Instrumental Support)

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Mastectomy (N=124)

Lumpectomy (N=33)

Time: F (1.070, 165.873) = 21.466; p<0.001 Interaction Effect: F (1.070, 165.873) = 4.388; p<0.05 Between Subjects Effect: F (1, 155) = 5.306; p<0.05 (8.2.2 a)

Time: F (2, 310) = 22.088; p<0.001 Interaction Effect: F (2, 310) = 0.976; ns Between Subjects Effect: F (1, 155) = 4.199; p<0.05 (8.2.2 b)

324

Table 8.5 (d): Split Plot Repeated Measure ANOVA: The Effect of the Types of Surgery on the Coping Strategies of the Women with Breast Cancer

Sources of Variation ss df ms f sign

Active Coping Within Subjects Effect: Active coping (Time) 283.204 2 141.602 103.368 p<0.001 Time x Types of surgery 3.917 2 1.959 1.430 ns Between Subjects Effect: 6.602 1 6.602 2.179 ns (Effect of Types of surgery)

Planning Within Subjects Effect: Planning (Time) 56.235 1.070 52.549 21.466 p<0.001 Time x Types of surgery 11.496 1.070 10.743 4.388 p<0.05 Between Subjects Effect: 26.067 1 26.067 5.306 p<0.05 (Effect of Types of surgery)

Positive Reframing Within Subjects Effect: Positive reframing (Time) 116.977 2 58.488 33.735 p<0.001 Time x Types of surgery 0.977 2 0.488 0.282 ns

Between Subjects Effect: 0.113 1 0.113 0.038 ns (Effect of Types of surgery)

Acceptance Within Subjects Effect: Acceptance (Time) 31.477 1.031 30.523 16.690 p<0.001 Time x Types of surgery 0.658 1.031 0.638 0.349 ns

Between Subjects Effect: 1.123 1 1.123 0.268 ns (Effect of Types of surgery)

Using Emotional Support Within Subjects Effect: Using Emotional Support (Time)

75.483 2 37.742 22.751 p<0.001

Time x Types of surgery 7.279 2 3.640 2.194 ns

Between Subjects Effect: 17.629 1 17.629 4.982 ns (Effect of Types of surgery)

Using Instrumental Support Within Subjects Effect: Using Instrumental Support (Time)

87.642 2 43.821 22.088 p<0.001

Time x Types of surgery 3.871 2 1.935 0.976 ns

Between Subjects Effect: 14.840 1 14.840 4.199 p<0.05 (Effect of Types of surgery)

Table 8.5 (d), Continued.

325

ss df ms f sign Self-distraction

Within Subjects Effect: Self-distraction (Time) 23.594 1.017 23.204 9.353 p<0.01 Time x Types of surgery 8.851 1.017 8.705 3.509 ns Between Subjects Effect: 0.060 1 0.060 0.011 ns (Effect of Types of surgery)

Denial Within Subjects Effect: Denial (Time) 0.156 1.813 23.204 0.086 ns Time x Types of surgery 0.020 1.813 0.011 3.509 ns Between Subjects Effect: 1.199 1 1.199 0.188 ns (Effect of Types of surgery)

Venting Within Subjects Effect: Venting (Time) 0.538 1.161 0.464 3.028 ns Time x Types of surgery 0.233 1.161 0.200 1.309 ns

Between Subjects Effect: 0.757 1 0.757 0.105 ns (Effect of Types of surgery)

Behavioural Disengagement Within Subjects Effect: Behavioural Disengagement (Time)

0.051 1.583 0.032 1.213 ns

Time x Types of surgery 0.085 1.583 0.054 2.015 ns

Between Subjects Effect: 6.920 1 6.920 1.727 ns (Effect of Types of surgery)

Self-blame Within Subjects Effect: Self-blame (Time) 0.972 1.190 0.816 6.438 p<0.01 Time x Types of surgery 0.055 1.190 0.046 0.361 ns

Between Subjects Effect: 2.084 1 2.084 0.375 ns (Effects of Types of surgery)

Problem-focused Strategy Within Subjects Effect: Problem-focused Strategy (Time)

39.907 1.650 24.191 1.884 ns

Time x Types of surgery 57.572 1.650 34.898 2.718 ns

Between Subjects Effect: 152.659 1 152.659 5.701 p<0.05 (Effect of Types of surgery)

Emotion-focused Strategy Within Subjects Effect: Emotion-focused Strategy (Time)

125.534 1.944 64.565 5.427 p<0.01

Time x Types of surgery 142.681 1.944 73.384 6.169 p<0.01

Table 8.5 (d), Continued.

326

ss df ms f sign Between Subjects Effect: 79.290 1 79.290 2.241 ns (Effect of Types of surgery)

Note: The domains of Humour and Substance Use of Brief COPE were excluded from the analysis as the assumptions for the parametric test were not met

and Problem-focused Strategy [F (1, 155) = 5.70; p<0.05] [The lumpectomy group was

found to use more Problem-focused Strategy in all situations (prior-to=16.97±4.33;

during=18.79±3.51; post-chemotherapy=17.39±2.70), as compared to the mastectomy

group (prior-to=16.52±3.96; during=16.26±4.93; post-chemotherapy=16.19±3.24)]

[Table 8.5 (d); Figure 8.2.2 (c)].

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Pre-Chemotherapy DuringChemotherapy

Post Chemotherapy

Figure 8.2.2 (c): The Effect of Types of Surgery on Women's Coping Strategy (Problem-focused Strategy)

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s

Mastectomy (N=124)

Lumpectomy (N=33)

However, there was no significant effect of the types of surgery on Active Coping [F

(1, 155) = 2.18; ns] [Table 7.5 (d); Figure 7.2.2 (d)], Positive Reframing [F (1, 155) =

0.04; ns] [Table 7.5 (d); Figure 7.2.2 (e)], Acceptance [F (1, 155) = 0.27; ns] [Table 7.5

(d); Figure 7.2.2 (f)], Using Emotional Support [F (1, 155) = 4.98; ns] [Table 7.5 (d);

Figure 7.2.2 (g)], Self-distraction [F (1, 155) = 0.01; ns] [Table 7.5 (d); Figure 7.2.2

(h)], Denial [F (1, 155) = 0.19; ns] [Table 7.5 (d); Figure 7.2.2 (i)], Venting [F (1, 155) =

0.11; ns] [Table 7.5 (d); Figure 7.2.2 (j)], Behavioural Disengagement [F (1, 155) = 1.73; ns]

Time: F (1.650, 255.703) = 1.884; ns Interaction Effect: F (1.650, 255.703) = 2.718; ns Between Subjects Effect: F (1, 155) = 5.701; p<0.05 (8.2.2 c)

327

[Table 7.5 (d); Figure 7.2.2 (k)], Self-blame [F (1, 155) = 0.38; ns] [Table 7.5 (d); Figure 7.2.2

(l)] and Emotion-focused Strategy [F (1, 155) = 2.24; ns] [Table 8.5 (d); Figure 8.2.2 (m)].

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Pre-Chemotherapy DuringChemotherapy

Post Chemotherapy

Figure 8.2.2 (d): The Effect of Types of Surgery on Women's Coping Strategy (Active Coping)

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s

Mastectomy (N=124)

Lumpectomy (N=33)

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Pre-Chemotherapy DuringChemotherapy

Post Chemotherapy

Figure 8.2.2 (e): The Effect of Types of Surgery on Women's Coping Strategy (Positive Reframing)

Mea

n sc

ores

Mastectomy (N=124)

Lumpectomy (N=33)

Time: F (2, 310) = 103.368; p<0.001 Interaction Effect: F (2,310) = 1.430; ns Between Subjects Effect: F (1, 155) = 2.179; ns (8.2.2 d)

Time: F (2, 310) = 33.735; p<0.001 Interaction Effect: F (2, 310) = 0.282; ns Between Subjects Effect: F (1, 155) = 0.038; ns (8.2.2 e)

328

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Pre-Chemotherapy DuringChemotherapy

Post Chemotherapy

Figure 8.2.2 (f): The Effect of Types of Surgery on Women's Coping Strategy (Acceptance)

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an

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es

Mastectomy (N=124)

Lumpectomy (N=33)

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Post Chemotherapy

Figure 8.2.2 (g): The Effect of Types of Surgery on Women's Coping Strategies (Using Emotional Support)

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s

Mastectomy (N=124)

Lumpectomy (N=33)

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Pre-Chemotherapy DuringChemotherapy

Post Chemotherapy

Figure 8.2.2 (h): The Effect of Types of Surgery on Women's Coping Strategy (Self-distraction)

Mea

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core

s

Mastectomy (N=124)

Lumpectomy (N=33)

Time: F (1.031, 159.842) = 16.690; p<0.001 Interaction Effect: F (1.031, 159.842) = 0.349, ns Between Subjects Effect: F (1, 155) = 0.268; ns (8.2.2 f)

Time: F (2, 310) = 22.751; p<0.001 Interaction Effect: F (2, 310) = 2.194; ns Between Subjects Effect: F (1, 155) =4.982; ns (8.2.2 .g)

Time: F (1.017, 157.61) = 9.353; p<0.01 Interaction Effect: F (1.017, 157.61) = 3.509; ns Between Subjects Effect: F (1, 155) = 0.011; ns (8.2.2 h)

329

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Pre-Chemotherapy DuringChemotherapy

Post Chemotherapy

Figure 8.2.2 (i): The Effect of Types of Surgery on Women's Coping Strategy (Denial)

Mea

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s

Mastectomy (N=124)

Lumpectomy (N=33)

02468

10

Pre-Chemotherapy DuringChemotherapy

Post Chemotherapy

Figure 8.2.2 (j): The Effect of Types of Surgery on Women's Coping Strategy (Venting)

Mea

n s

core

s

Mastectomy (N=124)

Lumpectomy (N=33)

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Pre-Chemotherapy DuringChemotherapy

Post Chemotherapy

Figure 8.2.2 (k): The Effect of Types of Surgery on Women's Coping Strategy (Behavioral Disengagement)

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Mastectomy (N=124)

Lumpectomy (N=33)

Time: F (1.813, 280.941) = 0.086; ns Interaction Effect: F (1.813, 280.941) = 3.509; ns Between Subjects Effect: F (1, 155) = 0.188; ns (8.2.2 i)

Time: F (1.583, 245.352) = 1.213; ns Interaction Effect: F (1.583, 245.352) = 2.015; ns Between Subjects Effect: F (1, 155) = 1.727; ns (8.2.2 k)

Time: F (1.161, 180.016) = 3.028; ns Interaction Effect: F (1.161, 180.016) = 1.309; ns Between Subjects Effect: F (1, 155) = 0.105; ns (8.2.2 j) (ven)

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Figure 8.2.2 (l): The Effect of Types of Surgery on Women's Coping Strategies (Self-blame)

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Mastectomy (N=124)

Lumpectomy (N=33)

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Figure 8.2.2 (m): The Effect of Types of Surgery on Women's Coping Strategy (Emotion-focused Strategy)

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Mastectomy (N=124)

Lumpectomy (N=33)

An equivalent analysis, which was carried out to observe the effect of the breast

cancer stages on the women’s coping strategies, indicated the non-significant effect in

all types of the coping strategies: Active coping [F (1, 142) = 0.04; ns] [Table 8.5 (e);

Figure 8.2.3 (a)], Planning [F (1, 142) = 3.27; ns] [Table 8.5 (e); Figure 8.2.3 (b)],

Positive Reframing [F (1, 142) = 1.21; ns] [Table 8.5 (e); Figure 8.2.3 (c)], Acceptance

[F (1, 142) = 1.26; ns] [Table 8.5 (e); Figure 8.2.3 (d)], Using Emotional Support [F (1,

142) = 1.26; ns] [Table 8.5 (e); Figure 8.2.3 (e)], Using Instrumental Support [F (1,

Time: F (1.190, 184.471) = 6.438; p<0.01 Interaction Effect: F (1.190, 184.471) = 0.361; ns Between Subjects Effect: F (1, 155) = 0.375; ns (8.2.2 l)

Time: F (1.944, 301.369) = 5.427; p<0.01 Interaction Effect: F (1.944, 301.369) = 6.169; p<0.01 Between Subjects Effect: F (1, 155) = 2.241; ns (8.2.2 m)

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142) = 0.21; ns] [Table 8.5 (e); Figure 8.2.3 (f)], Self-distraction [F (1, 142) = 0.02; ns]

[Table 8.5 (e); Figure 8.2.3 (g)], Denial [F (1, 142) = 1.68; ns] [Table 8.5 (e); Figure

8.2.3 (h)], Venting [F (1, 142) = 0.21; ns] [Table 8.5 (e); Figure 8.2.3 (i)], Behavioural

Disengagement [F (1, 142) = 0.03; ns] [Table 8.5 (e); Figure 8.2.3 (j)], Self-blame [F

(1. 142) = 0.08; ns] [Table 8.5 (e); Figure 8.2.3 (k)], Problem-focused Strategy [F (1,

142) = 0.51; ns] [Table 8.5 (e); Figure 8.2.3 (l)] and Emotion-focused Strategy [F (1,

142) = 0.27; ns] [Table 8.5 (e); Figure 8.2.3 (m)].

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Figure 8.2.3 (a): The Effect of Breast Cancer Stages on Women's Coping Strategies (Active Coping)

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Stage Two (N=89)

Stage Three (N=55)

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Figure 8.2.3 (b): The Effect of Breast Cancer Stages on Women's Coping Strategies (Planning)

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Stage Two (N=89)

Stage Three (N=55)

Time: F (1.948, 276.555) = 121.825; p<0.001 Interaction Effect: F (1.948, 276.555) = 2.325; ns Between Subjects Effect: F (1, 142) = 0.036; ns (8.2.3 a)

Time: F (1.051, 149.301) = 16.059; p<0.001 Interaction Effect: F (1.051, 149.301) = 0.021; ns Between Subjects Effect: F (1, 142) = 3.274; ns (8.2.3 b)

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Table 8.5 (e): Split Plot Repeated Measure ANOVA: The Effect of the Breast Cancer Stages on the Coping Strategies of the Women with Breast Cancer

Sources of Variation ss df ms f sign

Active Coping Within Subjects Effect: Active coping (Time) 329.058 1.948 168.96 121.825 p<0.001 Time x Breast Cancer Stages 6.280 1.948 3.225 2.325 ns Between Subjects Effect: 0.112 1 0.112 0.036 ns (Effect of Breast Cancer Stages)

Planning Within Subjects Effect: Planning (Time) 41.609 1.051 39.574 16.059 p<0.001 Time x Breast Cancer Stages 0.053 1.051 0.051 0.021 ns Between Subjects Effect: 17.338 1 17.338 3.274 ns (Effect of Breast Cancer Stages)

Positive Reframing Within Subjects Effect: Positive reframing (Time) 128.614 2 64.307 37.726 p<0.001 Time x Breast Cancer Stages 3.300 2 1.650 0.968 ns

Between Subjects Effect: 3.665 1 3.665 1.206 ns (Effect of Breast Cancer Stages)

Acceptance Within Subjects Effect: Acceptance (Time) 51.800 1.033 50.144 26.309 p<0.001 Time x Breast Cancer Stages 0.884 1.033 0.856 0.449 ns

Between Subjects Effect: 5.269 1 5.269 1.260 ns (Effect of Breast Cancer Stages)

Using Emotional Support Within Subjects Effect: Using Emotional Support (Time) 66.42 2 33.211 20.719 p<0.001 Time x Breast Cancer Stages 5.144 2 3.572 1.604 ns

Between Subjects Effect: 2.258 1 2.258 0.599 ns (Effect of Breast Cancer Stages)

Using Instrumental Support Within Subjects Effect: Using Instrumental Support (Time)

85.078 2 42.539 22.663 p<0.001

Time x Breast Cancer Stages 1.189 2 0.595 0.317 ns

Between Subjects Effect: 0.787 1 0.787 0.214 ns (Effect of Breast Cancer Stages)

Table 8.5 (e), Continued.

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ss df ms f sign Self-distraction

Within Subjects Effect: Self-distraction (Time) 11.377 1.019 11.163 4.817 p<0.05 Time x Breast Cancer Stages 1.266 1.019 1.242 0.536 ns

Between Subjects Effect: 0.083 1 0.083 0.015 ns (Effect of Breast Cancer Stages)

Denial Within Subjects Effect: Denial (Time) 0.247 1.831 0.135 1.731 ns Time x Breast Cancer Stages 0.081 1.831 0.044 0.565 ns Between Subjects Effect: 10.269 1 10.269 1.682 ns (Effect of Breast Cancer Stages)

Venting Within Subjects Effect: Venting (Time) 1.236 1.176 1.051 6.934 p<0.001 Time x Breast Cancer Stages 0.013 1.176 0.011 0.075 ns

Between Subjects Effect: 1.520 1 1.520 0.209 ns (Effect of Breast Cancer Stages)

Behavioural Disengagement Within Subjects Effect: Behavioural Disengagement (Time)

0.024 1.613 0.015 0.563 ns

Time x Breast Cancer Stages 0.042 1.613 0.026 1.005 ns

Between Subjects Effect: 0.105 1 0.105 0.029 ns (Effect of Breast Cancer Stages)

Self-blame Within Subjects Effect: Self-blame (Time) 1.631 1.194 1.365 10.189 p<0.001 Time x Breast Cancer Stages 0.075 1.194 0.063 0.470 ns

Between Subjects Effect: 0.354 1 0.354 0.067 ns (Effect of Breast Cancer Stages)

Problem-focused Strategy Within Subjects Effect: Problem-focused Strategy (Time) 5.508 1.674 3.290 0.268 ns Time x Breast Cancer Stages 12.786 1.674 7.637 0.623 ns

Between Subjects Effect: (Effect of Breast Cancer Stages)

15.107 1 15.107 0.511 ns

Emotion-focused Strategy Within Subjects Effect: Emotion-focused Strategy (Time) 149.939 2 74.969 7.118 p<0.01 Time x Breast Cancer Stages 50.272 2 25.136 2.387 ns

Table 8.5 (e), Continued.

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ss df ms f sign Between Subjects Effect: 10.282 1 10.282 0.270 ns (Effect of Breast Cancer Stages)

Note: The domains of Humour and Substance Use of Brief COPE were excluded from the analysis as the assumptions for the parametric test were not met

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Figure 8.2.3 (c): The Effect of Breast Cancer on Women's Coping Strategy (Positive Reframing)

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Stages Two (N=89)

Stages Three (N=55)

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Figure 8.2.3 (d): The Effect of Breast Cancer Stages on Women's Coping Strategy (Acceptance)

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Stages Two (N=89)

Stages Three (N=55)

Time: F (2, 284) = 37.726; p<0.001 Interaction Effect: F (2, 284) = 0.968; ns Between Subjects Effect: F (1, 142) = 1.206; ns (8.2.3 c)

Time: F (1.033, 146.691) = 26.309; p<0.001 Interaction Effect: F (1.033, 146.691) = 0.449; ns Between Subjects Effect: F (1, 142) = 1.260; ns (8.2.3 d)

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Figure 8.2.3 (e): The Effect of Breast Cancer Stages on Women's Coping Strategy (Using Emotional Support)

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Stages Two (N=89)

Stages Three (N=55)

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Figure 8.2.3 (f): The Effect of Breast Cancer Stages on Women's Coping Strategy

(Using Instrumental Support)

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Stages Two (N=89)

Stages Three (N=55)

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Figure 8.2.3 (g): The Effect of Breast Cancer Stages on Women's Coping Strategies (Self-distraction)

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Stage Two (N=89)

Stage Three (N=55)

Time: F (2, 284) = 20.719; p<0.001 Interaction Effect: F (2, 284) = 1.604; ns Between Subjects Effect: F (1, 142) = 0.600; ns (8.2.3 e)

Time: F (2, 284) = 22.663; p<0.001 Interaction Effect: F (2, 284) = 0.317; ns Between Subjects Effect: F (1, 142) = 0.214; ns (8.2.3 f)

Time: F (1.019, 144.717) = 4.817; p<0.05 Interaction Effect: F (1.019, 144.717) = 0.536; ns Between Subjects Effect: F (1, 142) = 0.015; ns (8.2.3 g)

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Figure 8.2.3 (h): The Effect of Breast Cancer Stages on Women's Coping Strategy (Denial)

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Stage Two (N=89)

Stage Three (N=55)

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Figure 8.2.3 (i): The Effect of Breast Cancer on Women's Coping Strategy (Venting)

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Stage Two (N=89)

Stage Three (N=55)

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Figure 8.2.3 (j): The Effect of Breast Cancer Stages on Women's Coping Strategy

(Behavioral Disengagement)

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Stage Two (N=89)

Stage Three (N=55)

Time: F (1.831, 259.932) = 1.731; ns Interaction Effect: F (1.831, 259.932) = 0.565; ns Between Subjects Effect: F (1, 142) = 1.682; ns (8.2.3 h)

Time: F (1.176, 166.986) = 6.934; p<0.001 Interaction Effect: F (1.176, 166.986) = 0.075; ns Between Subjects Effect: F (1, 142) = 0.209; ns (8.2.3 i-vent)

Time: F (1.613, 229.016) = 0.563; ns Interaction Effects: F (1.613, 229.016) = 1.005; ns Between Subjects Effect: F (1, 142) = 0.029; ns (8.2.3 j)

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Figure 8.2.3 (k): The Effect of Breast Cancer Stages on Women's Coping Strategies (Self-blame)

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Stage Two (N=89)

Stage Three (N=55)

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Figure 8.2.3 (l): The Effect of Breast Cancer Stages on Women's Coping Strategy (Problem-focused strategy)

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Stage Two (N=89)

Stage Three (N=55)

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Figure 8.2.3 (m): The Effect of Breast Cancer Stages on Women's Coping Strategy (Emotion-focused strategy)

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Stage Two (N=89)

Stage Three (N=55)

Time: F (1.194, 169.580) = 10.189; p<0.001 Interaction Effect: F (1.194, 169.580) = 0.470; ns Between Subjects Effect: F (1, 142) = 0.067; ns (8.2.3 k)

Time: F (2, 284) = 7.118; p<0.01 Interaction Effect: F (2,284) = 2.387; ns Between Subjects Effect: F (1, 142) = 0.270; ns (8.2.3 m)

Time: F (1.674, 237.731) = 0.268; ns Interaction Effect: F (1.674, 237.731) = 0.623; ns Between Subjects Effect: F (1, 142) = 0.511; ns (8.2.3 l)

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An analysis of the Split Plot Repeated Measure ANOVA proved that the

menopausal status of the women with breast cancer had a major effect to a number of

women’s coping strategies, which included Active [F (1, 142) = 14.75; p<0.001] [Pre-

menopausal group used more Active coping in all occasions (prior-to=5.86±1.43;

during=7.27±1.22; post-chemotherapy=5.40±1.55) than the women in the post-

menopausal group (prior-to=5.35±1.59; during=6.79±1.18; post-

chemotherapy=4.48±1.08)] [Table 8.5 (f); Figure 8.2.4 (a)], Planning [F (1, 142) =

9.37; p<0.01] [Pre-menopausal group stated to use Planning strategy more often prior-

to (5.73±1.63), during (6.40±1.42) and post-chemotherapy (6.46±1.42), as compared to

the patients in the post-menopausal group (prior-to=5.24±1.78; during=5.68±1.70;

post-chemotherapy=5.68±1.69)] [Table 8.5 (f); Figure 8.2.4 (b)], Positive Reframing

[F (1, 142) = 6.96; p<0.01] [Once again, the women in the pre-menopausal group were

found to employ more Positive Reframing strategy in all occasions (prior-

to=5.31±1.34; during=6.53±1.29; post-chemotherapy=6.21±1.59) than those in the

post-menopausal group (prior-to=4.75±1.26; during=6.38±1.53; post-

chemotherapy=5.63±1.73)] [Table 8.5 (f); Figure 8.2.4 (c)], Using Emotional Support

[F (1, 142) = 6.35; p<0.05] [Patients in the pre-menopausal group engaged in more

Emotional Support strategy in all conditions (prior-to=5.36±1.43; during=6.35±1.67;

post-chemotherapy=5.35±1.45) as compared to those in the post-menopausal group

(prior to=5.35±1.38; during=5.52±1.79; post=4.79±1.31)] [Table 8.5 (f); Figure 8.2.4

(d)], Using Instrumental Support [F (1, 142) = 4.85; p<0.05] [Pre-menopausal women

were also demonstrated to make use of the Instrumental Support prior- to (5.72±1.68),

during (6.52±1.59) and post-chemotherapy (5.48±1.57) more often than the patients in

the post-menopausal group (prior to=5.29±1.74; during=6.06±1.65; post-

chemotherapy=5.13±1.44)] [Table 8.5 (f); Figure 8.2.4 (e)], Self-distraction [F (1, 142)

= 5.30; p<0.05] [Pre-menopausal group displayed more Self-distraction strategy prior-

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Table 8.5 (f): Split Plot Repeated Measure ANOVA: The Effect of Menopausal Status on the Coping Strategies of the Women with Breast Cancer

Sources of Variation ss df ms f sign

Active Coping Within Subjects Effect: Active coping (Time) 325.128 2 162.564 122.931 p<0.001 Time x Menopausal Status 4.329 2 2.120 1.603 ns Between Subjects Effect: 43.175 1 43.175 14.749 p<0.001 (Effect of Menopausal Status)

Planning Within Subjects Effect: Planning (Time) 30.877 1.074 28.745 11.225 p<0.01 Time x Menopausal Status 1.581 1.074 1.472 0.575 ns Between Subjects Effect: 46.173 1 46.173 9.372 p<0.01 (Effect of Menopausal Status)

Positive Reframing Within Subjects Effect: Positive reframing (Time) 147.731 2 73.866 41.251 p<0.01 Time x Menopausal Status 4.148 2 2.074 1.158 ns

Between Subjects Effect: 19.580 1 19.580 6.955 p<0.01 (Effect of Menopausal Status)

Acceptance Within Subjects Effect: Acceptance (Time) 44.313 1.034 42.849 42.849 p<0.001 Time x Menopausal Status 0.008 1.034 0.007 0.007 ns

Between Subjects Effect: 0.103 1 0.103 0.103 ns (Effect of Menopausal Status)

Using Emotional Support Within Subjects Effect: Using Emotional Support (Time) 55.127 2 27.563 16.573 p<0.001 Time x Menopausal Status 12.154 2 6.077 3.654 p<0.05

Between Subjects Effect: 22.584 1 22.584 6.347 p<0.05 (Effect of Menopausal Status)

Using Instrumental Support Within Subjects Effect: Using Instrumental Support (Time)

77.333 2 38.667 19.050 p<0.001

Time x Menopausal Status 0.195 2 0.195 0.048 ns

Between Subjects Effect: 18.159 1 18.159 4.846 p<0.05 (Effect of Menopausal Status)

Self-distraction Within Subjects Effect: Self-distraction (Time) 15.500 1.018 15.222 6.129 p<0.05

Table 8.5 (f), Continued.

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ss df ms f sign Time x Menopausal Status

0.500 1.018 0.491 0.198 ns

Between Subjects Effect: 27.811 1 27.811 5.302 p<0.05 (Effect of Menopausal Status)

Denial Within Subjects Effect: Denial (Time) 0.331 1.816 0.182 2.255 ns Time x Menopausal Status 0.127 1.816 0.070 0.866 ns Between Subjects Effect: 92.074 1 92.074 16.465 p<0.001 (Effect of Menopausal Status)

Venting Within Subjects Effect: Venting (Time) 1.451 1.164 1.247 7.596 p<0.01 Time x Menopausal Status 0.025 1.164 0.022 0.132 ns

Between Subjects Effect: 57.319 1 57.319 8.127 p<0.01 (Effect of Menopausal Status)

Behavioural Disengagement Within Subjects Effect: Behavioural Disengagement (Time)

0.024 1.585 0.015 0.510 ns

Time x Menopausal Status 0.024 1.585 0.015 0.015 ns

Between Subjects Effect: 7.540 1 7.540 1.893 ns (Effect of Menopausal Status)

Self-blame Within Subjects Effect: Self-blame (Time) 1.556 1.214 1.282 10.586 p<0.01 Time x Menopausal Status 0.111 1.214 0.092 0.758 ns

Between Subjects Effect: 32.122 1 32.122 5.684 p<0.05 (Effect of Menopausal Status)

Problem-focused Strategy Within Subjects Effect: Problem-focused Strategy (Time) 5.995 1.656 3.620 0.280 ns Time x Menopausal status 7.124 1.656 4.303 0.333 ns

Between Subjects Effect: 340.459 1 340.459 12.701 p<0.001 (Effects of Menopausal Status)

Emotion-focused Strategy Within Subjects Effect: Emotion-focused Strategy (Time) 97.707 2 48.854 3.962 p<0.05 Time x Menopausal Status 2.504 2 1.252 0.102 ns

Between Subjects Effect: 256.473 1 256.473 7.914 p<0.01 (Effect of Menopausal Status)

Note: The domains of Humour and Substance Use of Brief COPE were excluded from the analysis as the assumptions for the parametric test were not met

341

-to (5.65±1.47), during (5.99±1.76) and post-chemotherapy (5.65±1.47) as compared

to the post-menopausal group (prior-to=5.11±1.70; during=5.57±1.56; post-

chemotherapy=5.08±1.71)] [Table 8.5 (f); Figure 8.2.4 (f)], Denial [F (1, 142) = 16.47;

p<0.001] [Pre-menopausal women exhibited more Denial strategy in all the treatment

phases (prior-to=6.00±1.47; during=5.93±1.53; post-chemotherapy=6.02±1.49) as

compared to the post-menopausal group (prior-to=5.08±1.21; during=5.03±1.26;

post-chemotherapy=5.05±1.18] [Table 8.5 (f); Figure 8.2.4 (g)], Venting [F (1, 142) =

8.13; p<0.01] [Pre-menopausal women were also found to indicate more use of the

Venting strategy prior-to (5.99±1.52), during (6.11±1.53) and post-chemotherapy

(6.14±1.55) as compared to the post-menopausal women (prior-to=5.27±1.52;

during=5.38±1.61; post-chemotherapy=5.38±1.61)] [Table 8.5 (f); Figure 8.2.4 (h)],

Self-blame [F (1, 142) = 5.68; p<0.05] [Pre-menopausal women tended to use Self-

blame more often in all the treatment phases (prior- to=5.28±1.33; during=5.43±1.52;

post-chemotherapy=5.46±1.54) than those in the post-menopausal group (prior-

to=4.78±1.17; during=4.87±1.34; post-chemotherapy=4.87±1.340] [Table 8.5 (f);

Figure 8.2.4 (i)], Problem-focused Strategy [F (1, 142) = 12.70; p<0.001] [Problem-

focused strategy was higher among the pre-menopausal women in all occasions (prior-

to=17.31±3.85; during=17.46±4.61; post-chemotherapy=17.33±3.27)] [Table 8.5 (f);

Figure 8.2.4 (j)], Emotion-focused Strategy [F (1, 142) = 7.91; p<0.01] [Emotion-

focused Strategy was also higher among the pre-menopausal women prior-to

(29.86±4.65), during (30.46±4.20) and post-chemotherapy (30.93±4.27) as compared

to the post-menopausal women (prior- to=28.13±4.78; during=29.10±4.53; post-

chemotherapy=29.37±3.62)] [Table 8.5 (f); Figure 8.2.4 (k)].

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Figure 8.2.4 (a): The Effect of Menopausal Status on Women's Coping Strategy (Active)

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Pre-menopausal(N=81)Post-menopausal(N=63)

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Figure 8.2.4 (b): The Effect of Menopausal Status on Women's Coping Strategy (Planning)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

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Figure 8.2.4 (c): The Effect of Menopausal Status on Women's Coping Strategy (Positive Reframing)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

Time: F (2, 284) = 122.931; p<0.001 Interaction Effect: F (2, 284) = 1.603; ns Between Subjects Effect: F (1, 142) = 14.749; p<0.001 (8.2.4 a)

Time: F (1.074, 152.53) =11.225; p<0.01 Interaction Effect: F (1.074, 152.53) = 0.575; ns Between Subjects Effect: F (1, 142) = 9.372; p<0.01 (8.2.4 b)

Time: F (2, 284) = 41.251; p<0.001 Interaction Effect: F (2, 284) = 1.158; ns Between Subjects Effect: F (1, 142) = 6.955; p<0.01 (8.2.4 c)

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Figure 8.2.4 (d): The Effect of Menopausal Status on Women's Coping Strategy (Using Emotional Support)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

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Figure 8.2.4 (e): The Effect of Menopausal Status on Women's Coping Strategy

(Using Instrumental Support)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

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Figure 8.2.4 (f): The Effect of Menopausal Status on Women's Coping Strategy (Self-distraction)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

Time: F (2, 284) = 16.573; p<0.001 Interaction Effect: F (2, 284) = 3.654; p<0.05 Between Subjects Effect: F (1, 142) = 6.347; p<0.05 (8.2.4 d)

Time: F (2, 284) = 19.050; p<0.001 Interaction Effect: F (2, 284) = 0.048; ns Between Subjects Effect: F (1, 142) = 4.846; p<0.05 (8.2.4 e)

Time: F (1.018, 144.597) = 6.129; p<0.05 Interaction Effect: F (1.018, 144.597) = 0.198; ns Between Subjects Effect: F (1, 142) = 5.302; p<0.05 (8.2.4 f)

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Figure 8.2.4 (g): The Effect of Menopausal Status on Women's Coping Strategy (Denial)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

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PostChemotherapy

Figure 8.2.4 (h): The Effect of Menopausal Status on Women's Coping Strategy (Venting)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

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PostChemotherapy

Figure 8.2.4 (i): The Effect of Menopausal Status on Women's Coping Strategy (Self-blame)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

Time: F (1.816, 257.897) = 2.255; ns Interaction Effects: F (1.816, 257.897) = 0.866; ns Between Subjects Effect: F (1, 142) = 16.465; p<0.001 (8.2.4 g)

Time: F (1.164, 165.302) = 7.596; p<0.01 Interaction Effects: F (1.164, 165.30) = 0.132; ns Between Subjects Effect: F (1, 142) = 8.127; p<0.01 (8.2.4 h-ven)

Time: F (1.214, 172.340) = 10.586; p<0.01 Interaction Effect: F (1.214, 172.340) = 0.758; ns Between Subjects Effect: F (1, 142) = 5.684; p<0.05 (8.2.4 i)

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Figure 8.2.4 (j): The Effect of Menopausal Status on Women's Coping Strategy (Problem-focused Strategy)

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Post-menopausal (N=63)

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Figure 8.2.4 (k): The Effect of Menopausal Status on Women's Coping Strategy (Emotion-focused Strategy)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

Nevertheless, the menopausal status of the patients was observed to be insignificant for

Acceptance [F (1, 142) = 0.03; ns] [Table 8.7 (f); Figure 8.3.4 (l)] and Behavioural

Disengagement [F (1, 142) = 1.89; ns] [Table 8.7 (f); Figure 8.3.4 (m)].

Time: F (1.656, 235.128) = 0.280; ns Interaction Effect: F (1.656, 235.128) = 0.333; ns Between Subjects Effect: F (1, 142) = 12.701; p<0.001 (8.2.4 j)

Time: F (2, 284) = 3.962; p<0.05 Interaction Effect: F (2, 284) = 0.012; ns Between Subjects Effect: F (1, 142) = 7.914; p<0.01 (8.2.4 k)

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Figure 8.2.4 (l): The Effect of Menopausal Status on Women's Coping Strategy (Acceptance)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

0

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Figure 8.2.4 (m): The Effect of Menopausal Status on Women's Coping Strategy

(Behavioral Disengagement)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

As indicated by analysis of the Split Plot Repeated Measure ANOVA, ethnicity

was found to impose a significant effect on nearly all types of the breast cancer

patients’ coping strategies like Active Coping [F (1, 154) = 8.44; p<0.001] [Indian

women used more Active strategy prior-to chemotherapy (5.97±1.50), followed by

Malay women (5.87±1.42) and Chinese women (5.00±1.61). However, Malay women

indicated the highest score for Active strategy during (7.30±1.08) and post-

chemotherapy (5.22±1.37), followed by Indian women (during=7.27±1.11; post-

Time: F (1.034, 146.852) = 23.502; p<0.001 Interaction Effect: F (1.034, 146.852) = 0.004; ns Between Subjects Effect: F (1, 142) = 0.025; ns (8.2.4 l)

Time: F (1.585, 225.061) = 0.510; ns Interaction Effect: F (1.585, 225.061) = 0.015; ns Between Subjects Effect: F (1, 142) = 1.893; ns (8.2.4 m)

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chemotherapy=4.93±1.53) and Chinese women (during=6.71±1.33; post-

chemotherapy=4.61±1.31)] [Table 8.5 (g); Figure 8.2.5 (a)], Planning [F (2, 154) =

6.75; p<0.01] [Malay women were indicated to use the Planning strategy prior-to

(5.83±1.54), during (6.38±1.30) and post-chemotherapy (6.46±1.32) more often than

the Indian (prior-to=5.67±1.79; during=6.30±1.56; post-chemotherapy=6.23±1.63)

and Chinese women (prior-to=4.86±1.67; during=5.67±1.84; post-

chemotherapy=5.69±1.77)] [Table 8.5 (g); Figure 8.2.5 (b)], Positive Reframing [F (2,

154) = 8.78; p<0.001] [Prior to chemotherapy, Indian women (5.43±1.36) used more of

the Positive Reframing strategy, and this was closely trailed by the Malay (5.08±1.34)

and Chinese women (4.73±1.18). During and post-chemotherapy, Malay women

scored the highest (during=6.72±1.27; post-chemotherapy=6.18±1.45) for the use of

Positive Reframing, followed by Indian women (during=6.70±1.12; post-

chemotherapy=6.07±1.82) and Chinese women (during=5.84±1.54; post-

chemotherapy=5.47±1.75)] [Table 8.5 (g); Figure 8.2.5 (c)], Acceptance [F (2, 154) =

8.07; p<0.001] [Once again, the Malay women were found to use more of the

Acceptance Strategy prior-to (6.91±1.22) and during chemotherapy (6.89±1.25), as

compared to the Indian women (prior-to=6.37±1.16; during=5.78±1.74) and Chinese

women (prior=5.75±1.72; during=5.78±1.74). However, Indian women were found to

score the highest in the use of Acceptance strategy at post- chemotherapy (7.27±1.14),

followed by Malay (7.21±1.15) and Chinese women (7.02±1.56)] [Table 8.5 (g); Figure

8.2.5 (d)], Using Emotional Support [F (2, 154) = 5.01; p<0.01] [Indian women used

more Emotional Support in all occasions (prior-to=5.77±1.10; during=6.50±1.53;

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Table 8.5 (g): Split Plot Repeated Measure ANOVA: The Effect of Ethnicity on the Use of Coping Strategies Among Women with Breast Cancer

Sources of Variation ss df ms f sign

Active Coping Within Subjects Effect: Active coping (Time) 334.773 2 167.386 121.516 p<0.001 Time x Ethnicity 4.317 4 1.079 0.784 ns Between Subjects Effect: 47.043 2 23.521 8.442 p<0.001 (Effect of Ethnicity)

Planning Within Subjects Effect: Planning (Time) 40.587 1.075 37.744 15.017 p<0.001 Time x Ethnicity 1.339 2.151 0.623 0.248 ns Between Subjects Effect: 63.478 2 31.739 6.750 p<0.01 (Effect of Ethnicity)

Positive Reframing Within Subjects Effect: Positive Reframing (Time) 125.015 2 62.507 36.140 p<0.001 Time x Ethnicity 5.729 4 1.432 0.828 ns

Between Subjects Effect: 46.603 2 23.301 8.783 p<0.001 (Effect of Ethnicity)

Acceptance Within Subjects Effect: Acceptance (Time) 61.245 1.039 58.933 34.418 p<0.001 Time x Ethnicity 18.960 2.078 9.122 5.327 p<0.01

Between Subjects Effect: 61.776 2 30.888 8.073 p<0.001 (Effect of Ethnicity )

Using Emotional Support Within Subjects Effect: Using Emotional Support (Time) 75.310 2 37.655 22.379 p<0.001 Time x Ethnicity 3.303 4 0.826 0.491 ns

Between Subjects Effect: 34.608 2 17.304 5.014 p<0.01 (Effect of Ethnicity)

Using Instrumental Support Within Subjects Effect: Using Instrumental Support (Time) 88.280 2 44.140 22.489 p<0.001 Time x Ethnicity 14.341 4 3.585 1.827 ns

Between Subjects Effect: 129.406 2 14.703 4.246 p<0.05 (Effect of Ethnicity)

Self-distraction

Within Subjects Effect: Self-distraction (time) 14.662 1.023 14.329 5.679 p<0.05

Table 8.5 (g), Continued.

349

ss df ms f sign Time x Ethnicity 2.268 2.046 1.108 0.439 ns Between Subjects Effect: 127.906 2 63.953 13.522 p<0.01 (Effects of Ethnicity)

Denial Within Subjects Effect: Denial (Time) 0.225 1.812 0.124 1.666 ns Time x Ethnicity 0.226 3.624 0.062 0.837 ns Between Subjects Effect: 28.773 2 14.386 2.305 ns (Effect of Ethnicity)

Venting Within Subjects Effect: Venting (Time) 0.956 1.164 0.821 5.367 p<0.05 Time x Ethnicity 0.352 2.329 0.151 0.989 ns

Between Subjects Effect: 111.024 2 55.512 8.495 p<0.001 (Effect of Ethnicity )

Behavioural Disengagement Within Subjects Effect: Behavioural Disengagement (Time) 0.016 1.590 0.010 0.010 ns Time x Ethnicity 0.032 3.181 0.010 0.010 ns

Between Subjects Effect: 18.289 2 9.144 9.144 ns (Effect of Ethnicity)

Self-blame Within Subjects Effect: Self-blame (Time) 1.818 1.203 1.512 12.324 p<0.001 Time x Ethnicity 0.725 2.406 0.302 2.458 ns

Between Subjects Effect: 20.930 2 10.465 1.912 ns (Effect of Ethnicity)

Problem-focused Strategy Within Subjects Effect: Problem-focused Strategy (Time) 17.095 1.644 10.401 0.799 ns Time x Ethnicity 47.750 3.287 14.526 1.116 ns

Between Subjects Effect: 418.334 2 209.167 8.292 p<0.001

(Effect of Ethnicity) Emotion-focused Strategy

Within Subjects Effect: Emotion-focused Strategy (Time) 99.306 1.948 50.970 4.191 p<0.05 Time x Ethnicity 78.698 3.897 20.196 1.661 ns

Between Subjects Effect: 1116.100 2 558.0 19.328 p<0.001

Note: The domains of Humour and Substance Use of Brief COPE were excluded from the analysis as the assumptions for the parametric test were not met

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Figure 8.2.5 (a): The Effect of Ethnicity onWomen's Coping Strategy (Active)

Mea

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Chinese (N=51)

Indian (N=30)

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Figure 8.2.5 (b): The Effect of Ethnicity on Women's Coping Strategy (Planning)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.2.5 (c): The Effect of Ethnicity on Women's Coping Strategy (Positive Reframing)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (1.075, 165.599) = 15.017; p<0.001 Interaction Effect: F (2.151, 165.599) = 0.248; ns Between Subjects Effect: F (2, 154) = 6.750; p<0.01 (8.2.5 b)

Time: F (2, 308) = 36.140; p<0.001 Interaction Effect: F (4, 308) = 0.828; ns Between Subjects Effect: F (2, 154) = 8.783; p<0.001 (8.2.5 c)

Time: F (2, 308) = 121.516; p<0.001 Interaction Effect: F (4, 308) = 0.784; ns Between Subjects Effect: F (2, 154) = 8.44; p<0.001 (8.2.5 a)

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Figure 8.2.5 (d): The Effect of Ethnicity on Women's Coping Strategy (Acceptance)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.2.5 (e): The Effect of Ethnicity on Women's Coping Strategy (Using Emotional Support)

Mea

n s

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s

Malay (N=76)

Chinese (N=51)

Indian (N=30)

post-chemotherapy=5.27±1.41), as compared to the Malay women (prior-

to=5.45±1.35; during=6.04±5.75; post-chemotherapy=5.22±1.36) and Chinese women

(prior-to=4.84±1.59; during=5.75±1.83; post-chemotherapy=4.75±1.40)] [Table 8.5

(g); Figure 8.2.5 (e)], Using Instrumental Support [F (2, 154) = 4.25; p<0.05] [Malay

women had the highest scores of the use of Instrumental Support prior-to (5.72±1.68)

and post-chemotherapy (5.43±1.44), and this was followed by Indian women (prior-

to=6.13±1.53; post-chemotherapy=5.27±1.72) and the Chinese (prior-to=4.86±1.59;

post-chemotherapy=5.14±1.39). Nevertheless, both Malay (6.50±1.56) and Indian

women (6.50±1.48) scored the same level for the use of Instrumental Support during

Time: F (1.039, 160.041) = 34.418; p<0.001 Interaction Effect: F (2.078, 160.041) = 5.327; p<0.01 Between Subjects Effect: F (2, 154) = 8.073; p<0.001 (8.2.5 d)

Time: F (2, 308) = 22.379; p<0.001 Interaction Effect: F (4, 308) = 0.491; ns Between Subjects Effect: F (2, 154) = 5.014; p<0.01 (8.2.5 e)

352

chemotherapy, followed by Chinese women (6.14±1.73)] [Table 8.5 (g); Figure 8.2.5

(f)], Self-distraction [F (2, 154) = 13.52; p<0.01] [Once again, the Malay women

obtained the highest scores for Self-distraction throughout the three phases (prior-

to=5.93±1.56, during=6.16±1.38 and post-chemotherapy=5.91±1.58), followed by

Indian women (prior=5.63±1.52; during=6.03±1.69; post-menopausal=5.63±1.52)

and Chinese women (prior-to=4.65±1.48; during=5.22±1.89; post-

chemotherapy=4.65±1.48)] [Table 8.5 (g); Figure 8.2.5 (g)], Venting [F (2, 154) =

8.50; p<0.001][Indian women exhibited more Venting strategy in all the treatment

phases (prior-to=6.23±1.45; during=6.23±1.45; post-chemotherapy=6.30±1.49) than

the Malay women (prior-to=5.87±1.53; during=6.04±1.57; post-

chemotherapy=6.04±1.57) and Chinese women (prior-to=4.98; during=5.08±1.44;

post-chemotherapy=5.08±1.44)] [Table 8.5 (g); Figure 8.2.5 (h)], Problem-focused

Strategy [F (2, 154) = 8.29; p<0.001] [Indian women demonstrated more Problem-

focused strategy prior-to (17.77±4.11) and during chemotherapy (17.60±5.00), and this

was closely followed by Malay women (prior-to=17.42±3.52; during=17.26±3.79) and

Chinese women (prior-to=14.73±4.10; during=15.61±5.72). Nonetheless, Malay

women demonstrated more of such strategy at post-chemotherapy (17.12±2.75), than

the Indian (16.43±3.30) and Chinese women (15.43±3.45)] [Table 8.5 (g); Figure 8.2.5

(i)] and Emotion-focused Strategy [F (2, 154) = 19.33; p<0.001] [Indian women

exhibited more Emotion-focused strategy throughout the three phases (prior-

to=30.67±4.68, during=31.30±4.68 and post-chemotherapy=30.80±4.32), as

compared to the Malay women (prior-to=30.30±3.67; during=30.75±3.43; post-

chemotherapy=30.97±3.67) and Chinese women (prior-to=26.02±5.27;

during=27.80±4.80; post-chemotherapy=28.57±4.11)] [Table 8.5 (g); Figure 8.2.5 (j)].

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Figure 8.2.5 (f): The Effect of Ethnicity on Women's Coping Strategy (Using Instrumental Support)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.2.5 (g): The Effect of Ethnicity Women's Coping Strategy (Self-distraction)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.2.5 (h): The Effect of Ethnicity on Women's Coping Strategy (Venting)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (2, 308) = 22.489; p<0.001 Interaction Effect: F (4, 308) = 1.827; ns Between Subjects Effect: F (2, 154) = 4.246; p<0.05 (8.2.5 f)

Time: F (1.023, 157.579) = 5.679; p<0.05 Interaction Effect: F (2.046, 157.579) = 0.439; ns Between Subjects Effect: F (1, 154) = 13.522; p<0.01 (8.2.5 g)

Time: F (1.164, 179.318) = 5.367; p<0.05 Interaction Effect: F (2.329, 179.318) = 0.989; ns Between Subjects Effect: F (2, 154) = 8.495; p<0.001 (8.2.5 h)

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Figure 8.2.5 (i): The Effect of Ethnicity on Women's Coping Strategy (Problem-focused Strategy)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.2.5 (j): The Effect of Ethnicity on Women's Coping Strategy (Emotion-focused Strategy)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

However, the significant effect of ethnicity was not indicated for Denial [F (2, 154) =

2.31; ns] [Table 8.5 (g); Figure 8.2.4 (l)], Behavioural Disengagement [F (2, 154) =

2.31; ns] and Self-blame [F (2, 154) = 1.91; ns] [Table 8.5 (g); Figure 8.2.5 (m)].

Time: F (1.644, 253.121) = 0.799; ns Interaction Effect: F (3.287, 253.121) = 1.116; ns Between Subjects Effect: F (2, 154) = 8.292; p<0.001 ( 8.2.5 i-prob)

Time: F (1.948, 300.043) = 4.191; p<0.05 Interaction Effect: F (3.897, 300.043) = 1.661; ns Between Subjects Effect: F (2, 154) = 19.328; p<0.001 (8.2.5 j)

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Figure 8.2.5 (k): The Effect of Ethnicity on Women's Coping Strategy (Denial)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.2.5 (l): The Effect of Ethnicity on Women's Coping Strategy (Behavioral Disengagement)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.2.5 (m): The Effect of Ethnicity on Women's Coping Strategy (Self-blame)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (1.812, 279.052) = 1.666; ns Interaction Effect: F (3.624, 279.057) = 0.837; ns Between Subjects Effect (2, 154) = 2.305; ns (8.2.5 k)

Time: F (1.590, 244.906) = 0.38; ns Interaction Effect: F (3.181, 244.906) = 0.367; ns Between Subjects Effect: F (2, 154) = 2.310; ns (8.2.5 l)

Time: F (1.203, 185.240) = 12.324; p<0.001 Interaction Effect: F (2.406; 185.240) = 2.458; ns Between Subjects Effect: F (2, 154) = 1.912; ns (8.2.5 m)

356

A separate analysis carried out at the individual level for the husbands

revealed the significant effect of time for most of the husbands’ coping strategies,

including Active Coping [F (2, 312) = 41.94; p<0.001] [Husbands’ Active coping was

found to increase from prior-to (4.29±1.29) to during chemotherapy (5.45±1.40), but

reduced at post-chemotherapy (4.84±1.27)], Planning [F (1.00, 156) = 1548.45;

p<0.001] [In the same way, the husbands’ Planning strategy was also demonstrated as

improving from prior-to (4.74±1.40) to during (5.74±1.40), but it declined at post-

chemotherapy (4.84±1.27)], Positive Reframing [F (1.02, 159.78) = 12.71; p<0.001]

[Husbands’ Positive Reframing was elevated from prior-to (5.10±1.36) to during

(5.59±1.56), but slightly declined at post-chemotherapy (5.56±1.55)], Religion [F (2,

312) = 73.50; p<0.001] [Husbands’ focus on Religion was obviously improved from

prior-to (4.90±1.33) to during chemotherapy (6.07±1.45), but this was revealed to

lessen at post-chemotherapy (4.83±1.54)], Using Emotional Support [F (1.73, 269.85)

= 5.46; p<0.01] [As for Emotional Support, the husband’s use of this type of support

was slightly increased from prior-to (5.31±1.44) to during chemotherapy (5.39±1.33),

but it diminished at post-chemotherapy (4.88±1.88)], Using Instrumental Support [F

(1.74, 270.78) = 8.29; p<0.05] [Husbands’ use of Instrumental Strategy increased from

prior-to (5.65±1.41) to during chemotherapy 73±1.48), but it decreased after that

(post-chemotherapy=5.15±1.74)], Self-distraction [F (2, 312) = 36.82; p<0.001] [The

utilization of the Self-distraction strategy by the husbands was shown to raise from

prior-to (5.21±1.38) to during the treatment (6.02±1.47), but it was found to dwindle

post-chemotherapy (4.87±1.47)], Denial [F (1.04, 161.70) = 437.06; p<0.001] [A slight

increment was observed by the husbands’ use of Denial strategy from prior to

(4.85±1.27) to during chemotherapy (4.87±1.31), but their use of this particular

strategy was indicated to drop thereafter (post-chemotherapy=2.47±1.14)], Venting [F

(2, 312) = 201.51; p<0.001] [The same pattern of use was demonstrated for the Venting

357

strategy by the husband; i.e. it increased from prior-to (5.27±1.27) to during

chemotherapy (5.55±1.34), but declined at post-chemotherapy (3.38±1.52)], Problem-

focused Strategy [F (1.94, 302.98) = 25.00; p<0.001] [Husbands were found to employ

more Problem-focused Strategy prior-to (14.68±3.16) and during chemotherapy

(16.04±3.93); nevertheless, they indicated to use this particular strategy slightly lesser

at post-chemotherapy (14.54±2.99)] and Emotion-focused Strategy [F (2, 312) =

22.663; p<0.001] [On the contrary to the utilization of other strategies, the husbands’

use of Emotion-focused Strategy was found to decrease over time (prior-

to=26.59±4.20; during=25.74±4.92; post-chemotherapy=23.97±4.35] [Table 8.5 (h);

Figures 8.2.6 (a), (b)]. For this, the results gathered from the Friedman analysis also

suggested the significant effect of time on Humour (χ2 = 29.57; df = 2; p<0.001)

[Husbands’ use of Humour strategy was found to decline over time (prior-

to=2.68±1.22; during=2.59±1.27; post-chemotherapy=2.22±0.79] [Table 8.5 (i);

Figure 8.2.6 (a)]. However, no significant effect of time was detected for some other

coping strategies, such as Acceptance [F (1.85, 288.45) = 1.02; ns], Behavioural

Disengagement [F (1.05, 163.29) = 0.25; ns], Self-blame [F (1.51, 234.99) = 1.00; ns]

[Table 8.5 (h); Figures 8.2.6 (a)] and Substance Use (χ2 = 3.29; df = 2; ns) [Table 8.5

(i); Figure 8.2.6 (a)].

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Table 8.5 (h): One-way Repeated Measure ANOVA: The Coping Strategies of the Husbands

Sources of Variation ss df ms f sign Active Coping 115.686 2 57.843 41.939 p<0.001 Planning 95.087 1.000 95.087 1548.452 p<0.001 Positive reframing 23.648 1.024 23.088 12.705 p<0.001 Acceptance 3.834 1.849 2.074 1.019 ns Humour* (Non-Parametric Table) Religion 152.870 2 76.435 73.499 p<0.001 Using emotional support 23.711 1.730 13.708 5.459 p<0.01 Using instrumental support 31.138 1.736 17.940 8.287 p<0.05 Self-distraction 109.992 2 54.996 36.821 p<0.001 Denial 600.374 1.037 579.208 437.057 p<0.001 Venting 436.641 2 218.321 201.512 p<0.001 Substance Use* (Non-Parametric Table) Behavioural Disengagement 0.204 1.047 0.195 0.254 ns Self-blame 0.051 1.506 0.034 1.000 ns Problem-focused Strategy 217.329 1.942 111.899 25.002 p<0.001 Emotion-focused Strategy 557.363 2 278.682 22.663 p<0.001

*The non-parametric analysis was used as the assumptions for the parametric analysis were not met

Table 8.5 (i): Non-parametric Analysis (Friedman Test): The Coping Strategies of the Husbands.

χ2 df sign Humour

29.57

2

p<0.001

Substance Use

3.29 2 ns

Note: The non-parametric analysis was used as the assumptions for the parametric analysis were not met

359

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Figure 8.2.6 (b): Husbands' Problem- and Emotion-focused Strategies

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DuringChemotherapyPost-chemotherapy

With the exception given to Positive Reframing [F (1, 155) = 5.16; p<0.05]

[The lumpectomy group exhibited using more of the Active strategy prior-to

(4.30±1.36) and during chemotherapy (5.91±1.51), as compared to the mastectomy

group (prior-to=4.28±1.27; during=5.32±1.64). On the contrary, the mastectomy

group indicated more use of this Active strategy than the lumpectomy group post-

chemotherapy (4.58±1.38 and 4.45±1.15 respectively)] [Table 8.5 (j); Figure 8.2.7 (a)],

the analysis of the Split Plot Repeated Measure ANOVA revealed that the types of

surgery did not significantly influence the husbands’ coping strategies, such as Active

[F (1, 155) = 0.61; ns] [Table 8.5 (j); Figure 8.2.7 (b)], Planning [F (1, 155) = 0.07; ns]

[Table 8.5 (j); Figure 8.2.7 (c)], Acceptance [F (1, 155) = 1.67; ns] [Table 8.5 (j);

Figure 8.2.7 (d)], Religion [F (1, 155) = 0.54; ns] [Table 8.5 (j); Figure 8.2.7 (e)], Using

Emotional Support [F (1, 155) = 0.01; ns] [Table 8.5 (j); Figure 8.2.7 (f)], Using

Instrumental Support [F (1, 155) = 0.32; ns] [Table 8.5 (j); Figure 8.2.7 (g)], Self-

distraction [F (1, 155) = 0.65; ns] [Table 8.5 (j); Figure 8.2.7 (h)], Denial [F (1, 155) =

0.40; ns] [Table 8.5 (j); Figure 8.2.7 (i)], Venting [F (1, 155) = 0.02; ns] [Table 8.5 (j);

Figure 8.2.7 (j)], Behavioural Disengagement [F (1, 155) = 1.66; ns] [Table 8.5 (j);

F (1.94, 302.98) = 25.00; p<0.001

F (2, 312) = 22.663; p<0.001

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Table 8.5 (j): Split Plot Repeated Measure ANOVA: The Effect of the Types of Surgery on the Husbands’ Coping Strategies

Sources of Variation ss df ms f sign

Active Coping Within Subjects Effect: Active coping (Time) 104.518 2 52.259 38.304 p<0.01 Time x Types of surgery 7.380 2 3.690 2.705 ns Between Subjects Effect: 2.012 1 2.012 0.605 ns (Effect of Types of surgery)

Planning Within Subjects Effect: Planning (Time) 62.753 2 31.377 1016.464 p<0.01 Time x Types of surgery 0.010 2 0.005 0.168 ns Between Subjects Effect: 0.386 1 0.386 0.070 ns (Effect of Types of surgery)

Positive Reframing Within Subjects Effect: Positive reframing (Time) 33.071 1.032 32.058 18.257 p<0.001 Time x Types of surgery 9.589 1.032 9.295 5.294 p<0.05

Between Subjects Effect: 24.303 1 24.303 5.158 p<0.05 (Effect of Types of surgery)

Acceptance Within Subjects Effect: Acceptance (Time) 5.391 1.856 2.904 1.429 ns Time x Types of surgery 2.248 1.856 1.211 0.596 ns

Between Subjects Effect: 4.827 1 4.827 1.669 ns (Effect of Types of surgery)

Religion Within Subjects Effect: Religion (Time) 107.666 2 53.833 51.483 p<0.001 Time x Types of surgery 0.311 2 0.156 0.149 ns

Between Subjects Effect: 2.253 1 2.253 0.537 ns (Effect of Types of surgery)

Using Emotional Support Within Subjects Effect: Using Emotional Support (Time) 16.919 1.731 9.774 3.894 p<0.05 Time x Types of surgery 4.129 1.731 2.385 0.950 ns

Between Subjects Effect: 0.016 1 0.016 0.005 ns (Effect of Types of surgery)

Using Instrumental Support Within Subjects Effect: Using Instrumental Support (Time)

33.525 1.709 19.613 9.078 p<0.001

Table 8.5 (j), Continued.

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ss df ms f sign Time x Types of surgery 13.754 1.709 8.046 3.724 p<0.05

Between Subjects Effect: 1.091 1 1.091 0.316 ns (Effects of Types of surgery)

Self-distraction Within Subjects Effect: Self-distraction (Time) 84.162 2 42.081 28.247 p<0.001 Time x Types of surgery 4.188 2 2.094 1.405 ns Between Subjects Effect: 2.111 1 2.111 0.648 ns (Effect of Types of surgery)

Denial Within Subjects Effect: Denial (Time) 398.599 1.043 382.16 288.345 p<0.001 Time x Types of surgery 0.026 1.043 0.025 0.019 ns Between Subjects Effect: 1.303 1 1.303 0.398 ns (Effect of Types of surgery)

Venting Within Subjects Effect: Venting (Time) 303.323 2 151.66 139.502 p<0.001 Time x Types of surgery 139.502 2 0.502 0.462 ns

Between Subjects Effect: 303.323 1 0.066 0.019 ns (Effect of Types of surgery)

Behavioural Disengagement Within Subjects Effect: Behavioural Disengagement (Time)

0.903 1.054 0.857 1.130 ns

Time x Types of surgery 1.175 1.054 1.115 1.469 ns

Between Subjects Effect: 2.525 1 2.525 1.655 ns (Effects of Types of surgery)

Self-blame Within Subjects Effect: Self-blame (Time) 0.085 1.520 0.056 1.675 ns Time x Types of surgery 0.0051 1.520 0.034 1.008 ns

Between Subjects Effect: 1.242 1 1.242 0.714 ns (Effect of Types of surgery)

Problem-focused Strategy Within Subjects Effect: Problem-focused Strategy (Time) 239.606 1.947 123.04 28.141 p<0.001 Time x Types of surgery 36.277 1.947 18.628 4.261 p<0.05

Between Subjects Effect: 0.697 1 0.697 0.027 ns (Effect of Types of surgery)

Table 8.5 (j), Continued.

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ss df ms f sign Emotion-focused Strategy

Within Subjects Effect: Emotion-focused Strategy (Time) 333.793 2 166.90 13.642 p<0.001 Time x Types of surgery 44.154 2 22.077 1.805 ns

Between Subjects Effect: 22.690 1 22.690 0.626 ns (Effect of Types of surgery)

Note: The domains of Humour and Substance Use of Brief COPE were excluded from the analysis as the assumptions for the parametric test were not met

Figure 8.2.7 (k)], Self-blame [F (1, 155) = 0.71; ns] [Table 8.5 (j); Figure 8.2.7 (l)],

Problem-focused Strategy [F (1, 155) = 0.03] [Table 8.5 (j); Figure 8.2.7 (m)] and

Emotion-focused Strategy [F (1, 155) = 0.63; ns] [Table 8.5 (j); Figure 8.2.7 (n)].

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Figure 8.2.7 (a): The Effect of Types of Surgery on Husbands Coping Strategy (Positive Reframing)

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Mastectomy (N=124)

Lumpectomy (N=33)

Time: F (1.032, 159.898) = 18.257; p<0.001 Interaction Effect: F (1.032, 159.898) = 5.294; p<0.05 Between Subjects Effect: F (1, 155) = 5.158; p<0.05 (8.2.7 a)

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Figure 8.2.7 (b): The Effect of Types of Surgery on Husbands' Coping Strategy (Active)

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Mastectomy (N=124)

Lumpectomy (N=33)

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Figure 8.2.7 (c): The Effect of Type of Surgery on Husbands' Coping Strategy (Planning)

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Lumpectomy (N=33)

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Figure 8.2.7 (d): The Effect of Type of Surgery on Husbands' Coping Strategy (Acceptance)

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Mastectomy (N=124)

Lumpectomy (N=33)

Time: F (2, 310) = 38.304; p<0.01 Interaction Effect: F (2, 310) = 2.705; ns Between Subjects Effect: F (1, 155) = 0.605; ns (8.2.7 b)

Time: F (2, 310) = 1016.464; p<0.01 Interaction Effect: F (2, 310) = 0.168; ns Between Subjects Effect: F (1, 155) = 0.070; ns (8.2.7 c)

Time: F (1.856, 287.685) = 1.429; ns Interaction Effect: F (1.856, 287.685) = 0.596; ns Between Subjects Effect: F (1, 155) = 1.669; ns (8.2.7 d)

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Figure 8.2.7 (e): The Effect of Types of Surgery on Husbands' Coping Strategy (Religion)

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Mastectomy (N=124)

Lumpectomy (N=33)

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Figure 8.2.7 (f): The Effect of Types of Surgery on Husbands' Coping Strategy (Using Emotional Support)

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Mastectomy (N=124)

Lumpectomy (N=33)

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Figure 8.2.7 (g): The Effect of Types of Surgery on Husbands' Coping Strategy

(Using Instrumental Support)

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Mastectomy (N=124)

Lumpectomy (N=33)

Time: F (2, 310) = 51.483; p<0.001 Interaction Effect: F (2, 310) = 0.149; ns Between Subjects Effect: F (1, 155) = 0.537; ns (8.2.7 e)

Time: F (1.731, 268.291) = 3.894; p<0.05 Interaction Effect: F (1.731, 268.291) = 0.950; ns Between Subjects Effect: F (1, 155) = 0.005; ns (8.2.7 f)

Time: F (1.709, 264.949) = 9.078; p<0.001 Interaction Effect: F (1.709, 264, 949) = 3.724; p<0.05 Between Subjects Effect: F (1, 155) = 0.316; ns (8.2.7 g)

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Figure 8.2.7 (h): The Effect of Types of Surgery on Husbands' Coping Strategy (Self-distraction)

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Mastectomy (N=124)

Lumpectomy (N=33)

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Figure 8.2.7 (i): The Effect of Types of Surgery on Husbands' Coping Strategy (Denial)

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Mastectomy (N=124)

Lumpectomy (N=33)

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Figure 8.2.7 (j): The Effect of Types of Surgery on Husbands' Coping Strategy (Venting)

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Mastectomy (N=124)

Lumpectomy (N=33)

Time: F (2, 310) = 28.247; p<0.001 Interaction Effect: F (2, 310) = 1.405; ns Between Subjects Effect: F (1, 155) = 0.648; ns (8.2.7 h)

Time: F (1.043, 161.669) = 288.345; p<0.001 Interaction Effect: F (1.043, 161.669) = 0.019; ns Between Subjects Effect: F (1, 155) = 0.398; ns (8.2.7 i-den)

Time: F (2, 310) = 139.502; p<0.001 Interaction Effect: F (2, 310) = 0.462; ns Between Subjects Effect: F (1, 155) = 0.019; ns (8.2.7 j)

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Figure 8.2.7 (l): The Effect of Types of Surgery on Husbands Coping Strategy (Self-blame)

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Lumpectomy (N=33)

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Figure 8.2.7 (k): The Effect of Types of Surgery on Husbands' Coping Strategy (Behavioral Disengagement)

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Lumpectomy (N=33)

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Figure 8.2.7 (m): The Effect of Types of Surgery on Husbands' Coping Strategy (Problem-focused Strategy)

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Lumpectomy (N=33)

Time: F (1.054, 163.355) = 1.130; ns Interaction Effect: F (1.054, 163.355) = 1.469; ns Between Subjects Effect: F (1, 155) = 1.655; ns (8.2.7 k)

Time: F (1.520, 235.571) = 1.675; ns Interaction Effect: F (1.520, 235.571) = 1.008; ns Between Subjects Effect: F (1, 155) = 0.714; ns (8.2.7 l)

Time: F (1.947, 301.850) = 28.141; p<0.001 Interaction Effect: F (1.947, 301.850) = 4.261; p<0.05 Between Subjects Effect: F (1, 155) = 0.027; ns (8.2.7 m)

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Figure 8.2.7 (n): The Effect of Types of Surgery on Husbands Coping Strategy (Emotion-focused Strategy)

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Mastectomy (N=124)

Lumpectomy (N=33)

Breast cancer stages revealed the non-significant effect for all types of the

husbands’ coping strategies, which included Active Coping [F (1, 142) = 0.11; ns]

[Table 7.5 (k); Figure 7.2.8 (a)], Planning [F (1, 142) = 0.01; ns] [Table 7.5 (k); Figure

7.2.8 (b)], Positive Reframing [F (1, 142) = 2.45; ns] [Table 8.5 (k); Figure 8.2.8 (c)],

Acceptance [F (1, 142) = 0.35; ns] [Table 8.5 (k); Figure 8.2.8 (d)], Religion [F (1, 142)

= 1.00; ns] [Table 8.5 (k); Figure 8.2.8 (e)], Using Emotional Support [F (1, 142) =

3.51; ns] [Table 8.5 (k); Figure 8.2.8 (f)], Using Instrumental Support [F (1, 142) =

1.07; ns] [Table 8.5 (k); Figure 8.2.8 (g)], Self-distraction [F (1, 142) = 2.04; ns] [Table

8.5 (k); Figure 8.2.8 (h)], Denial [F (1, 142) = 0.00; ns] [Table 8.5 (k); Figure 8.2.8 (i)],

Venting [F (1, 142) = 0.26; ns] [Table 8.5 (k); Figure 8.2.8 (j)], Behavioural

Disengagement [F (1, 142) = 0.02; ns] [Table 8.5 (k); Figure 8.2.8 (k)], Self-blame [F

(1, 142) = 0.68; ns] [Table 8.5 (k); Figure 8.2.8 (l)], Problem-focused Strategy [F (1,

142) = 0.11; ns] [Table 8.5 (k); Figure 8.2.8 (m)] and Emotion-focused Strategy [F (1,

142) = 2.53; ns] [Table 8.5 (k); Figure 8.2.8 (n)].

Time: F (2, 310) = 13.642; p<0.001 Interaction Effect: F (2, 310) = 1.805; ns Between Subjects Effect: F (1, 155) = 0.626; ns (8.2.7 n)

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Table 8.5 (k): Split Plot Repeated Measure ANOVA: The Effect of Breast Cancer Stages on the Husbands’ Coping Strategies

Sources of Variation ss df ms f sign

Active Coping Within Subjects Effect: Active coping (Time) 105.489 2 52.745 37.100 p<0.001 Time x Breast Cancer Stages 4.980 2 2.490 1.751 ns Between Subjects Effect: 0.375 1 0.395 0.113 ns (Effect of Breast Cancer Stages)

Planning Within Subjects Effect: Planning (Time) 82.878 1.007 82.294 1335.482 p<0.001 Time x Breast Cancer Stages 0.146 1.007 0.145 2.354 ns Between Subjects Effect: 0.050 1 0.050 0.009 ns (Effect of Breast Cancer Stages)

Positive Reframing Within Subjects Effect: Positive reframing (Time) 17.340 1.034 16.773 9.335 p<0.05 Time x Breast Cancer Stages 1.702 1.034 1.646 0.916 ns

Between Subjects Effect: 10.950 1 10.950 2.452 ns (Effect of Breast Cancer Stages)

Acceptance Within Subjects Effect: Acceptance (Time) 2.534 1.883 1.346 0.665 ns Time x Breast Cancer Stages 7.905 1.883 4.199 2.074 ns

Between Subjects Effect: 0.998 1 0.998 0.354 ns (Effect of Breast Cancer Stages)

Religion Within Subjects Effect: Religion (Time) 136.603 2 68.302 65.283 p<0.001 Time x Breast Cancer Stages 0.224 2 0.112 0.107 ns

Between Subjects Effect: 4.040 1 4.040 1.000 ns (Effect of Breast Cancer Stages)

Using Emotional Support Within Subjects Effect: Using Emotional Support (Time) 18.861 1.755 10.748 4.303 p<0.05 Time x Breast Cancer Stages 4.574 1.755 2.607 1.044 ns

Between Subjects Effect: 10.159 1 10.159 3.506 ns (Effect of Breast Cancer Stages)

Using Instrumental Support Within Subjects Effect: Using Instrumental Support (Time)

29.750 1.764 16.864 8.040 p<0.01

Table 8.5 (k), Continued.

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ss df ms f sign Time x Breast Cancer Stages 3.750 1.764 2.126 1.013 ns Between Subjects Effect: 3.707 1 3.707 1.065 ns (Effect of Breast Cancer Stages)

Self-distraction Within Subjects Effect: Self-distraction (Time) 93.240 2 46.620 30.689 p<0.001 Time x Breast Cancer Stages 1.184 2 0.592 0.390 ns Between Subjects Effect: 6.003 1 6.003 2.035 ns (Effect of Breast Cancer Stages)

Denial Within Subjects Effect: Denial (Time) 534.371 1.047 510.40 390.070 p<0.001 Time x Breast Cancer Stages 1.705 1.047 1.628 1.244 ns Between Subjects Effect: 0.003 1 0.003 0.001 ns (Effect of Breast Cancer Stages)

Venting Within Subjects Effect: Venting (Time) 386.312 2 193.16 178.988 p<0.001 Time x Breast Cancer Stages 0.571 2 0.286 0.265 ns

Between Subjects Effect: 0.910 1 0.910 0.260 ns (Effect of Breast Cancer Stages)

Behavioural Disengagement Within Subjects Effect: Behavioural Disengagement (Time)

0.396 1.057 0.007 0.478 ns

Time x Breast Cancer Stages 0.007 1.057 0.007 0.008 ns

Between Subjects Effect: 0.024 1 0.024 0.015 ns (Effect of Breast Cancer Stages)

Self-blame Within Subjects Effect: Self-blame (Time) 0.030 1.608 0.019 0.805 ns Time x Breast Cancer Stages 0.030 1.608 0.019 0.805 ns

Between Subjects Effect: 1.221 1 1.221 0.680 ns (Effect of Breast Cancer Stages)

Problem-focused Strategy Within Subjects Effect: Problem-focused Strategy (Time)

185.096 1.952 94.809 20.462 p<0.001

Time x Breast Cancer Stages 0.790 1.952 0.405 0.087 ns

Between Subjects Effect: 2.790 1 2.790 0.107 ns (Effect of Breast Cancer Stages)

Table 8.5 (k), Continued.

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ss df ms f sign Emotion-focused Strategy

Within Subjects Effect: Emotion-focused Strategy (Time)

505.240 2 252.62 19.649 p<0.001

Time x Breast Cancer Stages

9.406 2 4.703 0.366 ns

Between Subjects Effect: 93.164 1 93.164 2.528 ns (Effect of Breast Cancer Stages)

Note: The domains of Humour and Substance Use of Brief COPE were excluded from the analysis as the assumptions for the parametric test were not met

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Figure 8.2.8 (a): The Effect of Breast Cancer Stages on Husbands' Coping Strategies (Active Coping)

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Stage Two (N=89)

Stage Three(N=55)

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Figure 8.2.8 (b): The Effect of Breast Cancer Stages on Husbands' Coping Strategy (Planning)

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Stage Two (N=89)

Stage Three (N=55)

Time: F (1.007, 143.007) = 1335.482; p<0.001 Interaction Effect: F (1.007, 143.007) = 2.354; ns Between Subjects Effect: F (1, 142) = 0.009; ns (8.2.8 b)

Time: F (2, 284) = 37.100; p<0.001 Interaction Effect: F (2, 284) = 1.751; ns Between Subjects Effect: F (1, 142) = 0.113; ns (8.2.8 a)

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Figure 8.2.8 (c): The Effect of Breast Cancer Stages on Husbands' Coping Strategy (Positive Reframing)

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Stages Two (N=89)

Stages Three (N=55)

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Figure 8.2.8 (d): The Effect of Breast Cancer Stages on Husbands' Coping Strategy (Acceptance)

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Stages Two (N=89)

Stages Three (N=55)

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Figure 8.2.8 (e): The Effect of Breast Cancer Stages on Husbands' Coping Strategy (Religion)

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Stages Two (N=89)

Stages Three (N=55)

Time: F (1.034, 146.808) = 9.335; p<0.05 Interaction Effect: F (1.034, 146.808) = 0.916; ns Between Subjects Effect: F (1, 142) = 2.452; ns (8.2.8 c)

Time: F (1.883, 267.322) = 0.665; ns Interaction Effect: F (1.883, 267.322) = 2.074; ns Between Subjects Effect: F (1, 142) = 0.354; ns (8.2.8 d)

Time: F (2, 284) = 65.283; p<0.001 Interaction Effect: F (2, 284) = 0.107; ns Between Subjects Effect: F (1, 142) = 1.000; ns (8.2.8 e)

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Figure 8.2.8 (f): The Effect of Breast Cancer Stages on Husbands' Coping Strategy (Using Emotional Support)

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Stages Two (N=89)

Stages Three (N=55)

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Figure 8.2.8 (g): The Effect of Breast Cancer Stages on Husbands' Coping Strategy

(Using Instrumental Support)

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Stages Two (N=89)

Stages Three (N=55)

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Figure 8.2.8 (h): The Effect of Breast Cancer Stages on Husbands' Coping Strategy (Self-distraction)

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Stage Two (N=89)

Stage Three (N=55)

Time: F (1.755, 249.194) = 4.304; p<0.05 Interaction Effect: F (1.755, 249.194) = 1.044; ns Between Subjects Effect: F (1, 142) = 3.506; ns (8.2.8 f)

Time: F (2, 284) = 46.620; p<0.001 Interaction Effect: F (2, 284) = 0.390; ns Between Subjects Effect: F (1, 142) = 2.035; ns (8.2.8 h)

Time: F (1.764, 250.501) = 8.040; p<0.01 Interaction Effect: F (1.764, 250.501) = 1.013; ns Between Subjects Effect: F (1, 142) = 1.065; ns (8.2.8 g)

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Figure 8.2.8 (i): The Effect of Breast Cancer Stages on Husbands' Coping Strategies (Denial)

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Stage Two (N=89)

Stage Three (N=55)

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Figure 8.2.8 (j): The Effect of Breast Cancer Stages on Husbands' Coping Strategy (Venting)

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Stage Two (N=89)

Stage Three (N=55)

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Figure 8.2.8 (k): The Effect of Breast Cancer Stages on Husbands' Coping Strategy (Behavioral Disengagement)

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Stage Two (N=89)

Stage Three (N=55)

Time: F (2, 284) = 178.988; p<0.001 Interaction Effect: F (2, 284) = 0.265; ns Between Subjects Effect: F (1, 142) = 0.260; ns (8.2.8 j)

Time: F (1.057, 150.092) = 0.478; ns Interaction Effect: F (1.057, 150.092) = 0.008; ns Between Subjects Effect: F (1, 142) = 0.015; ns (8.2.8 k)

Time: F (1.047, 148.671) = 390.070; p<0.001 Interaction Effect: F (1.047, 148.671) = 1.244; ns Between Subjects Effect: F (1, 142) = 0.001; ns (8.2.8 i-den)

375

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Figure 8.2.8 (l): The Effect of Breast Cancer Stages on Husbands' Coping Strategy (Self-blame)

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Stage Two (N=89)

Stage Three (N=55)

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Figure 8.2.8 (m): The Effect of Breast Cancer Stages on Husbands' Coping Strategy

(Problem-focused Strategy)

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Stage Two (N=89)

Stage Three (N=55)

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Figure 8.2.8 (n): The Effect of Breast Cancer Stages on Husbands' Coping Strategy (Emotion-focused Strategy)

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Stage Two (N=89)

Stage Three (N=55)

Time: F (1.608, 228.402) = 0.805; ns Interaction Effect: F (1.608, 228.402) = 0.805; ns Between Subjects Effect: F (1, 142) = 0.680; ns (8.2.8 l)

Time: F (1.952, 277.226) = 20.462; p<0.001 Interaction Effect: F (1.952, 277.226) = 0.087; ns Between Subjects Effect: F (1, 142) = 0.107; ns (8.2.8 m)

Time: F (2, 284) = 19.649; p<0.001 Interaction Effect: F (2, 284) =0.366; ns Between Subjects Effect: F (1, 142) = 2.528; ns (8.2.8 n)

376

Except for the Acceptance [F (1, 142) = 1.17; ns] [Table 7.5 (l); Figure 7.2.9

(a)], Behavioural Disengagement [F (1, 142) = 0.06; ns] [Table 8.5 (l); Figure 8.2.9 (c)]

and Self-blame [F (1, 142) = 1.53; ns], all other coping strategies, employed by the

husbands of the breast cancer patients, were found to be significantly affected by their

wives’ menopausal status. These strategies were such as Active [F (1, 142) = 26.96;

p<0.001] [Pre-menopausal group indicated to use more Active strategy in all situations

(prior-to=4.58±1.20; during=5.91±1.42; post-chemotherapy=4.79±1.28) than the

post-menopausal group (prior-to=3.79±1.30; during=4.67±1.59; post-

chemotherapy=4.24±1.36)] [Table 8.5 (l); Figure 8.2.9 (d)], Planning [F (1, 142) =

12.46; p<0.01] [The pre-menopausal group was also found to employ more of the

Planning strategy throughout the treatment phases; prior-to (5.02±1.41), during

(6.02±1.41), post-chemotherapy (5.12±1.25), as compared to the post-menopausal

group (prior-to=4.25±1.26; during=5.25±1.26; post-chemotherapy=4.37±1.17)]

[Table 8.5 (l); Figure 8.2.9 (e)], Positive Reframing [F (1, 142) = 12.50; p<0.01]

[Positive Reframing was higher among the pre-menopausal group in all the treatment

phases (prior-to=5.40±1.17; during=5.93±1.49; post-chemotherapy=5.90±1.50), as

compared to the post-menopausal group (prior-to=4.70±1.49; during=5.19±1.56;

post-chemotherapy=5.14±1.54)] [Table 8.5 (l); Figure 8.2.9 (f)], Religion [F (1, 142) =

11.71; p<0.01] [The participants were found to fall back on their religion (strategy) in

coping with the disease and its treatment; the use of this particular strategy was higher

among the pre-menopausal group prior-to (5.20±1.13), during (6.41±1.34) and post-

chemotherapy (5.21±1.60) than the post-menopausal group (prior-to=4.63±1.48;

during=5.79±1.48; post-chemotherapy=4.40±1.43)] [Table 8.5 (l); Figure 8.2.9 (g)],

Using Emotional Support [F (1, 142) = 9.14; p<0.01] [Pre- menopausal group

indicated of using Emotional Support more often in all the treatment phases (prior-

to=5.47±1.49; during=5.63±1.27; post-chemotherapy=5.09±1.89) than the post-

377

Table 8.5 (l): Split Plot Repeated Measure ANOVA: The Effect of the Breast Cancer Patients’ Menopausal Status on Their Husbands’ Coping Strategies

Sources of Variation ss df ms f sign

Active Coping Within Subjects Effect: Active coping (Time) 91.014 2 45.507 35.178 p<0.001 Time x Menopausal Status 8.857 2 4.428 3.423 p<0.05 Between Subjects Effect: 78.967 1 78.967 26.961 p<0.001 (Effect of Menopausal Status)

Planning Within Subjects Effect: Planning (Time) 85.624 1.007 85.021 1357.785 p<0.001 Time x Menopausal Status 0.004 1.007 0.004 0.057 ns Between Subjects Effect: 62.479 1 62.479 12.457 p<0.01 (Effect of Menopausal Status)

Positive Reframing Within Subjects Effect: Positive Reframing (Time) 23.097 1.034 22.329 12.671 p<0.001 Time x Menopausal Status 0.069 1.034 0.067 0.038 ns

Between Subjects Effect: 56.679 1 56.679 12.498 p<0.01 (Effect of Menopausal Status)

Acceptance Within Subjects Effect: Acceptance (Time) 2.586 1.817 1.423 0.706 ns Time x Menopausal Status 3.475 1.817 1.912 0.949 ns

Between Subjects Effect: 3.418 1 3.418 1.169 ns (Effect of Menopausal Status)

Religion Within Subjects Effect: Religion (Time) 146.380 2 73.190 73.003 p<0.001 Time x Menopausal Status 1.241 2 0.620 0.619 ns

Between Subjects Effect: 46.751 1 46.751 11.706 p<0.01 (Effect of Menopausal Status)

Using Emotional Support Within Subjects Effect: Using Emotional Support (Time)

21.308 1.683 12.659 4.939 p<0.05

Time x Menopausal Status 1.030 1.683 0.612 0.239 ns

Between Subjects Effect: 26.672 1 26.672 9.135 p<0.01 (Effect of Menopausal Status)

Table 8.5 (l), Continued.

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ss df ms f sign Using Instrumental Support

Within Subjects Effect: Using Instrumental Support (Time)

27.344 1.692 16.164 7.385 p<0.01

Time x Menopausal Status

4.122 1.692 2.437 1.113 ns

Between Subjects Effect: 23.870 1 23.870 7.040 p<0.01 (Effect of Menopausal Status)

Self-distraction Within Subjects Effect: Self-distraction (Time) 101.506 2 50.753 34.939 p<0.001 Time x Menopausal Status 12.450 2 6.225 4.285 p<0.05 Between Subjects Effect: 38.228 1 38.228 12.860 p<0.001 (Effect of Menopausal Status)

Denial Within Subjects Effect: Denial (Time) 542.924 1.046 519.268 380.192 p<0.001 Time x Menopausal Status 0.257 1.046 0.246 0.180 ns Between Subjects Effect: 31.984 1 31.984 10.074 p<0.01 (Effect of Menopausal Status)

Venting Within Subjects Effect: Venting (Time) 422.180 2 211.090 208.782 p<0.001 Time x Menopausal Status 3.069 2 1.535 1.518 ns

Between Subjects Effect: 30.360 1 30.360 8.572 p<0.01 (Effect of Menopausal Status)

Behavioural Disengagement Within Subjects Effect: Behavioural Disengagement (Time)

0.288 1.056 0.273 0.339 ns

Time x Menopausal Status 0.177 1.056 0.168 0.208 ns

Between Subjects Effect: 0.096 1 0.096 0.059 ns (Effects of Menopausal Status)

Self-blame Within Subjects Effect: Self-blame (Time) 0.073 1.528 0.048 1.322 ns Time x Breast Cancer Stages 0.147 1.528 0.096 2.671 ns

Between Subjects Effect: 2.296 1 2.296 1.527 ns (Effect of Menopausal Status)

Problem-focused Strategy Within Subjects Effect: Problem-focused Strategy (Time)

158.512 2 79.256 19.256 p<0.001

Time x Menopausal Status 18.854 2 9.427 2.290 ns

Table 8.5 (l), Continued.

379

ss df ms f sign Between Subjects Effect: 477.249 1 477.249 20.523 p<0.001 (Effect of Menopausal Status)

Emotion-focused Strategy Within Subjects Effect: Emotion-focused Strategy (Time)

515.454 2 257.727 21.399 p<0.001

Time x Menopausal Status

9.065 2 4.533 0.376 ns

Between Subjects Effect: 704.894 1 704.894 21.745 p<0.001 (Effect of Menopausal Status)

Note: The domains of Humour and Substance Use of Brief COPE were excluded from the analysis as the assumptions for the parametric test were not met

menopausal group (prior-to=5.10±1.39; during=5.02±1.36; post-

chemotherapy=4.57±1.79)] [Table 8.5 (l); Figure 8.2.9 (h)], Using Instrumental

Support [F (1, 142) = 7.04; p<0.01] [For this strategy, the pre-menopausal group was

stated as using more of the Instrumental Support in all occasions (prior-to=5.75±1.46;

during=5.98±1.33; post-chemotherapy=5.41±1.72), as compared to the husbands of

the patients in the post-menopausal (prior-to=5.56±1.37; during=5.33±1.60; post-

chemotherapy=4.83±1.73)] [Table 8.5 (l); Figure 8.2.9 (i)], Self-distraction [F (1, 142)

= 12.86; p<0.001] [Once again, the husbands of the women in the pre-menopausal

group were found to engaged in Self-distraction strategy more in all the three phases

(prior-to =5.30±1.33; during=6.16±1.44; post-chemotherapy=5.25±1.46) than those in

the post-menopausal group (prior-to=5.06±1.47; during=5.65±1.46; post-

chemotherapy=4.19±1.20)] [Table 8.5 (l); Figure 8.2.9 (j)], Denial [F (1, 142) = 10.07;

p<0.01] [Pre-menopausal group indicated of using Denial strategy prior-to

(5.11±1.40), during (5.16±1.46) and post-chemotherapy (2.69±1.44) more than those in

the post-menopausal group (prior-to=4.56±1.06; during=4.56±1.06; post-

chemotherapy=2.21±0.60)] [Table 8.5 (l); Figure 8.2.9 (k)], Venting [F (1, 142) = 8.57;

p<0.01] [Pre-menopausal group was also found to engage in more in the Venting

strategy in all occasions (prior-to=5.51±1.28; during=5.70±1.42; post-

380

chemotherapy=3.68±1.69) than post-menopausal group (prior-to=5.08±1.20;

during=5.30±1.28; post-chemotherapy=2.90±1.15)] [Table 8.5 (l); Figure 8.2.9 (l)],

Problem-focused Strategy [F (1, 142) = 20.52; p<0.001] [The use of Problem-focused

Strategy was higher among the husbands of the pre-menopausal women throughout the

treatment phases (prior-to=15.36±3.10; during=17.07±3.51; post-

chemotherapy=15.32±2.94), as compared to the post-menopausal group (prior-

to=13.60±3.12; during=14.37; post-chemotherapy=13.43±2.87)] [Table 8.5 (l); Figure

8.2.9 (m)] and Emotion-focused Strategy [F (1, 142) = 21.75; p<0.001] [Pre-

menopausal group was shown to make use of the Emotion-focused Strategy more often

(prior-to=27.63±3.81; during=26.99±4.41; post-chemotherapy=25.23±4.61) than the

other group (prior-to=25.46±4.32; during=24.14±5.13; post-

chemotherapy=22.52±3.62) in all situations] [Table 8.5 (l); Figure 8.2.9 (n)].

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Figure 8.2.9 (a): The Effect of Menopausal Status on Husbands' Coping Strategy (Acceptance)

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Pre-menopausal(N=81)

Post-menopausal(N=63)

Time: F (1.817, 258.019) = 0.706; ns Interaction Effect: F (1.817, 258.019) = 0.949; ns Between Subjects Effect: F (1, 142) = 1.169; ns (8.2.9 a)

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Figure 8.2.9 (b): The Effect of Menopausal Status on Husbands' Coping Strategy (Behavioral Disengagement)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

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Figure 8.2.9 (c): The Effect of Menopausal Status on Husbands' Coping Strategy (Self-blame)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

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Figure 8.2.9 (d): The Effect of Menopausal Status on Husbands' Coping Strategy (Active)

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Pre-menopausal (N=81)

Post-menopausal(N=63)

Time: F (1.056, 149.892) = 0.339; ns Interaction Effect: F (1.056, 149.892) = 0.208; ns Between Subjects Effect: F (1, 142) = 0.059; ns (8.2.9 b)

Time: F (1.528, 217.009) = 1.322; ns Interaction Effect: F (1.528, 217.009) = 2.671; ns Between Subjects Effect: F (1, 142) = 1.527; ns (8.2.9 c)

Time: F (2, 284) = 35.178; p<0.001 Interaction Effect: F (2, 284) = 3.423; p<0.05 Between Subjects Effect: F (1, 142) = 26.961; p<0.001 (8.2.9 d)

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Figure 8.2.9 (e): The Effect of Menopausal Status on Husbands' Coping Strategy (Planning)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

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Figure 8.2.9 (f): The Effect of Menopausal Status on Husbands' Coping Strategy (Positive Reframing)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

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Figure 8.2.9 (g): The Effect of Menopausal Status on Husbands' Coping Strategy (Religion)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

Time: F (1.007, 143.007) = 1357.785; p<0.001 Interaction Effect: F (1.007, 143.007) = 0.057; ns Between Subjects Effect: F (1, 142) = 12.457; p<0.01 (8.2.9 e)

Time: F (1.034, 146.886) = 12.671; p<0.001 Interaction Effect: F (1.034, 146.886) = 0.038; ns Between Subjects Effect: F (1, 142) = 12.498; p<0.01 (8.2.9 f)

Time: F (2, 284) = 73.003; p<0.001 Interaction Effect: F (2, 284) = 0.619; ns Between Subjects Effect: F (1, 142) = 11.706; p<0.01 (8.2.9 g)

383

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Figure 8.2.9 (h): The Effect of Menopausal Status on Husbands' Coping Strategy (Using Emotional Support)

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s

Pre-menopausal (N=81)

Post-menopausal (N=63)

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Figure 8.2.9 (i): The Effect of Menopausal Status on Husbands' Coping Strategy (Using Instrumental Support)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

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Figure 8.2.9 (j): The Effect of Menopausal Status on Husbands' Coping Strategy (Self-distraction)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

Time: F (1.683, 239.014) = 4.939; p<0.05 Interaction Effect: F (1.683, 239.014) = 0.239; ns Between Subjects Effect: F (1, 142) = 9.135; p<0.01 (8.2.9 h)

Time: F (1.692, 240.219) = 7.385; p<0.001 Interaction Effect: F (1.692, 240.219) = 1.113; ns Between Subjects Effect: F (1, 142) = 7.040; p<0.01 (8.2.9 i-use instru)

Time: F (2, 284) = 34.939; p<0.001 Interaction Effect: F (2, 284) = 4.285; p<0.05 Between Subjects Effect: F (1, 142) = 12.860; p<0.001 (8.2.9 j)

384

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Figure 8.2.9 (k): The Effect of Menopausal Status on Husbands' Coping Strategy (Denial)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

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Figure 8.2.9 (l): The Effect of Menopausal Status on Husbands' Coping Strategy (Venting)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

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Figure 8.2.9 (m): The Effect of Menopausal Status on Husbands' Coping Strategy (Problem-focused Strategy)

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Pre-menopausal (N=81)

Post-menopausal (N=63)

Time: F (1.046, 148.469) = 380.192; p<0.001 Interaction Effect: F (1.046, 148.469) = 0.180; ns Between Subjects Effect: F (1, 142) = 10.074; p<0.01 (8.2.9 k)

Time: F (2, 284) = 208.782; p<0.001 Interaction Effect: F (2, 284) = 1.518; ns Between Subjects Effect: F (1, 142) = 8.572; p<0.01 (8.2.9 l)

Time: F (2, 284) = 19.256; p<0.001 Interaction Effect: F (2, 284) = 2.290; ns Between Subjects Effect: F (1, 142) = 20.523; p<0.001 (8.2.9 m)

385

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Figure 8.2.9 (n): The Effect of Menopausal Status on Husbands' Coping Strategy (Emotion-focused Strategy)

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sPre-menopausal (N=81)

Post-menopausal (N=63)

Based on the findings of this study, a number of the coping strategies used by

the patients’ husbands were found to be clearly influenced by their ethnicity. These

were Positive Reframing [F (2, 154) = 5.83; p<0.001] [Malay husbands indicated the

highest score for Positive Reframing in all occasions (prior-to=5.36±1.22;

during=5.92±1.59; post-chemotherapy=5.87±1.59), followed by Indian husbands

(prior-to=5.20±1.16; during=5.60±1.57; post-chemotherapy=5.57±1.57) and Chinese

husbands (prior-to=4.67±1.58; during=5.10±1.39; post-chemotherapy=5.10±1.39)]

[Table 8.5 (m); Figure 8.2.10 (a)], Acceptance [F (2, 154) = 6.41; p<0.01] [Prior-to

chemotherapy, Malay husbands once again indicated the highest scores for the use of

Acceptance strategy (6.91±1.22) than the Indian (6.37±1.16) and Chinese husbands

(5.75±1.72). On the other hand, Indian husbands used more Acceptance strategy

during (6.83±1.34) and post-chemotherapy (6.67±1.21), followed by the Malay

husbands (during=6.50±1.52; post-chemotherapy=6.18±1.64) and Chinese husbands

(during=6.12±1.54; post-chemotherapy=6.08±1.37)] [Table 8.5 (l); Figure 8.2.9 (b)],

Religion [F (2, 154) = 25.86; p<0.001] [Malay husbands indicated to fall back on the

Religion strategy more often prior-to (5.39±1.00) and post-chemotherapy (5.28±1.53)

Time: F (2, 284) = 21.399; p<0.001 Interaction Effect: F (2, 284) = 0.376; ns Between Subjects Effect: F (1, 142) = 21.745; p<0.001 (8.2.9 n)

386

than the Indian husbands (prior-to=5.27±1.08; post-chemotherapy=4.93±1.68) and

Chinese husbands (prior-to=3.94; post-chemotherapy=4.10±1.20). Nonetheless,

during chemotherapy, Indian husbands were found to score the highest (6.50±1.33) for

this particular strategy, followed by the Malay husbands (6.47±1.33) and Chinese

husbands (5.22±1.33)] [Table 8.5 (m); Figure 8.2.10 (c)], Using Emotional Support [F

(2, 154) = 3.26; p<0.05] [Similarly, Indian husbands scored the highest for the use

Emotional Support throughout the treatment phases (prior-to=5.60±1.28,

during=5.70±1.29 and post-chemotherapy=5.10±1.99), followed by the Malay

husbands (prior-to=5.37±1.53; during=5.45±1.38; post-chemotherapy=4.99±1.94)

and Chinese husbands (prior-to=5.06±1.39; during=5.12±1.26; post-

chemotherapy=4.59±1.70)] [Table 8.5 (m); Figure 8.2.10 (d)], Venting [F (2, 154) =

5.05; p<0.01] [Malay husbands exhibited more Venting strategy prior-to (5.43±1.27),

during (5.79±1.36) and post-chemotherapy (3.72±1.53) than the Indian (prior-

to=5.27±1.46; during=5.70±1.49; post-chemotherapy=3.20±1.85) and Chinese

husbands (prior-to=5.04±1.13; during=5.10±1.10; post-chemotherapy=2.98±1.18]

[Table 8.5 (m); Figure 8.2.10 (e)], Problem-focused Strategies [F (2, 154) = 3.45;

p<0.05] [Indian husbands stated that they used Problem-focused Strategies more often

(prior-to=15.17±2.87; during=16.83±4.00; post-chemotherapy=14.93±3.07) than the

Malay (prior-to=15.16±3.44; during=16.45±3.95; post-chemotherapy=14.74±3.18)

and Chinese husbands (prior-to=13.67±2.66; during=14.98±3.71; post-

chemotherapy=14.02±2.63)] [Table 8.5 (m); Figure 8.2.10 (f)] and Emotion-focused

Strategy [F (2, 154) = 19.01; p<0.001] [Among these husbands, the Malays indicated

highest scores for the use of Emotion-focused Strategy prior to chemotherapy

(27.95±3.64), as compared to other races (Indian=27.57±3.71; Chinese=23.98±4.11).

Nonetheless, Indian husbands displayed more Emotion-focused Strategy during

(27.83±4.57) and post-chemotherapy (24.90±4.23), followed by the Malay

387

Table 8.5 (m): Split Plot Repeated Measure ANOVA: The Effect of Ethnicity on the Husbands’ Coping Strategies

Sources of Variation ss df ms f sign

Active Coping Within Subjects Effect: Active coping (Time) 100.557 2 50.279 356.492 p<0.001 Time x Ethnicity 5.950 4 1.488 1.080 ns Between Subjects Effect: 17.611 2 8.805 2.713 ns (Effect of Ethnicity)

Planning Within Subjects Effect: Planning (Time) 82.700 1.013 81.633 1339.557 p<0.001 Time x Ethnicity 0.072 2.026 0.036 0.585 ns Between Subjects Effect: 31.721 2 15.860 2.963 ns (Effect of Ethnicity)

Positive Reframing Within Subjects Effect: Positive Reframing (Time) 18.551 1.037 17.883 9.856 p<0.01 Time x Ethnicity 0.486 2.075 0.234 0.129 ns

Between Subjects Effect: 53.132 2 26.566 5.832 p<0.01 (Effect of Ethnicity)

Acceptance Within Subjects Effect: Acceptance (Time) 2.352 1.901 1.237 0.643 ns Time x Ethnicity 23.804 3.803 6.260 3.256 p<0.05

Between Subjects Effect: 34.838 2 17.419 6.414 p<0.01 (Effect of Ethnicity)

Religion Within Subjects Effect: Religion (Time) 141.300 2 70.650 67.782 p<0.001 Time x Ethnicity 3.431 4 0.858 0.823 ns

Between Subjects Effect: 164.028 2 82.014 25.857 p<0.001 (Effects of Ethnicity)

Using Emotional Support Within Subjects Effect: Using Emotional Support (Time)

22.253 1.753 12.696 5.060 p<0.05

Time x Ethnicity 0.296 3.506 0.085 0.034 ns

Between Subjects Effect: 19.280 2 9.640 3.264 p<0.05 (Effect of Ethnicity)

Using Instrumental Support Within Subjects Effect: Using Instrumental Support (Time) 27.802 1.755 15.845 7.337 p<0.01

Table 8.5 (m), Continued.

388

ss df ms f sign Time x Ethnicity 2.654 3.509 0.756 0.350 ns

Between Subjects Effect: 17.665 2 8.833 2.622 ns (Effect of Ethnicity)

Self-distraction Within Subjects Effect: Self-distraction (Time) 95.618 2 47.809 31.816 p<0.001 Time x Ethnicity 3.191 4 0.798 0.531 ns Between Subjects Effect: 6.638 2 3.319 1.021 ns (Effect of Ethnicity)

Denial Within Subjects Effect: Denial (Time) 525.090 1.050 500.084 378.439 p<0.001 Time x Ethnicity 0.615 2.100 0.293 0.222 ns Between Subjects Effect: 14.768 2 7.384 2.303 ns (Effect of Ethnicity)

Venting Within Subjects Effect: Venting (Time) 400.639 2 200.319 184.839 p<0.001 Time x Ethnicity 4.230 4 1.058 0.976 ns

Between Subjects Effect: 34.076 2 17.038 5.055 p<0.01 (Effects of Ethnicity)

Behavioural Disengagement Within Subjects Effect: Behavioural Disengagement (Time)

0.217 1.061 0.204 0.272 ns

Time x Ethnicity 2.406 2.122 1.134 1.510 ns

Between Subjects Effect: 4.951 2 2.476 1.629 ns (Effect of Ethnicity)

Self-blame Within Subjects Effect: Self-blame (Time) 0.134 1.503 0.089 2.678 ns Time x Ethnicity 0.216 3.006 0.072 2.148 ns

Between Subjects Effect: 0.622 2 0.311 0.177 ns (Effect of Ethnicity)

Problem-focused Strategy Within Subjects Effect: Problem-focused Strategy (Time)

197.781 1.972 100.272 22.713 ns

Time x Ethnicity 14.980 3.945 3.797 0.860 ns

Between Subjects Effect: (Effect of Ethnicity)

171.996 2 85.998 3.451 p<0.05

Table 8.5 (m), Continued.

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ss df ms f sign Emotion-focused Strategy

Within Subjects Effect: Emotion-focused Strategy (Time)

481.018 2 240.509 19.625 p<0.001

Time x Ethnicity 62.052 4 15.513 1.266 ns

Between Subjects Effect: 1116.840 2 558.420 19.014 p<0.001 (Effect of Ethnicity)

Note: The domains of Humour and Substance Use of Brief COPE were excluded from the analysis as the assumptions for the parametric test were not met

(during=26.39±4.71; post-chemotherapy=24.83±4.77) and Chinese husbands

(during=23.53±4.68; post-chemotherapy=22.16±3.07)] [Table 8.5 (m); Figure 8.2.10

(g)].

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Pre-Chemotherapy DuringChemotherapy

PostChemotherapy

Figure 8.2.10 (a): The Effect of Ethnicity on Husbands' Coping Strategy (Positive Reframing)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (1.037, 159.752) = 9.856; p<0.01 Interaction Effect: F (2.075, 159.752) = 0.129; ns Between Subjects Effect: F (2, 154) = 5.832; p<0.01 (8.2.10 a)

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PostChemotherapy

Figure 8.2.10 (b): The Effect of Ethnicity on Husbands' Coping Strategy (Acceptance)

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Chinese (N=51)

Indian (N=30)

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Post Chemotherapy

Figure 8.2.10 (c): The Effect of Ethnicity on Husbands' Coping Strategy (Religion)

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Chinese (N=51)

Indian (N=30)

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Figure 8.2.10 (d): The Effect of Ethnicity on Husbands' Coping Strategy (Using Emotional Support)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (1.901, 292.793) = 0.643; ns Interaction Effect: F (3.803, 292.793) = 3.256; p<0.05 Between Subjects Effect: F (2, 154) = 6.414; p<0.01 (8.2.10 b)

Time: F (2, 308) = 67.782; p<0.001 Interaction Effect: F (4, 308) = 0.823; ns Between Subjects Effect: F (2, 154) = 25.857; p<0.001 (8.2.10 c)

Time: F (1.753, 269.926) = 5.060; p<0.05 Interaction Effect: F (3.506, 269.926) = 0.034; ns Between Subjects Effect: F (2, 154) = 3.264; p<0.05 (8.2.10 d)

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Post Chemotherapy

Figure 8.2.10 (e): The Effect of Ethnicity on Husbands' Coping Strategy (Venting)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.2.10 (f): The Effect of Ethnicity on Husbands' Coping Strategy (Problem-focused Strategy)

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Chinese (N=51)

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Figure 8.2.10 (g): The Effect of Ethnicity on Husbands' Coping Strategy (Emotion-focused Strategy)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (2, 308) = 184.839; p<0.001 Interaction Effect: F (4, 308) = 0.976; ns Between Subjects Effect: F (2, 154) = 5.055; p<0.01 (8.2.10 e)

Time: F (1.972, 303.756) = 22.713; ns Interaction Effect: F (3.945, 303.756) = 0.860; ns Between Subjects Effect: F (2, 154) = 3.451; p<0.05 (8.2.10 f)

Time: F (2, 308) = 19.625; p<0.001 Interaction Effect: F (4, 308) = 1.266; ns Between Subjects Effect: F (2, 308) = 19.014; p<0.001 (8.2.10 g)

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It is important to highlight that other coping strategies, proposed in this study, were not

influenced by ethnicity. These strategies were Active Coping [F (2, 154) = 2.71; ns]

[Table 7.5 (m); Figure 7.2.10 (h)], Planning [F (2, 154) = 2.96; ns] [Table 7.5 (m);

Figure 7.2.10 (i)], Using Instrumental Support [F (2, 154) = 19.01; ns] [Table 7.5 (m);

Figure 7.2.10 (j)], Self-distraction [F (2, 154) = 1.02; ns] [Table 8.5 (m); Figure 8.2.10

(k)], Denial [F (2, 154) = 2.30; ns] [Table 8.5 (m); Figure 8.2.10 (l)], Behavioural

Disengagement [F (2, 154) = 1.63; ns] [Table 8.5 (m); Figure 8.2.10 (m)] and Self-

blame [F (2, 154) = 0.18; ns] [Table 8.5 (m); Figure 8.2.10 (n)].

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Figure 8.2.10 (h): The Effect of Ethnicity on Husbands' Coping Strategy (Active Coping)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.2.10 (i): The Effect of Ethnicity on Husbands' Coping Strategy (Planning)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (2, 308) = 36.492; p<0.001 Interaction Effect: F (4, 308) = 1.080; ns Between Subjects Effect: F (2, 154) = 2.713; ns (8.2.10 h)

Time: F (1.013, 156.013) = 1339.557; p<0.001 Interaction Effect: F (2.026, 156.013) = 0.585; ns Between Subjects Effect: F (2, 154) = 2.963; ns (8.2.10 i-plan)

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Figure 8.2.10 (j): The Effect of Ethnicity on Husbands' Coping Strategy

(Using Instrumental Support)

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Malay (N=76)Chinese (N=51)Indian (N=30)

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Figure 8.2.10 (k): The Effect of Ethnicity on Husbands' Coping Strategy (Self-distraction)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.2.10 (l): The Effect of Ethnicity on Husbands' Coping Strategy (Denial)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (1.755, 270.219) = 7.337; p<0.01 Interaction Effect: F (3.509, 270.219) = 0.350; ns Between Subjects Effect: F (2, 154) = 2.622; ns (8.2.10 j)

Time: F (2, 308) = 31.816; p<0.001 Interaction Effect: F (4, 308) = 0.531; ns Between Subjects Effect: F (2, 154) = 1.021; ns (8.2.10 k)

Time: F (1.050, 525.090) = 378.439; p<0.001 Interaction Effect: F (2.100, 525.090) = 0.222; ns Between Subjects Effect: F (2, 154) = 2.303; ns (8.2.10 l)

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Figure 8.2.10 (m): The Effect of Ethnicity on Husbands' Coping Strategy

(Behavioural Disengagement)

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Chinese (N=51)

Indian (N=30)

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DuringChemotherapy

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Figure 8.2.10 (n): The Effect of Ethnicity on Husbands' Coping Strategy (Self-blame)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

7.1.3.1 Summary of the Results

In this study, the significant effects of time were observed for almost all types

of the couples’ coping strategies, which included Active Coping, Planning, Positive

Reframing, Acceptance, Using Emotional Support, Using Instrumental Support, Denial,

Venting, Self-blame, Emotion-focused Strategies and Problem-focused Strategies.

With the exception given for the strategies of Self-distraction and Behavioral

Disengagement, the above results support the hypothesis that treatment phases (prior-

Time: F (1.061, 163.378) = 0.272; ns Interaction Effect: F (2.122, 163.378) = 1.510; ns Between Subjects Effect: F (2, 154) = 1.629; ns (8.2.10 m)

Time: F (1.503, 231.452) = 2.678; ns Interaction Effect: F (3.006, 231.452) = 2.148; ns Between Subjects Effect: F (2, 154) = 0.177; ns (8.2.10 n)

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to, during and post-chemotherapy) have different effects on couples’ coping strategies.

Related to this, it was also observed that the couples had greater strategies during

chemotherapy, as compared to other phases of treatment i.e. prior-to and post-

chemotherapy. This pattern can be detected in most of the couples’ coping strategies

such as Active Coping, Planning, Positive Reframing, Acceptance, Using Emotional

Support, Using Instrumental Support, Self-distraction and Problem-focused Strategy.

This fact supports the study’s hypothesis that there are similarities in the patterns of

coping strategies between women with breast cancer and their husbands. In relation to

the use of coping strategies in all phases of the chemotherapy treatment, it was not

surprising to discover that women with breast cancer were the ones who were found to

rate higher levels (higher scores) of coping strategies more often than their husbands

did. In more specific, the strategies more frequently used by the women with breast

cancer were Active Coping, Planning, Positive Reframing, Using Emotional Support,

Using Instrumental Support, Denial, Venting, Self-blame, Emotion-focused Strategy,

Problem-focused Strategy and Behavioural Disengagement. With the exception given

for the strategies of Self-distraction and Behavioral Disengagement, this finding proves

the postulated hypothesis which state that women with breast cancer exhibit greater use

of coping strategies as compared to their husbands.

Based on the analysis carried out at the individual level, it was indicated that

almost all of the coping strategies, used by the women with breast cancer, were

significantly affected by time. These strategies were Active coping, Planning, Positive

Reframing, Acceptance, Religion, Using Emotional Support, Using Instrumental

Support, Self-distraction, Venting, Self-blame, Humour and Emotion-focused

Strategies. Except for the strategies of Denial, Substance Use and Behavioral

Disengagement, this findings accept the proposed hypothesis that treatment phases

(prior-to, during and post-chemotherapy) have different effects on women’s coping

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strategies. With regard to this, most of the coping strategies used by the women with

breast cancer indicated greater use of coping strategies particularly during

chemotherapy, as compared to prior-to and post-chemotherapy. The strategies

involved were Active Coping, Positive Coping, Religion, Using Emotional Support,

Using Instrumental Support, Self-distraction, Venting and Self-blame.

This finding is almost similar to one gathered for their husbands, whereby most

of the coping strategies indicated a significant main effect of time. These include

Active Coping, Planning, Positive Reframing, Religion, Using Emotional Support,

Using Instrumental Support, Self-distraction, Denial, Venting, Humour, Problem-

focused Strategy and Emotion-focused Strategy. With the exception given for the

husbands’ strategies of Acceptance and Substance Use, this finding confirms the

study’s hypothesis that treatment phases (prior-to, during and post-chemotherapy) have

different effects on husbands’ coping strategies. It was observed that most of the

husbands’ coping strategies demonstrated greater use during chemotherapy, as

compared to other phases of treatment i.e. prior-to and post-chemotherapy. In

particular, this situation could be observed for the use of Active Coping, Planning,

Positive Reframing, Religion, Using Emotional Support, Using Instrumental Support,

Self-distraction, Denial, Venting and Problem-focused Strategies.

On the other hand, the types of surgery and breast cancer stages were found to

be unimportant in affecting all types of the couples’ coping strategies, which is not in

line with the postulated hypothesis which states that medical aspects (types of surgery

and breast cancer stages) have significant effects on couples’ coping strategies.

Nevertheless, the analysis carried out individually for the women demonstrated that

strategies of planning, Using Instrumental Support and Problem-focused Strategy were

significantly affected by the types of surgery, which agrees with the study’s hypothesis

that aims to prove the types of surgery as a significant factor affecting women’s coping

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strategies. However, most coping strategies fail to support this hypothesis. As for the

other factor, i.e. the breast cancer stages, insignificant results were collected for all

types of the women’s coping strategies (these results were similar to the ones obtained

for the same strategies in the analysis done at the couple’s level) which was totally

rejected the study’s hypothesis which aim to prove that breast cancer stages has a

significant effect on women’s coping strategies. The finding was rather different for

their husbands, whereby both the independent factors (types of surgery and breast

cancer stages) did not influence all types of their coping strategies, which totally rejects

the study’s hypothesis which aims to prove that the medical aspects (types of surgery

and breast cancer stages) have significant effects on husbands’ coping strategies.

A number of the couples’ coping strategies were found to be influenced by the

patients’ menopausal status; these included Planning, Using Emotional Support, Using

Instrumental Support, Self-distraction, Denial, Venting, Self-blame, Problem-focused

Strategy and Emotion-focused Strategy. Meanwhile, other types of the couples’ coping

strategies such as Active Coping, Positive Reframing, Acceptance, Behavioural

Disengagement were unaffected by the menopausal status of the patients. As only a

number of coping strategies which do not show the significant effect from menopausal

status, this finding almost supports the hypothesis of the study which proposes that

women’s menopausal status has a significant effect on couples’ coping strategies. This

situation, however, was found to be different for the women’s coping strategies when

the analysis was done individually. Except for the strategies of Acceptance and

Behavioural Disengagement, all other types of the women’s strategies were influenced

by their menopausal status, which is in line with the proposed hypothesis i.e. the

menopausal status has a significant effect on women’s coping strategies. These coping

strategies were Active Coping, Planning, Positive Reframing, Using Emotional

Support, Using Instrumental Support, Self-distraction, Denial, Venting, Self-blame,

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Problem-focused Strategy and Emotion-focused Strategy. Almost a similar finding was

observed for their husbands; most of their coping strategies (Active Coping, Planning, Positive

Reframing, Religion, Using Emotional Support, Using Instrumental Support, Self-distraction,

Denial, Venting, Problem-focused Strategies and Emotion-focused Strategies) were affected by

their wives’ menopausal status, which almost confirms the study’s hypothesis that menopausal

status has significant effects on husbands’ coping strategies.

At the same time, ethnicity was shown to play a major role in the couple’s coping

strategies. Conforming the postulated hypothesis i.e. ethnicity has significant effects on

couples’ coping strategies (with the exception given to Self-blame strategy), almost all other

types of strategy clearly showed a significant effect of ethnicity. These were such as Active

Coping, Planning, Positive Reframing, Acceptance, Using Emotional and Instrumental

Supports, Self-distraction, Denial, Venting, Behavioural Disengagement, Problem-focused

Strategies and Emotion-focused Strategies. Similarly, confirming the postulated hypothesis

that ethnicity has significant effect on women’s coping strategies, the analysis that was carried

out at an individual level for the women’s coping strategies yielded almost a similar result;

where all types of the women’s strategies were found to be influenced by ethnicity, except for

Behavioural Disengagement and Self-blame strategies. Nonetheless, the result was slightly

different when the analysis was carried out at the husband’s individual level. Only a number of

strategies were shown to be significantly affected by ethnicity; there were Positive Reframing,

Acceptable, Religion, Using Emotional Support, Venting, Problem-focused Strategies and

Emotion-focused Strategies, which almost rejects the proposed hypothesis that ethnicity has a

significant effect on husbands’ coping strategies.

In the next main sections (i.e. Section 8.2: Breast Cancer: From the Women’s

Perspective; and Section 8.3: Breast Cancer: From the Husband’s Perspective), more results

related to other aspects of quality of life and interpersonal relationship of the women with

breast cancer and their husbands are presented.

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8.2 Breast Cancer: From the Women’s Perspective

This section is divided into three sub-sections - the quality of life, sexuality and

interpersonal relationship. The psychological aspects (anxiety and depression) of the

women and their coping strategies are not presented in this particular section because

they have been reported in detail in the previous section, “Breast Cancer: From the

Couple’s Perspective.” The results in every sub-section are presented in the following

sequence:

(1) First level of analysis i.e. the One-way Repeated Measure ANOVA (for the

parametric test) and the Friedman analysis (for the non-parametric test), to examine the

differences in terms of the quality of life, sexuality and interpersonal relationship at the

different phases of treatment, i.e. prior to, during and post-chemotherapy. In this

section, the analyses were carried out based on the whole sample size, as described in

earlier section (see Table 8.1 in Section 8.1 – Breast Cancer: From the Couples’

Perspective).

(2) Second level of analysis i.e. the Split Plot Repeated Measure ANOVA (one

within the subjects’ factors and one between the subjects’ factor) were conducted to

examine the differences of quality of life, sexuality and interpersonal relationship at

differences of treatment (prior-to, during and post-chemotherapy) among women with

breast cancer, by looking at the effects imposed by the types of surgery, breast cancer

stages, menopausal status and ethnicity. However, this analysis was only carried out

for the data that met the assumptions for the parametric test in this study. Different

sample size was used for this second level of analysis, as described earlier (see Table

8.2 in Section 8.1 - Breast Cancer: From Couples’ Perspective). For this analysis, only

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the results of Between Subjects Effect are highlighted because the results gathered for

the effect of time have already been reported and described in the first level of the

analysis which was based on the whole sample of this study. Therefore, the results for

the effect of time, from the second level of the analysis, are not reported in this section

as they will only be stated in the table of result presented in the respective sections.

Moreover, the different sample sizes of the independent factors (types of surgery,

breast cancer stages, menopausal status and ethnicity) used in the second level of the

analysis (Split Plot Repeated Measure ANOVA) revealed the different results in terms

of the time and interaction effects for each of these factors. Thus, only the results of

the time effect gathered from the whole sample are focused and highlighted. Types of

surgery and breast cancer stages were gathered from the patients’ medical records,

whereas, the classification of the women’s menopausal status was based on the

definition as given by Brambilla et al. (1994), described in earlier section (see Section

8.1 - Breast Cancer: From the Couples’ Perspective).

These results are presented in the following sequence to answer the hypotheses

postulated in the study, as follows:

General Hypothesis:

• The treatment phases (prior-to, during and post-chemotherapy) have different

effects on the women’s quality of life, interpersonal relationship and coping

strategies.

Specific Hypotheses:

(a) Women’s quality of life, psychological well-being and sexuality aspects are

worst during chemotherapy as compared to prior-to and post-chemotherapy.

[Note: Women’s psychological aspects (anxiety and depression) have been reported in detail

in the section entitled, “Breast Cancer: From the Couple’s Perspective”].

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(b) Women’s interpersonal relationship aspects (perceived husband’s support,

level of disclosure, empathy, relationship satisfaction, helpfulness of

disclosure, withdrawal, holding back and criticism) are better during

chemotherapy as compared to prior-to and post-chemotherapy.

[Note: Women’s relationship satisfaction has also been reported in detail in the section of

“Breast Cancer: From the Couple’s Perspective”].

(c) Women use greater coping strategies during chemotherapy than prior-to and

post-chemotherapy

[Note: Women’s coping strategies have been reported in detail in the section entitled, “Breast

Cancer: From the Couple’s Perspective”]

(d) Medical (types of surgery and breast cancer stages) and bio/socio-

demographic aspects (menopausal status and ethnicity) have a significant

impact to the women’s quality of life, sexuality, interpersonal relationship and

coping strategies.

[Note: Women’s psychological aspects (anxiety and depression), relationship satisfaction and

coping strategies have also been reported in detail in the section entitled, “Breast Cancer:

From the Couple’s Perspective”].

Thus, in the next sections, only the findings on the women’s quality of life,

sexuality and interpersonal relationship are presented.

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8.2.1 Quality of Life of the Women with Breast Cancer

The results gathered for the Quality of Life [European Organization for

Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ C30)

and Breast Module (QLQ-BR23)] and menopausal symptoms (Menopausal Symptoms

Scale) are presented in this section. Nevertheless, women’s psychological aspects

(Hospital Depression and Anxiety Scale) are not reported in this section because they

have been discussed in the previous section on “Breast Cancer: From the Couple’s

Perspective.” In this study, most of the data on the quality of life domains were

transformed (Log10) to allow the use of the parametric analysis.

An analysis of the One-way Repeated Measure ANOVA [Tables 8.6 (a), (b);

Figures 8.3.0 (a), (b), (c), (d), (e)] indicated that there was a significant effect of time

on most aspects of the women’s quality of life, such as their Global Health Status [F

(1.08, 168.31) = 562.79; p<0.001] [Women’s Global Health Status declined from prior-

to (70.97±19.33) to during (61.36±17.96) and increased post-chemotherapy

(71.13±19.26)], Physical Functioning [F (2, 312) = 8.62; p<0.001] [Women’s Physical

Functioning improved over time (prior-to=72.61±15.13; during=74.82±18.59; post-

chemotherapy=78.81±12.35)], Role Functioning [F (1.60, 248.20) = 52.63; p<0.001]

[Women’s Role Functioning decreased from prior-to (42.99±17.00) to during

(31.74±13.58) and this was increased at post-chemotherapy (44.48±16.39)], Emotional

Functioning [F (1.03, 161.21) = 5.01; p<0.05] [Women’s Emotional Functioning

declined from prior-to (59.60±21.08) to during chemotherapy (52.55±19.21) and

increased at post-chemotherapy (56.63±19.05)], Cognitive Functioning [F (1.62,

252.13) = 5.44; p<0.01] [Women’s Cognitive Functioning declined over time (prior-

to=81.89±21.13; during=80.89±21.17; post-chemotherapy=80.57±21.42)], Social

Functioning [F (1.86, 290.20) = 30.60; p<0.001] [Women’s Social Functioning declined

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from prior-to (58.17±21.90) to during (41.83±25.43) and increased at post-

chemotherapy (48.83±18.98)], Fatigue [F (2, 312) = 8.84; p<0.001] [Fatigue was

increased from prior-to (46.57±19.78) to during (50.88±20.80), but declined at post-

chemotherapy (41.33±18.53)], Insomnia [F (1.40, 217.76) = 3.56; p<0.05] [Insomnia

Table 8.6 (a): One-Way Repeated Measure ANOVA: The Quality of Life of the Women With Breast Cancer

Sources of Variation ss df ms f sign EORTC QLQ C-30: Global health status 9823.366 1.079 9105.184 562.79 p<0.001 Physical functioning 3100.354 2 1550.177 8.621 p<0.001 Role functioning (Log 10) 2.361 1.591 1.484 52.630 p<0.001 Emotional functioning (Log 10) 0.270 1.033 0.261 5.006 p<0.05 Cognitive functioning 43.642 1.616 27.003 5.435 p<0.01 Social functioning (Log 10) 2.806 1.860 1.508 30.600 p<0.001 Fatigue (Log 10) 0.775 2 0.388 8.843 p<0.001 Nausea and vomiting* (Non-parametric Table) Pain (Log 10) 0.016 1.027 0.016 0.726 ns Dyspnoea* (Non-parametric Table) Insomnia (Log 10) 0.011 1.396 0.008 3.557 p<0.05 Appetite loss (Log 10) 0.624 1.141 0.547 28.108 p<0.001 Constipation* (Non-parametric Table) Diarrhoea* (Non-parametric Table) Financial Difficulties (Log 10) 0.027 2 0.013 0.489 ns QLQ-BR23: Body image (Log 10) 4.024 1.875 2.146 50.515 p<0.001 Sexual functioning (Log 10) 0.436 1.023 0.426 15.046 p<0.001 Sexual enjoyment* (Non-parametric Table) Future perspective (Log 10) 0.169 1.105 0.153 5.315 p<0.05 Systemic therapy side effects (Log 10) 5.827 1.793 3.250 82.924 p<0.001 Breast symptoms (Log 10) 0.286 1.874 0.152 2.514 ns Arm symptoms (Log 10) 4.806 2 2.403 45.911 p<0.001 Upset by hair loss* (Non-parametric Table) Menopausal symptoms (Blatt Menopausal Index)

2990.323 1.007 2968.149 50.502 p<0.001

Note: Transformation data (log 10) was used for some quality of life domains to allow the use of parametric analysis *The domains of Nausea and Vomiting, Dyspnoea, Diarrhoea, Sexual Enjoyment and Upset by Hair from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ C-30) were excluded from the analyses as the assumptions for parametric test were unmet.

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Table 8.6 (b): Non-parametric Analysis (Friedman Test): The Quality of Life of

the Women with Breast Cancer

χ2 df sign EORTC QLQ C-30: Nausea and vomiting 124.58 2 p<0.001 Dyspnoea 0.63 2 ns Constipation 2.80 2 ns Diarrhoea 6.00 2 p<0.05 QLQ-BR23: Sexual enjoyment 56.61 2 p<0.001 Upset by hair loss

4.30 2 ns

Note: The non-parametric test was preceded as the assumptions for parametric analysis were unmet

rose from prior-to (49.47±19.48) to during (50.74±19.46), but it slightly decreased at

post-chemotherapy (50.32±19.47)], Appetite Loss [F (1.14, 177.93) = 28.11; p<0.001]

[Appetite loss was also observed to increase over time (prior-to=37.58±13.98;

during=45.86±18.65; post-chemotherapy=46.71±19.56)], Body Image [F (1.86,

292.53) = 50.52; p<0.001] [Women’s view of their body image improved over time

(prior-to=46.82±22.87; during=65.23±29.51; post-chemotherapy=70.28±23.95)],

Sexual Functioning [F (1.02, 159.62) = 15.05; p<0.001] [Sexual functioning was found

to improve over time (prior-to=69.32±24.79; during=69.75±24.81; post-

chemotherapy=78.87±22.91)], Future Perspective [F (1.11, 172.38) = 5.34; p<0.05)]

[Future Perspective was also increased from prior-to (51.80±23.99) to during

chemotherapy (52.87±24.18), but diminished at post-chemotherapy (47.13±21.03)],

Systemic Therapy Side-Effects [F (1.79, 279.69) = 82.92; p<0.001] [Systemic Therapy

Side-Effects were also increased from prior-to (29.85±17.76) to during chemotherapy

(47.98±17.32), but these were slightly reduced at post-chemotherapy (46.16±17.33)],

Arm Symptoms [F (2, 312) = 45.91; p<0.001] [Women’s arm symptoms were found to

reduce over time (prior-to=39.77±21.69; during=31.00±18.28; post-

chemotherapy=23.28±16.02)]. Similar analysis also indicated the significant effects of

405

time on the Menopausal Symptoms [F (1.02, 157.17) = 50.50; p<0.001] [Women’s

menopausal symptoms became worse all the way through the treatment phases (prior-

to=23.96±7.08; during=29.24±8.44; post-chemotherapy=29.37±8.42)]. In the same

vein, the Friedman analysis conducted also revealed a significant effect of time on

Nausea and Vomiting (χ2 = 124.58; df = 2; p<0.001) [Nausea and Vomiting were found

to increase throughout the treatment phases (prior-to=11.57±23.01;

during=31.95±23.03; post-chemotherapy=32.59±23.52)], Diarrhea (χ2 = 6.00; df = 2;

p<0.05) [Diarrhea also increased all the way through the treatment phases (prior-

to=9.34±21.63; during=9.77±21.77; post-chemotherapy=10.19±21.90)] and Sexual

Enjoyment (χ2 = 56.61; df = 2; p<0.001) [Women’s sexual enjoyment was found to

improve throughout the treatment phases (prior-to=36.84±16.29;

during=63.16±16.29; post-chemotherapy=71.93±23.39)]. However, certain aspects of

the women’s quality of life did not show any significant effect of time, such as Pain [F

(1.03, 160.25) = 0.73; ns], Dyspnoea (χ2 = 0.63; df = 2; ns) , Constipation (χ2 = 2.80; df

= 2; ns), Financial Difficulties [F (2, 312) = 0.49; ns], Breast Symptoms [F (1.87,

292.34) = 2.51; ns] and Upset by Hair Loss (χ2 = 4.30; df = 2; ns).

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Physical Cognitive Role Emotional Social

Figure 8.3.0 (a): Women's Quality of Life (Global Health Status and Functional-EORTC-QLQ C-30)

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p<0.001 p<0.001 p<0.001

p<0.001

p<0.05 p<0.001

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Figure 8.3.0 (b): Women's Quality of Life (Symptomatology-EORTC QLQ C-30)

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Body Image SexualFunctioning

Sexual Enjoyment FuturePerspectives

Figure 8.3.0 (c): Women's Quality of Life (Functional-BR23)

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During Chemo

Post-Chemo

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Breast Symptoms Arm Symptoms Upset by HairLoss

Figure 8.3.0 (b): Women's Quality of Life (Symptomatology-BR23)

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p<0.001 p<0.001

p<0.001

p<0.05

ns

p<0.001 ns

p<0.001

p<0.05

p<0.001 p<0.01

ns

ns

p<0.001

p<0.001

ns

p<0.05

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Figure 8.3.0 (b): Women's Menopausal Symptoms

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Post-Chemotherapy

Furthermore, the analysis of the Split Plot Repeated Measure ANOVA (with

one within the subject’s factors and one between the subject’s factors) was carried out

to examine the effects of the types of surgery, breast cancer stages, menopausal status

and ethnicity on the quality of life of the women with breast cancer. Nonetheless, only

the quality of life domains which met the assumption for the parametric analysis were

preceded with this analysis.

The results yielded in this study indicated that the types of surgery significantly

affected Fatigue [F (1, 155) = 14.20; p<0.001] [The lumpectomy group indicated higher

fatigue in all occasions (prior-to=73.48±17.36; during=63.64±16.00; post-

chemotherapy=73.74±17.19), as compared to the mastectomy group (prior-

to=70.30±19.83; during=60.75±18.46; post-chemotherapy=70.43±19.78)] [Table 8.6

(c); Figure 8.3.1 (a)], Appetite Loss [F (1, 155) = 6.29; p<0.05] [Prior-to

chemotherapy, the lumpectomy group was found to score higher for appetite loss

(40.40±18.18) than the mastectomy group (36.83±12.62). However, the mastectomy

group exhibited higher appetite loss during (48.39±19.64) and post-chemotherapy

(48.92±20.13) as compared to the women with lumpectomy during (36.36±9.73) and

post-chemotherapy (38.38±14.72)] [Table 8.6 (c); Figure 8.3.1 (b)] and Body Image [1,

F (1.02, 157.17) = 50.50; p<0.001

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155) = 15.86; p<0.001] [The lumpectomy group demonstrated a better view of their

body image in all occasions (prior-to=53.03±23.09; during=87.63±19.78; post-

chemotherapy=90.40±18.00) as compared to the women in the mastectomy group

(prior-to=45.16±22.62; during=59.27±28.85; post-chemotherapy=64.92±22.47)]

[Table 8.6 (c); Figure 8.3.1 (c)]. Global Health Status [F (1, 155) = 0.73; ns] [Table 8.6

(c); Figure 8.3.1 (d)] and other aspects of the life quality such as the Physical

Functioning [F (1, 155) = 2.39; ns] [Table 8.6 (c); Figure 8.3.1 (e)], Role Functioning

[F (1, 155) = 0.01; ns] [Table 8.8 (c); Figure 8.4.1 (f)], Emotional Functioning [F (1,

155) = 0.00; ns] [Table 8.6 (c); Figure 8.3.1 (g)], Cognitive Functioning [F (1, 155) =

2.09; ns] [Table 8.6 (c); Figure 8.3.1 (h)], Social Functioning [F (1, 155) = 0.16; ns]

[Table 8.6 (c); Figure 8.3.1 (i)], Pain [F (1, 155) = 1.16; ns] [Table 8.6 (c); Figure 8.3.1

(j)], Insomnia [F (1, 155) = 0.43; ns] [Table 8.6 (c); Figure 8.3.1 (k)], Financial

Difficulties [F (1, 155) = 0.29; ns] [Table 8.6 (c); Figure 8.3.1 (l)], Sexual Functioning

[F (1, 155) = 0.63; ns] [Table 8.6 (c); Figure 8.3.1 (m)], Future Perspective [F (1, 155)

= 0.73; ns] [Table 8.6 (c); Figure 8.3.1 (n)], Systemic Therapy Side-Effects [F (1, 155)

= 0.46; ns] [Table 8.6 (c); Figure 8.3.1 (o)], Breast Symptoms [F (1, 155) = 1.16; ns]

[Table 8.6 (c); Figure 8.3.1 (p)] and Arm Symptoms [F (1, 155) = 0.50; ns] [Table 8.6

(c); Figure 8.3.1 (q)] were unaffected by the types of surgery. The same result was also

observed for the women’s menopausal symptoms [F (1, 155) = 1.63; ns] [Table 8.8 (c);

Figure 8.4.1 (r)].

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Table 8.6 (c): Split Plot Repeated Measure ANOVA: The Effect of the Types of Surgery on the Quality of Life of the Women with Breast Cancer

Sources of Variation ss df ms f sign

EORTC QLQ C-30 – Global Health Status Within Subjects Effect: Global Health Status (Time) 6666.798 1.086 6139.820 379.848 p<0.001 Time x Types of Surgery 2.491 1.086 2.294 0.142 p<0.001 Between Subjects Effect: 764.414 1 764.414 0.727 ns (Effect of Types of Surgery)

EORTC QLQ C-30 – Physical Functioning Within Subjects Effect: Physical Functioning (Time) 3885.420 1.961 1981.543 10.913 p<0.001 Time x Types of Surgery 912.644 1.961 465.443 2.563 ns Between Subjects Effect: 869.073 1 869.073 2.387 ns (Effect of Types of Surgery)

EORTC QLQ C-30 – Role Functioning (Log 10) Within Subjects Effect: Role Functioning (Time) 1.444 1.602 0.901 32.022 p<0.001 Time x Types of Surgery 0.01 1.602 0.007 0.232 ns

Between Subjects Effect: 0.001 1 0.001 0.009 ns (Effect of Types of Surgery)

EORTC QLQ C-30 – Emotional Functioning (Log 10) Within Subjects Effect: Emotional Functioning (Time)

0.306 1.040 0.294 5.803 p<0.05

Time x Types of Surgery 0.255 1.040 0.245 4.85 p<0.05

Between Subjects Effect: 0.002 1 0.002 0.019 ns (Effect of Types of Surgery)

EORTC QLQ C-30 – Cognitive Functioning Within Subjects Effect: Cognitive Functioning (Time) 102433.65 1.0.24 100015.7 146.249 p<0.001 Time x Types of Surgery 112.345 1.024 109.693 0.160 ns Between Subjects Effect: 1775.641 1 1775.641 2.090 ns (Effect of Types of surgery)

EORTC QLQ C-30 – Social Functioning (Log 10) Within Subjects Effect: Social Functioning (Time) 2.444 1.874 1.305 26.813 p<0.001 Time x Types of Surgery 0.173 1.874 0.093 1.902 ns Between Subjects Effect: 0.011 1 0.011 0.161 ns (Effect of Types of Surgery)

EORTC QLQ C-30 – Fatigue (Log 10) Within Subjects Effect: Fatigue (Time) 1.226 2 0.601 26.813 p<0.001

Table 8.6 (c), Continued.

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ss df ms f sign Time x Types of Surgery 0.488 2 0.244 5.733 p<0.001

Between Subjects Effect: 0.839 1 0.839 14.196 p<0.001 (Effect of Types of Surgery)

EORTC QLQ C-30 – Pain (Log 10) Within Subjects Effect: Pain (Time) 0.003 1.034 0.002 0.117 ns Time x Types of Surgery 0.038 1.034 0.037 0.719 ns

Between Subjects Effect: 0.057 1 0.057 1.160 ns (Effect of Types of Surgery)

EORTC QLQ C-30 – Insomnia (Log 10) Within Subjects Effect: Insomnia (Time) 0.006 1.404 0.004 1.94 ns Time x Types of surgery 0.001 1.404 0.001 0.424 ns

Between Subjects Effect: 0.003 1 0.003 0.43 ns (Effect of Types of surgery)

EORTC QLQ C-30 – Appetite Loss (Log 10) Within Subjects Effect: Appetite Loss (Time) 0.120 1.160 0.104 5.835 p<0.05 Time x Types of Surgery 0.273 1.160 0.235 13.261 p<0.001

Between Subjects Effect: 0.241 1 0.241 6.278 p<0.05 (Effect of Types of Surgery)

EORTC QLQ C-30 – Financial Difficulties (Log 10) Within Subjects Effect: Financial Difficulties (Time) 0.019 2 0.009 0.339 ns Time x Types of Surgery 0.009 2 0.005 0.165 ns Between Subjects Effect: 0.015 1 0.015 0.293 ns (Effect of Types of surgery)

EORTC QLQ C-23 – Body Image (Log 10) Within Subjects Effect: Body Image (Time) 3.473 1.900 1.828 44.298 p<0.001 Time x Types of Surgery 0.272 1.900 0.143 3.473 p<0.05 Between Subjects Effect: 2.192 1 2.192 15.86 p<0.001 (Effect of Types of Surgery)

EORTC QLQ C-23 – Sexual Functioning (Log 10) Within Subjects Effect: Sexual Functioning (Time) 0.157 1.030 0.152 5.461 p<0.05 Time x Types of Surgery 0.060 1.030 0.058 2.076 ns

Between Subjects Effect: 0.038 1 0.038 0.628 ns (Effect of Types of Surgery)

EORTC QLQ C-23 – Future Perspective (Log 10) Within Subjects Effect: Future Perspective (Time) 0.003 1.117 0.003 0.003 ns

Table 8.6 (c), Continued.

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ss df ms f sign Time x Types of Surgery 0.249 1.117 0.222 8.192 p<0.01

Between Subjects Effect: 0.205 1 0.205 3.194 ns (Effect of Types of Surgery)

EORTC QLQ C-23 – Systemic Therapy Side Effects (Log 10) Within Subjects Effect: Systemic Therapy Side Effects (Time)

3.897 1.785 2.183 55.859 p<0.001

Time x Types of surgery 0.148 1.785 0.083 2.119 ns

Between Subjects Effect: 0.026 1 0.026 0.459 ns (Effect of Types of Surgery)

EORTC QLQ C-23 – Breast Symptoms (Log 10) Within Subjects Effect: Breast Symptoms (Time) 0.520 1.893 0.275 4.627 p<0.05 Time x Types of Surgery 0.314 1.893 0.166 2.792 ns

Between Subjects Effect: 0.170 1 0.170 1.157 ns (Effect of Types of Surgery)

EORTC QLQ C-23 – Arms Symptoms (Log 10) Within Subjects Effect: Arms Symptoms (Time) 4.075 2 2.038 39.073 p<0.001 Time x Types of Surgery 0.162 2 0.081 1.553 ns Between Subjects Effect: 0.051 1 0.051 0.495 ns (Effect of Types of Surgery)

Menopausal Symptoms (Blatt Menopausal Index) Within Subjects Effect: Menopausal symptoms (Time)

2389.694 1.014 2356.565 40.343 p<0.001

Time x Types of Surgery 55.664 1.014 54.893 0.940 ns Between Subjects Effect: 216.413 1 216.413 1.632 ns (Effect of Types of Surgery)

Note: Transformation data (log 10) was used for some quality of life domains to allow the use of parametric analysis

*The domains of Nausea and Vomiting, Dyspnoea, Diarrhoea, Sexual Enjoyment and Upset by Hair from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ C-30) were excluded from the analysis as the assumptions for parametric test were unmet.

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Figure 8.3.1 (a): The Effect of Types of Surgery on Women's Fatigue (EORTC QLQ C-30)

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Mastectomy(N=124)

Lumpectomy(N=33)

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Post Chemotherapy

Figure 8.3.1 (b): The Effects of Types of Surgery on Women's Appetite Loss (EORTC QLQ C-30)

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Mastectomy(N=124)

Lumpectomy(N=33)

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Figure 8.3.1 (c): The Effect of Types of Surgery on Women's Body Image (QLQ-BR23)

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Mastectomy(N=124)

Lumpectomy(N=33)

Time: F (2, 310) = 26.81; p<0.001 Interaction Effect: F (2, 310) = 5.73; p<0.001 Between Subjects Effect: F (1, 155) = 14.20; p<0.001 (8.3.1.a)

Time: F (1.16, 179.82) = 5.84; p<0.05 Interaction Effect: F (1.16, 179.82) = 13.26; p<0.001 Between Subjects Effect: F (1, 155) = 6.28; p<0.05 (8.3.1 b)

Time: F (1.90, 294.47) = 44.30; p<0.001 Interaction Effect: F (1.90, 294.47) = 3.47; p<0.05 Between Subjects Effect: F (1, 115) = 15.86; p<0.001 (8.3.1 c)

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Figure 8.3.1 (d): The Effect of Types of Surgery on Women's Global Health Status (EORTC QLQ C-30)

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Mastectomy(N=124)

Lumpectomy(N=33)

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Figure 8.3.1 (e): The Effect of Types of Surgery on Women's Physical Functioning (EORTC QLQ C-30)

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Mastectomy(N=124)

Lumpectomy(N=33)

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Figure 8.3.1 (f): The Effect of Types of Surgery on Women's Role Functioning (EORTC QLQ C-30)

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Mastectomy(N=124)

Lumpectomy(N=33)

Time: F (1.09, 168.3) = 379.85; p<0.001 Interaction Effect: F (1.09, 168.3) = 0.14; p<0.001 Between Subjects Effect: F (1, 155) = 0.73; ns (8.3.1 d)

Time: F (1.96, 303.94) = 10.91; p<0.001 Interaction Effect: F (1.96, 303.94) = 2.56; p<0.001 Between Subjects Effect: F (1, 155) = 2.39; ns (8.3.1 e)

Time: F (1.60, 248.31) = 32.02; p<0.001 Interaction Effect: F (1.60, 248.31) = 0.23; ns Between Subjects Effect: F (1, 155) = 0.01; ns (8.3.1 f)

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Figure 8.3.1 (g): The Effect of Types of Surgery on Women's Emotional Functioning (EORTC QLQ C-30)

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Mastectomy(N=124)Lumpectomy(N=33)

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Figure 8.3.1 (h): The Effect of Types of Surgery on Women's Cognitive Functioning

(EORTC QLQ C-30)

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Figure 8.3.1 (i): The Effect of Types of Surgery on Women's Social Functioning

(EORTC QLQ C-30)

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Mastectomy(N=124)

Lumpectomy(N=33)

Time: F (1.04, 161.24) = 5.80; p<0.05 Interaction Effect: F (1.04, 161.24) = 4.85; p<0.05 Between Subjects Effect: F (1, 155) = 0.02; ns (8.3.1 g)

Time: F (1.02, 158.75) =146.25; p<0.001 Interaction Effect: F (1.02, 158.75) = 0.16; ns Between Subjects Effect: F (1, 155) = 2.09; ns (8.3.1 h)

Time: F (1.87, 290.44) = 26.81; p<0.001 Interaction Effect: F (1.87, 290.44) =1.90; ns Between Subjects Effect: F (1, 155) = 0.16; ns (8.3.1 i-soc)

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Figure 8.3.1 (j): The Effect of Types of Surgery on Women's Pain

(EORTC QLQ C-30)

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Lumpectomy(N=33)

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Figure 8.3.1 (k): The Effect of Types of Surgery on Women's Insomnia (EORTC QLQ C-30)

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Lumpectomy(N=33)

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Figure 8.3.1 (l): The Effect of Types of Surgery on Women's Financial Difficulties

(EORTC QLQ C-30)

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Mastectomy(N=124)Lumpectomy(N=33)

Time: F (1.03, 160.29) = 0.12; ns Interaction Effect: F (1.03, 160.29) = 0.72; ns Between Subjects Effect: F (1, 155) = 1.16; ns (8.3.1 j)

Time: F (1.40, 217.65) = 1.94; ns Interaction Effect: F (1.40, 217.65) = 0.42; ns Between Subjects Effect: F (1, 155) = 0.43; ns (8.3.1 k)

Time: F (2, 310) = 0.34; ns Interaction Effect: F (2, 310) = 0.17; ns Between Subjects Effect: F (1, 155) = 0.29; ns (8.3.1 -l)

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Figure 8.3.1 (m): The Effect of Types of Surgery on Women's Sexual Functioning (QLQ-BR23)

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Figure 8.3.1 (o): The Effect of Type of Surgery on Women's Systemic Therapy Side Effect (QLQ-BR23)

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Mastectomy(N=124)Lumpectomy(N=33)

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Figure 8.3.1 (n): The Effect of Type of Surgery on Women's Future Perspective

(QLQ-BR23)

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Mastectomy(N=124)

Lumpectomy(N=33)

Time: F (1.03, 159.67) = 5.46; p<0.05 Interaction Effect: F (1.03, 159.67) = 2.08; ns Between Subjects Effect: F (1, 115) = 0.63; ns (8.3.1 m)

Time: F (1.12, 173.20) = 0.00; ns Interaction Effect: F (1.12, 173.20) = 8.19; p<0.01 Between Subjects Effect: F (1, 115) = 3.19; ns (8.3.1 n)

Time: F (1.79, 276.66) = 55.86; p<0.001 Interaction Effect: F (1.79, 276.66) = 2.12; ns Between Subjects Effect: F (1, 155) = 0.46; ns (8.3.1 o)

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Figure 8.3.1 (p): The Effect of Types of Surgery on Women's Breast Symptoms (QLQ-BR23)

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Mastectomy(N=124)

Lumpectomy(N=33)

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Figure 8.3.1 (q): The Effect of Type of Surgery on Women's Arm Symptoms (QLQ-BR23)

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Mastectomy(N=124)

Lumpectomy(N=33)

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Figure 8.3.1 (r): The Effect of Type of Surgery on Women's Menopausal Symptoms

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Mastectomy(N=124)

Lumpectomy(N=33)

Time: F (1.89, 293.42) = 4.63; p<0.05 Interaction Effect: F (1.89, 293.42) = 2.79; ns Between Subjects Effect: F (1, 155) = 1.16; ns (8.3.1 p)

Time: F (2, 310) =39.07; p<0.001 Interaction Effect: F (2, 310) = 1.56; ns Between Subjects Effect: F (1, 155) = 0.50; ns (8.3.1 q)

Time: F (1.01, 157.18) = 40.34; p<0.001 Interaction Effect: F (1.01, 157.18) = 0.94; ns Between Subjects Effect: F (1, 155) = 1.63; ns (8.3.1 r-surgery)

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Similar analysis indicated that most of the quality of life aspects such as the

patients’ Global Health Status [F (1, 142) = 0.11; ns] [Table 8.6 (d); Figure 8.3.2 (a)],

Physical Functioning [F (1, 142) = 0.00; ns] [Table 8.6 (d); Figure 8.3.2 (b)], Role

Functioning [F (1, 142) = 3.63; ns] [Table 8.6 (d); Figure 8.3.2 (c)], Emotional

Functioning [F (1, 142) = 0.20; ns] [Table 8.6 (d); Figure 8.3.2 (d)], Cognitive

Functioning [F (1, 142) = 0.03; ns] [Table 8.6 (d); Figure 8.3.2 (e)], Social Functioning

[F (1, 142) = 0.02; ns] [Table 8.6 (d); Figure 8.3.2 (f)], Fatigue [F (1, 142) = 0.34; ns]

[Table 8.6 (d); Figure 8.3.2 (g)], Pain [F (1, 142) = 0.90; ns] [Table 8.6 (d); Figure

8.3.2 (h)], Insomnia [F (1, 142) = 0.67; ns] [Table 8.6 (d); Figure 8.3.2 (i)], Appetite

Loss [F (1, 142) = 0.09; ns] [Table 8.6 (d); Figure 8.3.2 (j)], Body Image [F (1, 142) =

0.77; ns] [Table 8.6 (d); Figure 8.3.2 (k)], Sexual Functioning [F (1, 142) = 0.23; ns]

[Table 8.6 (d); Figure 8.3.2 (l)], Future Perspective [F (1, 142) = 0.34; ns] [Table 8.6

(d); Figure 8.3.2 (m)], Systemic Therapy Side-Effects [F (1, 142) = 1.33; ns] [Table 8.6

(d); Figure 8.3.2 (n)], Breast Symptoms [F (1, 142) = 0.00; ns] [Table 8.6 (d); Figure

8.3.2 (o)] and Arm Symptoms [F (1, 142) = 0.19; ns] [Table 8.6 (d); Figure 8.3.2 (p)]

were not significantly influenced by the breast cancer stages, except for the Financial

Difficulties [F (1, 142) = 4.30; p<0.05] [The mastectomy group exhibited more

financial difficulties in all occasions (prior-to=52.81±24.52; during=53.56±25.93;

post-chemotherapy=58.43±26.72) as compared to the women in the lumpectomy group

(prior-to=48.48±19.05; during=48.48±22.05; post-chemotherapy=49.09±26.34)]

[Table 7.6 (d); Figure 7.3.2 (q)]. A similar insignificant result was also yielded for the

effects of the stages of breast cancer on the menopausal symptoms [F (1, 142) = 0.52;

ns] [Table 8.6 (d); Figure 8.3.2 (r)].

419

Table 8.6 (d): Split Plot Repeated Measure ANOVA: The Effect of the Breast Cancer Stages on the Quality of Life of the Women with Breast Cancer

Sources of variation ss df ms f sign

EORTC QLQ C-30 – Global Health Status Within Subjects Effect: Global Health Status (Time) 8565.409 1.090 7856.022 467.565 p<0.000 Time x Breast Cancer Stages 11.525 1.090 10.571 0.629 ns Between Subjects Effect: 116.935 1 116.935 0.114 ns (Effect of Breast Cancer Stages)

EORTC QLQ C-30 – Physical Functioning Within Subjects Effect: Physical functioning (Time) 2491.080 2 1245.540 6.986 0.001 Time x Breast Cancer Stages 268.446 2 134.223 0.753 ns Between Subjects Effect: 0.219 1 0.219 0.001 ns (Effect of Breast Cancer Stages )

EORTC QLQ C-30 – Role Functioning (Log 10) Within Subjects Effect: Role Functioning (Time) 2.029 1.605 1.264 44.842 p<0.001 Time x Breast Cancer Stages 0.042 1.605 0.026 0.935 ns

Between Subjects Effect: 0.194 1 0.194 3.630 ns (Effect of Breast Cancer Stages )

EORTC QLQ C-30 – Emotional Functioning (Log 10) Within Subjects Effect: Emotional functioning (Time) 0.240 1.043 0.230 4.546 p<0.05 Time x Breast Cancer Stages 0.006 1.043 0.006 0.117 ns

Between Subjects Effect: 0.018 1 0.018 0.197 ns (Effect of Breast Cancer Stages)

EORTC QLQ C-30 – Cognitive Functioning Within Subjects Effect: Cognitive functioning (Time) 40.633 1.632 24.897 4.628 p<0.05 Time x Breast Cancer Stages 2.053 1.632 1.258 0.234 ns Between Subjects Effect: 39.881 1 39.881 0.030 ns (Effect of Breast Cancer Stages)

EORTC QLQ C-30 – Social Functioning (Log 10) Within Subjects Effect: Social functioning (Time) 2.398 1.850 1.296 26.288 p<0.001 Time x Breast Cancer Stages 0.003 1.850 0.002 0.032 ns

Between Subjects Effect: 0.002 1 0.002 0.023 ns (Effect of Breast Cancer Stages )

EORTC QLQ C-30 – Fatigue (Log 10) Within Subjects Effect: Fatigue (Time) 0.538 2 0.269 6.302 p<0.01 Time x Breast Cancer Stages 0.124 2 0.062 1.456 ns

Table 8.6 (d), Continued.

420

ss df ms f sign Between Subjects Effect: 0.022 1 0.022 0.344 ns (Effect of Breast Cancer Stages)

EORTC QLQ C-30 – Pain (Log 10) Within Subjects Effect: Pain (Time) 0.015 1.030 0.014 0.649 ns Time x Breast Cancer Stages 0.001 1.030 0.001 0.061 ns

Between Subjects Effect: 0.043 1 0.043 0.899 ns (Effect of Breast Cancer Stages)

EORTC QLQ C-30 – Insomnia (Log 10) Within Subjects Effect: Insomnia (Time) 0.010 1.406 0.007 3.147 ns Time x Breast Cancer Stages 0.000 1.406 0.000 0.112 ns

Between Subjects Effect: 0.049 1 0.049 0.668 ns (Effect of Breast Cancer Stages)

EORTC QLQ C-30 – Appetite Loss (Log 10) Within Subjects Effect: Appetite Loss (Time) 0.599 1.156 0.518 25.724 p<0.001 Time x Breast Cancer Stages 0.018 1.156 0.016 0.781 ns

Between Subjects Effect: 0.003 1 0.003 0.085 ns (Effect of Breast Cancer Stages )

EORTC QLQ C-30 – Financial Difficulties (Log 10) Within Subjects Effect: Financial Difficulties (Time) 0.021 2 0.011 0.387 ns Time x Breast Cancer Stages 0.056 2 0.028 1.018 ns Between Subjects Effect: 0.219 1 0.219 4.297 p<0.05 (Effect of Breast Cancer Stages )

EORTC QLQ C-23 – Body Image (Log 10) Within Subjects Effect: Body Image (Time) 3.629 1.916 1.894 44.554 p<0.001 Time x Breast Cancer Stages 0.033 1.916 0.017 0.410 ns

Between Subjects Effect: 0.118 1 0.118 0.765 ns (Effect of Breast Cancer Stages )

EORTC QLQ C-23 – Sexual Functioning (Log 10) Within Subjects Effect: Sexual Functioning (Time) 0.364 1.033 0.353 12.763 p<0.001 Time x Breast Cancer Stages 0.035 1.033 0.034 1.236 ns

Between Subjects Effect: 0.014 1 0.014 0.225 ns (Effect of Breast Cancer Stages)

EORTC QLQ C-23 – Future Perspective (Log 10) Within Subjects Effect: Future Perspective (Time) 0.148 1.119 0.133 4.506 p<0.05 Time x Breast Cancer Stages 0.003 1.119 0.003 0.105 ns

Table 8.6 (d), Continued.

421

ss df ms f sign Between Subjects Effect: 0.022 1 0.022 0.336 ns (Effect of Breast Cancer Stages)

EORTC QLQ C-23 – Systemic Therapy Side Effects (Log 10) Within Subjects Effect: Systemic Therapy Side Effects (Time)

5.106 1.790 2.802 74.585 p<0.001

Time x Breast Cancer Stages 0.003 1.790 0.002 0.041 ns

Between Subjects Effect: 0.074 1 0.074 1.329 ns (Effect of Breast Cancer Stages )

EORTC QLQ C-23 – Breast Symptoms (Log 10) Within Subjects Effect: Breast Symptoms (Time) 0.320 1.899 0.168 2.836 ns Time x Breast Cancer Stages 0.105 1.899 0.055 0.927 ns

Between Subjects Effect: 3.29 1 3.29 0.000 ns (Effect of Breast Cancer Stages )

EORTC QLQ C-23 – Arms Symptoms (Log 10) Within Subjects Effect: Arms Symptoms (Time) 4.177 2 2.089 40.713 p<0.001 Time x Breast Cancer Stages 0.247 2 0.124 2.411 ns Between Subjects Effect: 0.020 1 0.020 0.190 ns (Effect of Breast Cancer Stages )

Menopausal Symptoms (Blatt Menopausal Index) Within Subjects Effect: Menopausal Symptoms (Time) 2903.729 1.015 2860.474 47.711 p<0.001 Time x Breast Cancer Stages 6.117 1.015 6.026 0.101 ns

Between Subjects Effect: 65.690 1 65.690 0.518 ns (Effect of Breast Cancer Stages )

Note: Transformation data (log 10) was used for some quality of life domains to allow the use of parametric analysis

*The domains of Nausea and Vomiting, Dyspnoea, Diarrhoea, Sexual Enjoyment and Upset by Hair from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ C-30) were excluded from the analysis as the assumptions for the parametric test were not met

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Figure 8.3.2 (a): The Effect of Breast Cancer Stages on Women's Global Health Status (EORTC QLQ C-30)

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Figure 8.3.2 (b): The Effect of Breast Cancer Stages on Women's Physical Functioning (EORTC QLQ C-30)

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Stage Three(N=55)

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Figure 8.3.2 (c): The Effect of Breast Cancer Stages on Women's Role Functioning (EORTC QLQ C-30)

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Stage Two(N=89)

Stage Three(N=55)

Time: F (1.09, 154.82) = 467.57; p<0.001 Interaction Effect: F (1.09, 154.82) = 0.63; ns Between Subjects Effect: F (1, 142) = 0.11; ns (8.3.2 a)

Time: F (2, 284) = 6.99; p<0.001 Interaction Effect: F (2, 284) = 0.75; ns Between Subjects Effect: F (1, 142) = 0.00; ns (8.3.2 b)

Time: F (1.60, 227.95) = 44.84; p<0.001 Interaction Effect: F (1.60, 227.95) = 0.94; ns Between Subjects Effect: F (1, 142) = 3.63; ns (8.3.2 c)

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Figure 8.3.2 (d): The Effect of Breast Cancer Stages on Women's Emotional Functioning (EORTC QLQ C-30)

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Stage Three(N=55)

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Figure 8.3.2 (e): The Effect of Breast Cancer Stages on Women's Cognitive Functioning

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(N=89)

Stage Three(N=55)

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Figure 8.3.2 (f): The Effect of Breast Cancer Stages on Women's Social Functioning (EORTC QLQ C-30)

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Stage Two(N=89)

Stage Three(N=55)

Time: F (1.04, 148.10) = 4.55; p<0.05 Interaction Effect: F (1.04, 148.10) =0.12; ns Between Subjects Effect: F (1, 142) = 0.20; ns (8.3.2 d)

Time: F (1.63, 231.75) = 4.63; p<0.05 Interaction Effect: F (1.63, 231.75) = 0.23; ns Between Subjects Effect: F (1, 142) = 0.03; ns (8.3.2 e)

Time: F (1.85, 262.68) = 26.29; p<0.001 Interaction Effect: F (1.85, 262.68) =0.03; ns Between Subjects Effect: F (1, 142) = 0.02; ns (8.3.2 f)

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figure 8.3.2 (g): The Effect of Breast Cancer Stages on Women's Fatigue (EORTC QLQ C-30)

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Stage Two(N=89)

Stage Three(N=55)

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Figure 8.3.2 (h): The Effect of Breast Cancer Stages on Women's Pain (EORTC QLQ C-30)

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Stage Two(N=88)

Stage Three(N=55)

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Figure 8.3.2 (i): The Effect of Breast Cancer Stages on Women's Insomnia (EORTC QLQ C-30)

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Stage Two(N=89)

Stage Three(N=55)

Time: F (2, 284) =6.30; p<0.01 Interaction Effect: F (2,284) = 1.46; ns Between Subjects Effect: F (1, 142) = 0.34; ns (8.3.2 g)

Time: F (1.03, 146.26) = 0.65; ns Interaction Effect: F (1.03, 146.26) = 0.06; ns Between Subjects Effect: F (1, 142) = 0.90; ns (8.3.2 h)

Time: F (1.41, 199.71) = 0.01; ns Interaction Effect: F (1.41, 199.71) = 0.11; ns Between Subjects Effect: F (1, 142) = 0.66; ns (8.3.2 i)

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Figure 8.3.2 (j): The Effect of Breast Cancer Stages on Women's Appetite Loss (EORTC QLQ C-30)

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Stage Two(N=89)

Stage Three(N=55)

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Figure 8.3.2 (k): The Effect of Breast Cancer Stages on Women's Body Image (QLQ-BR23)

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Stage Three(N=55)

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Figure 8.3.2 (l): The Effect of Breast Cancer Stages on Women's Sexual Functioning (QLQ-BR23)

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Stage Two(N=89)

Stage Three(N=55)

Time: F (1.17, 164.12) = 25.74; p<0.001 Interaction Effect: F (1.16, 164.12) = 0.78; ns Between Subjects Effect: F (1, 142) = 0.09; ns (8.3.2 j)

Time: F (1.92, 272.06) = 44.55; p<0.001 Interaction Effect: F (1.92, 272.06) =0.41; ns Between Subjects Effect: F (1, 142) = 0.77; ns (8.3.2 k)

Time: F (1.03, 146.70) = 12.76; p<0.001 Interaction Effect: F (1.03, 146.70) =1.24; ns Between Subjects Effect: F (1, 142) = 0.24; ns (8.3.2 l)

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Figure 8.3.2 (m): The Effect of Breast Cancer Stages on Women's Future Perspective (QLQ-BR23)

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Stage Three(N=55)

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Figure 8.3.2 (n): The Effect of Breast Cancer Stages on Women's Systemic Therapy Side Effect (QLQ-BR23)

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(N=89)

Stage Three(N=55)

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Figure 8.3.2 (o): The Effect of Breast Cancer Stages on Women's Breast Symptoms (QLQ-BR23)

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Stage Two(N=89)

Stage Three(N=55)

Time: F (1.12, 158.88) = 4.15; p<0.05 Interaction Effect: F (1.12, 158.88) = 0.11; ns Between Subjects Effect: F (1, 142) = 0.34; ns (8.3.2 m)

Time: F (1.790, 254.25) =7 4.585; p<0.001 Interaction Effect: F (1.790, 254.25) = 0.041; ns Between Subjects Effect: F (1, 142) = 1.329; ns (8.3.2 n)

Time: F (1.90, 269.61) = 2.84; ns Interaction Effect: F (1.90, 269.61) =0.93; ns Between Subjects Effect: F (1, 142) = 0.00; ns (8.3.2 o)

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Figure 8.3.2 (p): The Effect of Breast Cancer Stages on Women's Arm Symptoms (QLQ-BR23)

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Figure 8.3.2 (q): The Effect of Breast Cancer Stages on Women's Financial Difficulties

(EORTC QLQ C-30)

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Stage Three(N=55)

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Figure 8.3.2 (r): The Effect of Breast Cancer Stages on Women's Menopausal Symptoms

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Stage Two(N=89)

Stage Three(N=55)

Time: F (2, 284) = 40.71; p<0.001 Interaction Effect: F (2,284) = 2.41; ns Between Subjects Effect: F (1, 142) = 0.19; ns (8.3.2 p)

Time: F (2, 284) = 0.39; ns Interaction Effect: F (2, 284) = 1.02; ns Between Subjects Effect: F (1, 142) = 4.30; p<0.05 (8.3.2 q)

Time: F (1.015, 144.147) = 47.711; p<0.001 Interaction Effect: F (1.015, 144.147) = 0.101; ns Between Subjects Effect: F (1, 142) = 0.518; ns (8.3.2 r)

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An analysis of the Split Plot Repeated Measure ANOVA (with one within the

subjects’ factors and one between the subjects factors), looking at the effect of the

women’s menopausal status, indicated a significant effect on certain aspects of the

women’s quality of life, such as Emotional Functioning [F (1, 142) = 7.53; p<0.01]

[The post-menopausal group indicated a better emotional functioning prior-to

(62.96±19.96) and during chemotherapy (55.29±18.83), as compared to the pre-

menopausal group (prior-to=56.48±21.93; during=49.79±19.59). However, both

groups revealed the same level of emotional functioning at post-chemotherapy

(51.44±20.78)] [Table 7.6 (e); Figure 7.3.3 (a)], Fatigue [F (1, 142) = 5.80; p<0.05]

[Pre-menopausal group indicated to be more fatigued prior-to (49.11±19.31) and post-

chemotherapy (44.17±18.00), as compared to the women in the post-menopausal group

(prior-to=42.68±20.08; post-chemotherapy=34.57±14.81). However, during

chemotherapy, post-menopausal women (51.85±19.65) were found as more fatigued

than those in the pre-menopausal group (50.21±20.87)] [Table 8.6 (e); Figure 8.3.3

(b)], Pain [F (1, 142) = 9.93; p<0.05] [Pre-menopausal women reported to experience

more pain in all conditions (prior-to=65.23±21.44; during=66.05±21.80; post-

chemotherapy=65.23±16.71), as compared to the post-menopausal women (prior-

to=56.61±20.00; during=57.41±20.47; post-chemotherapy=57.67±20.48)] [Table 8.6

(e); Figure 8.3.3 (c)], Body Image [F (1, 142) = 4.81; p<0.05] [Post-menopausal

women were found to have a better view of their body image in all occasions (prior-

to=50.93±22.31; during=71.43±28.19; post-chemotherapy=73.81±25.04) than the

patients in the pre-menopausal group (prior-to=42.49±23.33; during=60.29±30.22;

post-chemotherapy=66.67±24.08)] [Table 8.6 (e); Figure 8.3.3 (d)], Sexual

Functioning [F (1, 142) = 32.23; p<0.001] [Post-menopausal women demonstrated

better sexual functioning in all situations (prior-to=80.16±21.98; during=80.42±22.11;

post-chemotherapy=86.77±19.89) when compared to those in the pre-menopausal

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Table 8.6 (e): Split Plot Repeated Measure ANOVA: The Effect of Menopausal Status

on the Quality of Life of the Women with Breast Cancer Sources of Variation ss df ms f sign

EORTC QLQ C-30 – Global Health Status Within Subjects Effect: Global Health Status (Time) 8928.332 1.086 8222.314 475.553 p<0.001 Time x Menopausal Status 9.221 1.086 8.492 0.491 ns Between Subjects Effect: 183.266 1 183.266 0.173 ns (Effect of Menopausal Status)

EORTC QLQ C-30 – Physical Functioning Within Subjects Effect: Physical functioning (Time) 2808.743 2 1404.372 7.566 p<0.001 Time x Menopausal Status 20.677 2 10.339 0.056 ns Between Subjects Effect: 1.104 1 1.104 0.003 ns (Effect of Menopausal Status)

EORTC QLQ C-30 – Role Functioning (Log 10) Within Subjects Effect: Role Functioning (Time) 2.211 1.619 1.365 48.420 p<0.001 Time x Menopausal Status 0.071 1.619 0.044 1.545 ns

Between Subjects Effect: 0.009 1 0.009 0.165 ns (Effect of Menopausal Status)

EORTC QLQ C-30 – Emotional Functioning (Log 10) Within Subjects Effect: Emotional functioning (Time) 0.285 1.041 0.274 5.091 p<0.01 Time x Menopausal Status 0.119 1.041 0.114 2.115 ns

Between Subjects Effect: 0.717 1 0.717 7.533 p<0.01 (Effect of Menopausal Status)

EORTC QLQ C-30 – Cognitive Functioning Within Subjects Effect: Cognitive functioning (Time) 49.991 1.632 30.632 5.702 p<0.01 Time x Menopausal Status 3.695 1.632 2.264 0.421 ns Between Subjects Effect: 583.001 1 583.001 0.451 ns (Effect of Menopausal Status)

EORTC QLQ C-30 – Social Functioning (Log 10) Within Subjects Effect: Social functioning (Time) 2.764 1.880 1.470 30.941 p<0.001 Time x Menopausal Status 0.164 1.880 0.087 1.840 ns

Between Subjects Effect: 5.09 1 5.09 0.001 ns (Effect of Menopausal Status)

EORTC QLQ C-30 – Fatigue (Log 10) Within Subjects Effect: Fatigue (Time) 1.043 2 0.521 12.334 p<0.001

Table 8.6 (e), Continued.

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ss df ms f sign Time x Menopausal Status 0.329 2 0.164 3.886 p<0.05

Between Subjects Effect: 0.351 1 0.351 5.799 p<0.05 (Effects of Menopausal Status)

EORTC QLQ C-30 – Pain (Log 10) Within Subjects Effect: Pain (Time) 0.005 1.032 0.005 0.214 ns Time x Menopausal Status 0.000 1.032 0.000 0.007 ns

Between Subjects Effect: 0.452 1 0.452 9.933 p<0.05 (Effect of Menopausal Status)

EORTC QLQ C-30 – Insomnia (Log 10) Within Subjects Effect: Insomnia (Time) 0.013 1.411 0.009 4.059 p<0.05 Time x Menopausal Status 0.007 1.411 0.005 2.009 ns

Between Subjects Effect: 0.001 1 0.001 0.007 ns (Effect of Menopausal Status)

EORTC QLQ C-30 – Appetite Loss (Log 10) Within Subjects Effect: Appetite Loss (Time) 0.589 1.168 0.504 27.544 p<0.001 Time x Menopausal Status 0.025 1.168 0.022 1.191 ns

Between Subjects Effect: 0.027 1 0.027 0.667 ns (Effect of Menopausal Status)

EORTC QLQ C-30 – Financial Difficulties (Log 10) Within Subjects Effect: Financial Difficulties (Time) 0.018 2 0.009 0.349 ns Time x Menopausal Status 0.020 2 0.010 0.400 ns Between Subjects Effect: 0.006 1 0.006 0.121 ns (Effect of Menopausal Status)

EORTC QLQ C-23 – Body Image (Log 10) Within Subjects Effect: Body Image (Time) 3.689 1.896 1.946 44.381 p<0.001 Time x Menopausal Status 0.085 1.896 0.045 1.017 ns

Between Subjects Effect: 0.752 1 0.752 4.813 p<0.05 (Effect of Menopausal Status)

EORTC QLQ C-23 – Sexual Functioning (Log 10) Within Subjects Effect: Sexual Functioning (Time) 0.271 1.034 0.262 9.730 p<0.01 Time x Menopausal Status 0.026 1.034 1.034 0.921 ns

Between Subjects Effect: 1.610 1 1.610 32.227 p<0.001 (Effect of Menopausal Status)

Table 8.6 (e), Continued.

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ss df ms f sign EORTC QLQ C-23 – Future Perspective (Log 10)

Within Subjects Effect: Future Perspective (Time) 0.197 1.132 0.174 6.630 p<0.001 Time x Menopausal Status 0.171 1.132 0.151 5.738 p<0.05

Between Subjects Effect: 0.286 1 0.286 4.339 p<0.05 (Effect of Menopausal Status)

EORTC QLQ C-23 – Systemic Therapy Side Effects (Log 10) Within Subjects Effect: Systemic Therapy Side-Effects (Time)

5.246 1.791 2.929 72.632 p<0.001

Time x Menopausal Status 0.053 1.791 0.030 0.734 ns

Between Subjects Effect: 0.067 1 0.067 1.159 ns (Effect of Menopausal Status)

EORTC QLQ C-23 – Breast Symptoms (Log 10) Within Subjects Effect: Breast Symptoms (Time) 0.254 1.877 0.135 2.281 ns Time x Menopausal Status 0.260 1.877 0.138 2.331 ns

Between Subjects Effect: 0.984 1 0.984 6.659 p<0.05 (Effect of Menopausal Status)

EORTC QLQ C-23 – Arms Symptoms (Log 10) Within Subjects Effect: Arms Symptoms (Time) 4.092 2 2.046 39.635 p<0.001 Time x Menopausal Status 0.377 2 0.188 3.649 p<0.05 Between Subjects Effect: 0.803 1 0.803 7.592 p<0.01 (Effect of Menopausal Status)

Menopausal Symptoms (Blatt Menopausal Index) Within Subjects Effect: Menopausal symptoms (Time)

2301.539 1.016 2266.178 40.898 p<0.001

Time x Menopausal Status 401.187 1.016 395.024 7.129 p<0.01

Between Subjects Effect: 295.729 1 295.729 2.228 ns (Effect of Menopausal Status)

Note: Transformation data (log 10) was used for some quality of life domains to allow the use of parametric analysis

*The domains of Nausea and Vomiting, Dyspnoea, Diarrhoea, Sexual Enjoyment and Upset by Hair from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ C-30) were excluded from the analysis as the assumptions for the parametric test were not met

432

group (prior-to=60.91±23.74; during=61.52±23.81; post-

chemotherapy=70.37±22.82)] [Table 8.6 (e); Figure 8.3.3 (e)], Future Perspective [F

(1, 142) = 4.34; p<0.05] [The post-menopausal women indicated a better future

perspective prior-to (57.67±25.55) and during chemotherapy (58.73±25.90), than those

in the pre-menopausal group (prior to=47.33±22.28; during

chemotherapy=48.56±22.39). Nevertheless, there was a slight difference where pre-

menopausal women were found to have a better future perspective at post-

chemotherapy (47.33±20.99) as compared to the post-menopausal group

(47.09±22.11)] [Table 8.6 (e); Figure 8.3.3 (f)], Breast Symptoms [F (1, 142) = 6.67;

p<0.05] [Women in the pre-menopausal group also reported to experience more breast

symptoms in all conditions (prior-to=24.69±19.61; during=23.77±15.82; post-

chemotherapy=22.53±12.87) than the patients in the post-menopausal group (prior-

to=21.83±17.16; during=21.69±18.36; post-chemotherapy15.48±10.57)] [Table 8.6

(e); Figure 8.3.3 (g)] and Arm Symptoms [F (1, 142) = 7.59; p<0.01] [Pre-menopausal

women revealed to have more arm symptoms in all situations (prior-to=43.07±22.73;

during=32.24±19.05; post-chemotherapy=28.53±18.00) than the post-menopausal

women (prior-to=36.51±20.49; during=30.69±17.82; post-

chemotherapy=18.69±11.94)] [Table 8.6 (e); Figure 8.3.3 (h)]. However, the

menopausal status of these women was found to exhibit significant effect on the

patients’ Global Health Status [F (1, 142) = 0.17; ns] [Table 8.6 (e); Figure 8.3.3 (i)],

Physical Functioning [F (1, 142) = 0.00; ns] [Table 8.7 (e); Figure 8.3.3 (j)], Role

Functioning [F (1, 142) = 0.17; ns] [Table 8.6 (e); Figure 8.3.3 (k)], Cognitive

Functioning [F (1, 142) = 0.45; ns] [Table 8.6 (e); Figure 8.3.3 (l)], Social Functioning

[F (1, 142) = 0.00; ns] [Table 8.6 (e); Figure 8.3.3 (m)], Insomnia [F (1, 142) = 0.00;

ns] [Table 8.6 (e); Figure 8.3.3 (n)], Appetite Loss [F (1, 142) = 0.66; ns] [Table 8.6

(e); Figure 8.3.3 (o)], Financial Difficulties [F (1, 142) = 0.12; ns] [Table 8.6 (e);

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Figure 8.3.3 (p)] and Systemic Side-Effects [F (1, 142) = 1.16; ns] [Table 8.6 (e);

Figure 8.3.3 (q)]. Similarly, these women’s menopausal status was also found to be

insignificant for the women’s menopausal symptoms [F (1, 142) = 2.23; ns] [Table 8.6

(e); Figure 8.3.3 (r)].

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Figure 8.3.3 (a): The Effect of Menopausal Status on Women's Emotional Functioning (EORTC QLQ C-30)

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Pre-Menopausal(N=81)

Post-Menopausal(N=63)

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Figure 8.3.3 (b): The Effect of Menopausal Status on Women's Fatigue (EORTC QLQ C-30)

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Pre-Menopausal(N=81)

Post-Menopausal(N=63)

Time: F (1.04, 147.78) = 5.09; p<0.01 Interaction Effect: F (1.04, 147.78) =2.12; ns Between Subjects Effect: F (1, 142) = 7.53; p<0.01 (8.3.3-a)

Time: F (2, 284) = 12.33; p<0.001 Interaction Effect: F (2, 284) = 3.89; p<0.05 Between Subjects Effect: F (1, 142) = 5.80; p<0.05 (8.3.3 b)

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Figure 8.3.3 (c): The Effect of Menopausal Status on Women's Pain (EORTC QLQ C-30)

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Post-Menopausal(N=63)

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Figure 8.3.3 (d): The Effect of Menopausal Status on Women's Body Image (QLQ-BR23)

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Post-Menopausal(N=63)

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Figure 8.3.3 (e): The Effect of Menopausal Status on Women's Sexual Functioning (QLQ-BR23)

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Post-Menopausal(N=63)

Time: F (1.03, 146.55 = 0.21; ns Interaction Effect: F (1.03, 146.55) = 0.01; ns Between Subjects Effect: F (1, 142) = 9.93; p<0.05 (8.3.3 c)

Time: F (1.90, 269.19) = 44.30; p<0.001 Interaction Effect: F (1.90, 0.05) = 1.02; ns Between Subjects Effect: F (1, 142) = 4.81; p<0.05 (8.3.3 d)

Time: F (1.03, 146.79) = 9.73; p<0.01 Interaction Effect: F (1.03, 146.79) = 0.92; ns Between Subjects Effect: F (1, 142) = 32.21; p<0.001 (8.3.3 e)

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Figure 8.3.3 (f): The Effect of Menopausal Status on Women's Future Perspective (QLQ-BR23)

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Post-Menopausal(N=63)

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Figure 8.3.3 (g): The Effect of Menopausal Status on Women's Breast Symptoms (QLQ-BR23)

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Post-Menopausal(N=63)

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Figure 8.3.3 (h): The Effect of Menopausal Status on Women's Arm Symptoms (QLQ-BR23)

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(N=81)

Post-Menopausal(N=63)

Time: F (1.13, 160.68) = 6.63; p<0.001 Interaction Effect: F (1.13, 160.68) = 5.74; p<0.05 Between Subjects Effect: F (1, 142) = 4.34; p<0.05 (8.3.3 f)

Time: F (1.88, 266.52) = 2.28; ns Interaction Effect: F (1.88, 266.52) = 2.33; ns Between Subjects Effect: F (1, 142) = 6.66; p<0.05 (8.3.3 g)

Time: F (2, 284) = 39.64; p<0.001 Interaction Effect: F (2,284) = 3.65; p<0.05 Between Subjects Effect: F (1, 142) = 7.59; p<0.01 (8.3.3 h)

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Figure 8.3.3 (i): The Effect Of Menopausal Status on Women's Global Health Status (EORTC QLQ C-30)

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Post-Menopausal(N=63)

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Figure 8.3.3 (j): The Effect of Menopausal Status on Women's Physical Functioning (EORTC QLQ C-30)

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(N=81)

Post-Menopausal(N=63)

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Figure 8.3.3 (k): The Effect of Menopausal Status on Women's Role Functioning (EORTC QLQ C-30)

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Pre-Menopausal(N=81)

Post-Menopausal(N=63)

Time: F (1.09, 154.19) = 475.55; p<0.001 Interaction Effect: F (1.09, 154.19) = 0.49; ns Between Subjects Effect: F (1, 142) = 0.173; ns (8.3.3 i)

Time: F (2, 284) = 7.57; p<0.001 Interaction Effect: F (2, 284) = 0.06; ns Between Subjects Effect: F (1, 142) = 0.00; ns (8.3.3 j)

Time: F (1.62, 229.93) = 48.42; p<0.001 Interaction Effect: F (1.62, 229.93) =1.55; ns Between Subjects Effect: F (1, 142) = 0.17; ns (8.3.3 k)

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Figure 8.3.3 (l): The Effect of Menopausal Status on Women's Cognitive Functioning (EORTC QLQ C-30)

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Post-Menopausal(N=63)

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Figure 8.3.3 (m): The Effect of Menopausal Status on Women's Social Functioning (EORTC QLQ C-30)

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(N=81)

Post-Menopausal(N=63)

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Figure 8.3.3 (n): The Effect of Menopausal Status on Women's Insomnia (EORTC QLQ C-30)

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(N=81)

Post-Menopausal(N=63)

Time: F (1.88, 266.97) = 30.94; p<0.001 Interaction Effect: F (1.88, 266.97) =1.84; ns Between Subjects Effect: F (1, 142) = 0.00; ns (8.3.3 m)

Time: F (1.41, 200.33) = 4.06; p<0.05 Interaction Effect: F (1.41, 200.33) = 2.01; ns Between Subjects Effect: F (1, 142) =0.01; ns (8.3.3 n)

Time: F (1.63, 231.74) = 5.70; p<0.01 Interaction Effect: F (1.63, 231.74) = 0.42; ns Between Subjects Effect: F (1, 142) = 0.45; ns (8.3.3 l)

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Figure 8.3.3 (o): The Effect of Menopausal Status on Women's Appetite Loss

(EORTC QLQ C-30)

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Figure 8.3.3 (p): The Effect of Menopausal Status on Women's Financial Difficulties (EORTC QLQ C-30)

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Pre-Menopausal(N=81)

Post-Menopausal(N=63)

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Figure 8.3.3 (q): The Effect of Menopausal Status on Women's Systemic Therapy Side Effect (QLQ-BR23)

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Post-Menopausal(N=63)

Time: F (1.17, 165.88) = 27.54; p<0.001 Interaction Effect: F (1.17, 165.88) = 1.19; ns Between Subjects Effect: F (1, 142) = 0.67; ns (8.3.3 o)

Time: F (2, 284) = 0.35; ns Interaction Effect: F (2, 284) = 0.40; ns Between Subjects Effect: F (1, 142) = 0.12; ns (8.3.3 p)

Time: F (1.79, 254.35) = 72.63; p<0.001 Interaction Effect: F (1.79, 254.35) =2.79; ns Between Subjects Effect: F (1, 142) = 1.16; ns (8.3.3 q)

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Figure 8.3.3 (r): The Effects of Menopausal Status on Women's Menopausal symptoms

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Post-Menopausal(N=63)

A similar analysis, to observe the effect of ethnicity on the women’s quality of

life, indicated that certain aspects of life quality were significantly affected by the

patients’ races. These effects could be seen on the Pain [F (2, 154) = 9.34; p<0.001]

[Malay women exhibited more pain prior-to (64.25±21.38) and post-chemotherapy

(65.35±17.59), followed by Indian women (prior-to=64.44±21.32; post-

chemotherapy=63.89±17.00) and Chinese women (prior-to=52.61±19.54; post-

chemotherapy=54.58±19.17). On the other hand, Indian women were found to

experience more pain during chemotherapy (66.67±22.32), followed by Malay

(64.91±21.53) and Chinese women (52.94±19.63)] [Table 8.6 (f); Figure 8.3.4 (a)],

Sexual Functioning [F (2, 154) = 14.35; p<0.001] [Chinese women exhibited a better

sexual functioning in all the phases (prior-to=82.35±20.39; during=83.01±20.68; post-

chemotherapy=84.97±20.35), followed by Indian (prior-to=72.22±26.74;

during=72.22±26.74; post-chemotherapy=79.44±25.40) and Malay women (prior-

to=59.43±22.50; during=59.87±22.31; post-chemotherapy=74.56±22.85)] [Table 8.6

(f); Figure 8.3.4 (b)], Future Perspective [F (2, 154) = 3.60; p<0.05] [Chinese women

indicated to have a better future perspective prior-to (58.82±24.57), during

(58.82±24.57) and post-chemotherapy (50.33±22.48), as compared to Malay (prior-

Time: F (1.02, 144.216) = 40.90; p<0.001 Interaction Effect: F (1.02, 144.216) = 7.13; p<0.01 Between Subjects Effect: F (1, 142) = 2.23; ns (8.3.3 r-meno)

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to=48.68±23.37; during=50.44±24.03; post-chemotherapy=44.30±19.92) and Indian

women (prior-to=47.78±22.63; during=48.89±22.71; post-

chemotherapy=48.89±20.96)] [Table 8.6 (f); Figure 8.3.4 (c)], Systemic Therapy Side-

Effects [F (2, 154) = 5.55; p<0.01] [Indian women reported to experience more

systemic therapy side-effects prior-to (33.97±23.49) and during chemotherapy

(56.67±16.74), followed by Malay (prior-to=30.45±17.25; during

chemotherapy=48.93±17.00) and Chinese women (prior-to=26.52±14.00;

during=41.46±15.80). Nonetheless, Malay revealed more systemic therapy side-effects

at post-chemotherapy (48.18±17.54), and this was slightly different for the Indian

(47.14±18.01) and Chinese women (42.58±16.37)] [Table 8.6 (f); Figure 8.3.4 (d)] and

Arm Symptoms [F (2, 154) = 4.26; p<0.05] [Prior-to chemotherapy, Malay women had

more arm symptoms (42.69±21.78), as compared to Indian (41.85±23.65) and Chinese

women (34.20±19.61). On the other hand, Indian women showed more arm symptoms

during (37.40±21.34) and post-chemotherapy (25.19±18.44), followed by Malay

(during=31.87±17.99; post-chemotherapy=24.71±16.29) and Chinese women

(during=25.93±15.50; post-chemotherapy=20.04±13.70)] [Table 8.6 (f); Figure 8.3.4

(e)]. Most of the aspects in the women’s quality of life were demonstrated to be

unaffected by ethnicity, such as the patients’ Global Health Status [F (2, 154) = 0.36;

ns] [Table 8.8 (f); Figure 8.4.4 (f)], Physical Functioning [F (2, 154) = 1.13; ns] [Table

8.6 (f); Figure 8.3.4 (g)], Role Functioning [F (2, 154) = 0.55; ns] [Table 8.6 (f); Figure

8.3.4 (h)], Emotional Functioning [F (2, 154) = 4.36; ns] [Table 8.6 (f); Figure 8.3.4

(i)], Cognitive Functioning [F (2, 154) = 0.63; ns] [Table 8.6 (f); Figure 8.3.4 (j)],

Social Functioning [F (2, 154) = 0.35; ns] [Table 8.6 (f); Figure 8.3.4 (k)], Fatigue [F

(2, 154) = 1.12; ns] [Table 8.6 (f); Figure 8.3.4 (l)], Insomnia [F (2, 154) = 1.81; ns]

[Table 8.6 (f); Figure 8.3.4 (m)], Appetite Loss [F (2, 154) = 1.25; ns] [Table 8.6 (f);

Figure 8.3.4 (n)], Financial Difficulties [F (2, 154) = 0.98; ns] [Table 8.6 (f); Figure

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Table 8.6 (f): Split Plot Repeated Measure ANOVA: The Effect of Ethnicity on the Quality of Life of the Women with Breast Cancer

Sources of Variation ss df ms f sign

EORTC QLQ C-30 – Global Health Status Within Subjects Effect: Global Health Status (Time) 8467.843 1.091 7763.680 484.075 p<0.001

Time x Ethnicity 29.035 2.181 13.310 0.830 ns Between Subjects Effect: 729.452 2 364.726 0.345 ns (Effect of Ethnicity)

EORTC QLQ C-30 – Physical Functioning Within Subjects Effect: Physical functioning (Time) 3366.344 2 1683.172 9.350 p<0.001

Time x Ethnicity 653.029 4 163.257 0.907 ns Between Subjects Effect: 825.402 2 412.701 1.126 ns (Effect of Ethnicity)

EORTC QLQ C-30 – Role Functioning (Log 10) Within Subjects Effect: Role Functioning (Time) 2.146 1.591 1.349 1.349 p<0.001

Time x Ethnicity 0.098 3.182 0.031 1.089 ns

Between Subjects Effect: 0.062 2 0.031 0.548 ns (Effect of Ethnicity)

EORTC QLQ C-30 – Emotional Functioning (Log 10) Within Subjects Effect: Emotional functioning (Time) 0.295 1.047 0.281 5.474 p<0.01 Time x Ethnicity 0.124 2.094 0.059 1.156 ns

Between Subjects Effect: 0.785 2 0.392 4.357 p<0.05 (Effect of Ethnicity)

EORTC QLQ C-30 – Cognitive Functioning Within Subjects Effect: Cognitive functioning (Time) 30.127 1.639 18.376 3.741 p<0.01 Time x Ethnicity 12.458 3.279 3.799 0.773 ns Between Subjects Effect: 1713.273 2 856.636 0.634 ns (Effect of Ethnicity)

EORTC QLQ C-30 – Social Functioning (Log 10) Within Subjects Effect: Social functioning (Time) 2.959 1.881 1.573 32.513 p<0.001

Time x Ethnicity 0.290 3.762 0.077 1.591 ns

Between Subjects Effect: 0.048 2 0.024 0.353 ns (Effect of Ethnicity)

EORTC QLQ C-30 – Fatigue (Log 10) Within Subjects Effect: Fatigue (Time) 0.975 2 0.488 111.285 p<0.001

Time x Ethnicity 0.372 4 0.093 2.152 ns

Table 8.6 (f), Continued.

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ss df ms f sign Between Subjects Effect: 0.143 2 0.072 1.118 ns (Effect of Ethnicity)

EORTC QLQ C-30 – Pain (Log 10) Within Subjects Effect: Pain (Time) 0.011 1.040 0.010 0.470 ns Time x Ethnicity 0.007 2.080 0.003 0.150 ns

Between Subjects Effect: 0.831 2 0.416 9.340 p<0.001

(Effect of Ethnicity) EORTC QLQ C-30 – Insomnia (Log 10)

Within Subjects Effect: Insomnia (Time) 0.015 1.410 0.010 4.929 p<0.05 Time x Ethnicity 0.011 2.819 0.04 1.778 ns

Between Subjects Effect: 0.275 2 0.137 1.814 ns (Effect of Ethnicity)

EORTC QLQ C-30 – Appetite Loss (Log 10) Within Subjects Effect: Appetite Loss (Time) 0.475 1.156 0.411 21.469 p<0.001

Time x Ethnicity 0.056 2.312 0.024 1.262 ns

Between Subjects Effect: 0.099 1 0.049 1.245 ns (Effect of Ethnicity)

EORTC QLQ C-30 – Financial Difficulties (Log 10) Within Subjects Effect: Financial Difficulties (Time) 0.006 2 0.003 0.111 ns Time x Ethnicity 0.121 4 0.030 1.104 ns Between Subjects Effect: 0.100 2 0.050 0.979 ns (Effect of Ethnicity)

EORTC QLQ C-23 – Body Image (Log 10) Within Subjects Effect: Body Image (Time) 3.691 1.903 1.940 46.253 p<0.001

Time x Ethnicity 0.137 3.806 0.036 0.857 ns

Between Subjects Effect: 0.050 2 0.025 0.164 ns (Effect of Ethnicity)

EORTC QLQ C-23 – Sexual Functioning (Log 10) Within Subjects Effect: Sexual Functioning (Time) 0.281 1.038 0.271 10.017 p<0.01 Time x Ethnicity 0.190 2.075 0.092 3.379 p<0.05

Between Subjects Effect: 1.499 2 0.750 14.352 p<0.001

(Effect of Ethnicity) EORTC QLQ C-23 – Future Perspective (Log 10)

Within Subjects Effect: Future Perspective (Time) 0.101 1.120 0.090 3.194 ns

Table 8.6 (f), Continued.

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ss df ms f sign Time x Ethnicity 0.076 2.239 0.034 1.202 ns

Between Subjects Effect: 0.453 2 0.227 3.604 p<0.05 (Effect of Ethnicity)

EORTC QLQ C-23 – Systemic Therapy Side Effects (Log 10) Within Subjects Effect: Systemic Therapy Side-Effects (Time)

5.131 1.800 2.851 72.875 p<0.001

Time x Ethnicity 0.120 3.599 0.033 0.849 ns

Between Subjects Effect: 0.593 2 0.296 5.551 p<0.01 (Effect of Ethnicity)

EORTC QLQ C-23 – Breast Symptoms (Log 10) Within Subjects Effect: Breast Symptoms (Time) 0.302 1.899 0.159 2.633 ns Time x Ethnicity 0.050 3.798 0.013 0.219 ns

Between Subjects Effect: 0.286 2 0.143 0.969 ns (Effect of Ethnicity)

EORTC QLQ C-23 – Arms Symptoms (Log 10) Within Subjects Effect: Arms Symptoms (Time) 4.115 2 2.057 39.034 p<0.001

Time x Ethnicity 0.095 4 0.024 0.452 ns Between Subjects Effect: 0.878 2 0.439 4.255 p<0.05 (Effect of Ethnicity)

Menopausal Symptoms (Blatt Menopausal Index) Within Subjects Effect: Menopausal symptoms (Time) 3279.285 1.021 3211.767 57.489 p<0.001

Time x Ethnicity 452.587 2.042 221.634 3.967 p<0.05

Between Subjects Effect: 587.030 2 293.515 2.239 ns (Effect of Ethnicity)

Note: Transformation data (log 10) was used for some quality of life domains to allow the use of parametric analysis

*The domains of Nausea and Vomiting, Dyspnoea, Diarrhoea, Sexual Enjoyment and Upset by Hair from the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ C-30) were excluded from the analysis as the assumptions for parametric test were not met.

7.3.4 (o)], Body Image [F (2, 154) = 0.16; ns] [Table 7.6 (f); Figure 7.3.4 (p)] and

Breast Symptoms [F (2, 154) = 0.97; ns] [Table 8.6 (f); Figure 8.3.4 (q)]. Similarly, the

menopausal symptoms [F (2, 154) = 2.24; ns] were not significantly affected by

patients’ ethnicity [Table 8.6 (f); Figure 8.3.4 (r)].

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Figure 8.3.4 (a): The Effect of Ethnicity on Women's Pain (EORTC QLQ C-30)

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Chinese (N=51)

Tamil (N=30)

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Figure 8.3.4 (b): The Effect of Ethnicity on Women's Sexual Functioning (QLQ-BR23)

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es Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.3.4 (c): The Effect of Ethnicity on Women's Future Perspective (QLQ-BR23)

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Chinese (N=51)

Indian (N=30)

Time: F (1.04, 160.16) = 0.47; ns Interaction Effect: F (2.08, 160.16) = 0.15; ns Between Subjects Effect: F (2, 154) = 9.34; p<0.001 (8.3.4 a)

Time: F (1.04, 159.79) = 10.02; p<0.01 Interaction Effect: F (2.08, 159.79) = 3.38; p<0.05 Between Subjects Effect: F (2, 154) = 14.35; p<0.001 (8.3.4 b)

Time: F (1.12, 173.42) = 3.19; ns Interaction Effect: F (1.12, 173.42) = 1.20; ns Between Subjects Effect: F (2, 154) = 3.60; p<0.05 (8.3.4 c)

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Figure 8.3.4 (d): The Effect of Ethnicity on Women's Systemic Therapy Side Effect (QLQ-BR23)

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Chinese (N=51)

Indian (N=30)

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Figure 8.3.4 (e): The Effect of Ethnicity on Women's Arm Symptoms (QLQ-BR23)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.3.4 (f): The Effect of Ethnicity on Women's Global Health Status (EORTC QLQ C-30)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (1.80, 277.143) = 72.88; p<0.001 Interaction Effect: F (3.60, 277.143) = 0.85; ns Between Subjects Effect: F (2, 154) = 5.55; p<0.01 (8.3.4 d)

Time: F (2, 308) = 39.03; p<0.001 Interaction Effect: F (4,308) = 0.45; ns Between Subjects Effect: F (2, 154) = 4.26; p<0.05 (8.3.4 e)

Time: F (1.09, 167.97) = 484.08; p<0.001 Interaction Effect: F (2.18, 167.97) = 0.83; ns Between Subjects Effect: F (2, 154) = 0.35; ns (8.3.4 f)

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Figure 8.3.4 (g): The Effect of Ethnicity on Women's Physical Functioning (EORTC QLQ C-30)

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Chinese (N=51)

Indian (N=30)

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Figure 8.3.4 (h): The Effect of Ethnicity on Women's Role Functioning (EORTC QLQ C-30)

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s Malay (N=76)

Chinese (N=51)

Indian (N=31)

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Figure 8.3.4 (i): The Effect of Ethnicity on Women's Emotional Functioning (EORTC QLQ C-30)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (2, 308) = 9.35; p<0.001 Interaction Effect: F (4, 308) = 0.91; ns Between Subjects Effect: F (2, 154) = 1.126; ns (8.3.4 g)

Time: F (1.59, 245.04) = 1.35; p<0.001 Interaction Effect: F (3.18, 245.04) = 0.03; ns Between Subjects Effect: F (2, 154) = 0.55; ns (8.3.4 h)

Time: F (1.04, 161.24) = 5.80; p<0.05 Interaction Effect: F (2.09, 161.24) = 1.16; ns Between Subjects Effect: F (2, 154) = 4.36; p<0.05 (8.3.4 i-emo)

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Figure 8.3.4 (j): The Effect of Ethnicity on Women's Cognitive Functioning (EORTC QLQ C-30)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.3.4 (k): The Effect of Ethnicity on Women's Social Functioning (EORTC QLQ C-30)

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Chinese (N=51)

Tamil (N=30)

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Figure 8.3.4 (l): The Effect of Ethnicity on Women's Fatigue (EORTC QLQ C-30)

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Chinese (N=51)

Indian (N=30)

Time: F (1.64, 252.48) =3.74; p<0.05 Interaction Effect: F (3.28, 252.48) = 0.77; ns Between the Subjects Effect: F (2, 154) = 0.63; ns (8.3.4 j)

Time: F (1.88, 289.70) = 32.51; p<0.001 Interaction Effect: F (3.76, 289.70) =1.59; ns Between Subjects Effect: F (2, 154) = 0.35; ns (8.3.4 - k)

Time: F (2,308) = 11.29; p<0.001 Interaction Effect: F (4,308) =2.15; ns Between Subjects Effect: F (2, 154) = 1.12; ns (8.3.4 l)

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Figure 8.3.4 (m): The Effect of Ethnicity on Women's Insomnia (EORTC QLQ C-30)

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Chinese (N=51)

Indian (N=30)

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Figure 8.3.4 (n): The Effect of Ethnicity on Women's Appetite Loss (EORTC QLQ C-30)

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s Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.3.4 (0): The Effect of Ethnicity on Women's Financial Difficulties (EORTC QLQ C-30)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (1.41, 217.08) = 4.93; p<0.05 Interaction Effect: F (2.82, 217.08) =1.78; ns Between Subjects Effect: F (2, 154) = 1.81; ns (8.3.4 m)

Time: F (1.16, 178.01) = 21.47; p<0.001 Interaction Effect: F (2.31, 178.01) = 1.26; ns Between Subjects Effect: F (2, 154) = 1.25; ns (8.3.4 n)

Time: F (2, 308) = 0.11; ns Interaction Effect: F (4, 308) = 1.10; ns Between Subjects Effect: F (2, 154) = 0.98; ns (8.3.4 o)

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Figure 8.3.4 (p): The Effect of Ethnicity on Women's Body Image (QLQ-BR23)

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Chinese (N=51)

Indian (N=30)

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Figure 8.3.4 (q): The Effect of Ethnicity on Women's Breast Symptoms (QLQ-BR23)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.3.4 (e): The Effect of Ethnicity on Women's Arm Symptoms (QLQ-BR23)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (1.90, 293.07) = 46.25; p<0.001 Interaction Effect: F (3.81, 293.07) = 0.86; ns Between Subjects Effect: F (2, 154) = 0.16; ns (8.3.4 p)

Time: F (1.90, 292.47) =2.63; ns Interaction Effect: F (3.80, 292.47) = 0.22; ns Between Subjects Effect: F (2, 154) = 0.97; ns (8.3.4 q)

Time: F (2, 308) = 39.03; p<0.001 Interaction Effect: F (4,308) = 0.45; ns Between Subjects Effect: F (2, 154) = 4.26; p<0.05 (8.3.4 e)

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Figure 8.3.4 (r): The Effect of Ethnicity on Women's Menopausal Symptoms

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

7.2.1.1 Summary of the Results

The significant effect of time was observed for most of the quality of life

domains: Global Health Status, Physical Functioning, Role Functioning, Emotional

Functioning, Social Functioning, Insomnia, Appetite Loss, Body Image, Sexual

Functioning, Future Perspective, Systemic Therapy Side-Effects, Arm Symptoms,

Nausea and Vomiting, Diarrhoea and Sexual Enjoyment, as well as menopausal

symptoms. Most of the important domains in the quality of life, such as the Global

Health Status, Role Functioning, Emotional Functioning and Social Functioning, were

found to decline from prior-to to during chemotherapy, but they later increased at post-

chemotherapy. Other domains such as Fatigue, Insomnia, Future Perspective and

Systemic Therapy Side-Effects were indicated to enhance from prior-to to during

chemotherapy, but these domains decreased at post-chemotherapy. These findings

were generally in line with the postulated hypothesis that the treatment phases (prior-to,

during and post-chemotherapy have different effects on the quality of life of the women

with breast cancer.

Time: F (1.02, 157.24) = 57.49; p<0.001 Interaction Effect: F (2.04, 157.24) = 4.00; p<0.05 Between the Subjects Effect: F (1, 142) = 2.24; ns (8.3.4 r-ethnic)

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Fatigue, Appetite Loss and Body Image were affected by the types of surgery

undergone by the breast cancer patients in this study. However, most aspects of the

quality of life were not influenced by this particular factor. These include patients’

Physical Functioning, Role Functioning, Emotional Functioning, Cognitive

Functioning, Social Functioning, Pain, Insomnia, Financial Difficulties, Sexual

Functioning and menopausal symptoms. Similarly, the stages of breast cancer were

also not vital for nearly all aspects of the women’ quality of life, with the exception for

the Financial Difficulties. Many of the findings were not in line with the study’s

hypothesis that the medical aspects (types of surgery and breast cancer stages) have a

significant impact on the quality of life of women with breast cancer. A slight

difference was observed for the effect of menopausal status on the women’s quality of

life. Certain aspects of the women’s quality of life, such as their Emotional

Functioning, Fatigue, Pain, Body Image, Sexual Functioning, Future Perspective, as

well as Breast and Arm Symptoms demonstrated significant differences on the patients’

menopausal status, which is in line with the proposed hypothesis that women’s

menopausal status has a significant effect on their quality of life. Nevertheless, Global

Health Status, Physical Functioning, Role Functioning, Cognitive Functioning, Social

Functioning, Insomnia, Appetite Loss, Financial Difficulties, Systemic Therapy Side

Effect and menopausal symptoms were found to be no affected by the menopausal

status of the patients. Interestingly, the aspect of the women’s Pain, Sexual

Functioning, Future Perspective, Systemic Therapy Side-Effects and Arm Symptoms

were significantly affected by their ethnicity, which is parallel to the study’s hypothesis

i.e. ethnicity has a significant effect on the quality of life of the women with breast

cancer. Nonetheless, most aspects of the women’s quality of life were not affected by

ethnicity. These are Global Health Status, Physical Functioning, Role Functioning,

Emotional Functioning, Cognitive Functioning, Social Functioning, Body Image,

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Fatigue, Insomnia, Appetite Loss, Financial Difficulties, Breast Symptoms and

menopausal symptoms.

8.2.2 Sexual Aspect of the Women with Breast Cancer

The results gathered from the women’s view on their body image [this

particular variable was measured using the Body Image Scale (BIS) which is different

from the Body Image domains of Breast Module (QLQ-BR23)] and their view on their

sexual attractiveness are reported in this section.

The analysis of the One-way Repeated Measure ANOVA indicated that there

was a significant effect of time on the women’s body image [F (1.97, 307.62) = 110.65;

p<0.001] [Women’s negative view of their body image improved throughout the

treatment phases (prior-to=25.55±7.38; during=23.86±6.78; post-

chemotherapy=18.22±7.04)] and sexual attractiveness [F (1.93, 301.77) = 12.75;

p<0.001] [Women’s positive feelings of their sexual attractiveness deteriorated from

prior-to (44.78±9.47) to during (42.29±7.93), but improved at post-chemotherapy

(46.31±9.03)] [Table 8.7 (a); Figure 8.4 (a)].

Table 8.7 (a): One-Way Repeated Measure ANOVA: Sexual Aspects of the Women with Breast Cancer

Sources of Variation: ss df ms f sign Body image 4619.851 1.972 2342.796 110.647 p<0.001 Sexual Attractiveness

1296.577 1.934 670.260 12.754 p<0.001

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Body Image (Body Image Scale)

Sexual Attractiveness (Body Esteem Scale)

Figure 8.4 (a): Women's Body Image and Sexual Attractiveness

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Prior to Chemotherapy

During Chemotherapy

Post-Chemotherapy

The analysis of the Split Plot ANOVA (with one within the subjects’ factors

and one between the subjects’ factors), looking at the effects of the types of surgery on

the women’s body image, revealed a significant result [F (1, 155) = 31.42; p<0.001]

[The lumpectomy group exhibited a better body image in all the treatment phases

(prior-to=19.45±4.93; during=20.91±5.25; post-chemotherapy=12.97±4.81), as

compared to the mastectomy group (prior-to=27.17±7.08; during=24.65±6.95; post-

chemotherapy=19.62±6.89)] [Table 7.7 (b); Figure 7.4 (b)]. However, this particular

factor was found to be insignificant for the women’s sexual attractiveness [F (1, 155) =

0.40; ns] [Table 8.7 (b); Figure 8.4 (c)].

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Figure 8.4 (b): The Effect of Types of Surgery on Women's Body Image (Body Image Scale)

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Mastectomy (N=124)

Lumpectomy (N=33)

F (1.97, 307.62) = 110.65; p<0.001

F (1.94, 301.77) = 301.77; p<0.001

Time: F (2, 310) = 78.36; p<0.001 Interaction Effects: F (2, 310) = 5.45; p<0.01 Between Subjects Effect: F (1, 155) = 31.42; p<0.001 (8.4 –b)

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Table 8.7(b): Split Plot Repeated Measure ANOVA: The Effects of the Types of Surgery on the Sexual Aspects of the Women with Breast Cancer

Sources of Variation ss df ms f sign

Body Image Within Subjects Effect: Body Image (Time) 3180.904 2 1590.452 78.356 p<0.001 Time x Types of Surgery 221.193 2 110.596 5.449 p<0.01 Between Subjects Effect: 2846.919 1 2846.919 31.424 p<0.001 (Effect of Types of Surgery)

Sexual Attractiveness Within Subjects Effect: Sexual Attractiveness (Time) 716.020 1.946 367.992 7.007 p<0.001 Time x Types of Surgery 21.327 1.946 10.961 0.209 ns Between Subjects Effect: 53.022 1 53.022 0.398 ns (Effect of Types of Surgery)

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Figure 8.4 (c): The Effect of Types of Surgery on Women's Sexual Attractiveness

(Sexual Attractiveness-Body Esteem Scale)

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Mastectomy(N=124)

Lumpectomy(N=33)

Similar analysis, to investigate the effects of the stages of breast cancer on the

women’s body image and sexual attractiveness, indicated the insignificant results, [F

(1, 142) = 0.48; ns] [Table 8.7 (c); Figure 8.5 (e)] and [F (1, 142) = 0.01; ns] [Table 8.7

(c); Figure 8.5 (f)], respectively.

Time: F (1.95, 301.59) = 7.01; p<0.001 Interaction Effects: F (1.95, 301.59) = 0.21; ns Between Subjects Effect: F (1, 155) = 0.40; ns (8.4-c)

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Table 8.7 (c): Split Plot Repeated Measure ANOVA: The Effects of the Breast Cancer Stages on the Sexual Aspects of the Women with Breast Cancer

Sources of Variation ss df ms f sign

Body Image Within Subject Effect: Body Image (Time) 4169.352 2 2084.676 98.757 p<0.001 Time x Breast Cancer Stages 22.213 2 11.107 0.526 ns Between Subjects Effect: 52.904 1 52.904 0.483 ns (Effect of Breast Cancer Stages)

Sexual Attractiveness Within Subjects Effect: Sexual Attractiveness (Time) 1139.574 1.931 590.297 12.172 p<0.001 Time x Breast Cancer Stages 213.852 1.931 110.775 2.284 ns Between Subjects Effect: 1.776 1 1.776 0.013 ns (Effect of Breast Cancer Stages)

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Figure 8.4 (d): The Effect of Breast Cancer Stages on Women's Body Image (Body Image Scale)

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Stage Two (N=89)

Stage Three (N=55)

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Figure 8.4 (e): The Effect of Breast Cancer Stages on Women's Sexual Attractiveness

(Sexual Attractiveness-Body Image Scale)

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Stage Two(N=89)

Stage Three(N=55)

Time: F (2, 284) = 98.76; p<0.001 Interaction Effects: F (2, 284) = 0.53; ns Between Subjects Effect: F (1, 142) = 0.48; ns (8.4 –d )

Time: F (1.93, 274.13) = 12.17; p<0.001 Interaction Effects: F (1.93, 274.13) = 2.28; ns Between Subjects Effect: F (1, 142) = 0.01; ns (8.4 –e)

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Furthermore, a major effect of the menopausal status on the women’s body

image [F (1, 142) = 7.42; p<0.01] [Pre-menopausal women indicated higher negative

view of their body image throughout the treatment phases (prior-to=26.63±7.56;

during=25.30±7.04; post-chemotherapy=19.56±7.27), as compared to the patients in

the post-menopausal group (prior-to=24.13±6.95; during=22.38±6.59; post-

chemotherapy=16.71±7.04)] [Table 8.7 (d); Figure 8.5 (g)] and sexual attractiveness [F

(1, 142) =10.64; p<0.01] [Women in the post-menopausal indicated to have more

positive feeling towards their sexual attractiveness throughout the treatment phases

(prior-to=46.05±10.60; during=44.41±8.43; post-chemotherapy=49.92±9.66) than the

pre-menopausal women (prior-to=44.38±8.62; during=41.09±7.32; post-

chemotherapy=44.31±7.88)] [Table 8.7 (d); Figure 8.5 (h)] were also observed.

Table 8.7 (d): Split Plot Repeated Measure ANOVA: The Effect of Menopausal Status on the Sexual Aspects of the Women with Breast Cancer

Sources of Variation ss df ms f sign

Body Image Within Subjects Effect: Body Image (Time) 4128.209 2 2064.104 96.266 p<0.001 Time x Menopausal Status 3.431 2 1.716 0.080 ns Between Subjects Effect: 805.794 1 805.794 7.420 p<0.01 (Effect of Menopausal Status)

Sexual Attractiveness Within Subjects Effect: Sexual attractiveness (Time) 1358.019 2 679.009 13.176 p<0.001 Time x Menopausal Status 278.352 2 139.176 2.701 ns Between Subjects Effect: 1328.048 1 1328.048 10.640 p<0.01 (Effect of Menopausal Status)

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Figure 8.4 (f): The Effect of Menopausal Status on Women's Body Image (Body Image Scale)

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Pre-Menopausal(N=81)

Post-Menopausal(N=63)

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Figure 8.4 (g): The Effect of Menopausal Status on Women's Sexual Attractiveness

(Sexual Attractiveness-Body Esteem Scale)

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Pre-Menopausal(N=81)

Post-Menopausal(N=63)

Nevertheless, the effect of ethnicity on the women’s body image [F (2, 154) =

0.18; ns] [Table 8.7 (e); Figure 8.4 (i)] and sexual attractiveness [F (2, 154) = 1.67; ns]

[Table 8.7 (e); Figure 8.4 (j)] were insignificant.

Time: F (2, 284) = 96.27; p<0.001 Interaction Effects: F (2, 284) = 0.08; ns Between Subjects Effect: F (1, 142) = 7.42; p<0.01 (8.4-f)

Time: F (2, 284) = 13.18; p<0.001 Interaction Effects: F (2, 284) = 2.70; ns Between Subjects Effect: F (1, 142) = 10.64; p<0.01 (8.4-g)

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Table 8.7 (e): Split Plot Repeated Measure ANOVA: The Effect of Ethnicity on the Sexual Aspects of the Women with Breast Cancer

Sources of Variation ss df ms f sign

Body Image Within Subjects Effect: Body Image (Time) 3984.386 2 1992.193 94.568 p<0.001 Time x Ethnicity 25.053 4 6.263 0.297 ns Between Subjects Effect: 38.451 2 19.225 0.176 ns (Effect of Ethnicity)

Sexual Attractiveness Within Subjects Effect: Sexual Attractiveness (Time)

968.185 2 484.093 9.497 p<0.001

Time x Ethnicity 159.227 4 39.807 0.781 ns Between Subjects Effect: 438.518 2 219.259 1.667 ns (Effect of Ethnicity)

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Figure 8.4 (h): The Effect of Ethnicity on Women's Body Image (Body Image Scale)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (2, 308) = 94.57; p<0.001 Interaction Effects: F (4, 308) = 0.30; ns Between Subjects Effect: F (2, 154) = 0.18; ns (8.4-h)

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Figure 8.4 (i): The Effect of Ethnicity on Women's Sexual Attractiveness (Sexual Attractiveness-Body Esteem Scale)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

8.2.2.1 Summary of the Results

Significant effects of time were observed for the women’s body image and their

sexual attractiveness, which confirms the postulated hypothesis that the treatment

phases (prior-to, during and post-chemotherapy) have different effects on women’s

body image and sexual attractiveness. Women’s negative view of their body image

improved throughout the treatment phases, whereas the positive feeling of their sexual

attractiveness among these patients deteriorated from prior-to to during, but increased

at post-chemotherapy.

The types of surgery also had a significant impact on the women’s body image,

which is in line with the study’s hypothesis which state that types of surgery has

significant impact on the view of body image among women with breast cancer.

Nonetheless, this factor was found to be not important for their sexual attractiveness,

which is not in line with the proposed hypothesis i.e. type of surgery has a significant

effect on the feeling of sexual attractiveness among women with breast cancer.

Meanwhile, the patients’ menopausal status was found to affect both their body image

and sexual attractiveness, which confirms the study’s hypothesis i.e. menopausal status

Time: F (2, 308) = 9.50; p<0.001 Interaction Effects: F (4, 308) = 0.78; ns Between Subjects Effect: F (2, 154) = 1.67; ns (8.4-i)

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has a significant effect on the view of body image and feeling of sexual attractiveness

among women with breast cancer. Nevertheless, in contrast to the postulated

hypothesis in this study i.e. medical (breast cancer stages) and bio/socio-demographic

aspect (ethnicity) have significant effects on the view of body image and feeling of

sexual attractiveness among women with breast cancer, these independent factors

(breast cancer stages and ethnicity) did not show any significant influence on the

women’s body image and their sexual attractiveness.

8.2.3 The Aspect of the Interpersonal Relationship of the Women with Breast

Cancer

The results of the women’s interpersonal relationship aspects (Perceived

Husband’s Support, Empathy, Level of Disclosure, Helpfulness of Disclosure,

Withdrawal, Criticism and Holding Back) are reported in this section. However, the

women’s Relationship Satisfaction is not included here because it has been reported in

detail in the previous section on “Breast Cancer: From the Couple’s Perspective.”

The analysis of a One-way Repeated Measure ANOVA showed that a

significant effect of time was found for most aspects of the women’s interpersonal

relationship, such as the Perceived Husband’s Support [F (1.76, 274.42) = 20.43;

p<0.001] [Patients’ Perceived Husband’s Support was found to increase from prior-to

(110.95±32.62) to during chemotherapy (120.28±33.14), but at diminished post-

chemotherapy (102.99±24.54)] [Table 8.8 (a); Figure 8.5 (a)], Level of Disclosure [F

(1.76, 275.25) = 151.47; p<0.001], [Women’s Level of Disclosure increased throughout

the treatment phases (prior-to=15.99±4.46; during=17.77±5.34; post-

chemotherapy=17.92±5.27)] [Table 8.8 (a); Figure 8.5 (a)], Empathy [F (2, 312) =

25.11; p<0.001] [Women’s Empathy was heightened from prior-to (41.45±7.57) to

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during (43.40±6.67), but deteriorated at post-chemotherapy (38.96±5.90)] [Table 8.8

(a); Figure 8.5 (a)]. The analysis of Friedman also uncovered a similar result for

Holding Back (χ2 = 33.29; df = 2; p<0.001) [Holding Back was found to decline

throughout the treatment phases (prior-to=1.52±0.84; during=1.04±0.94; post-

chemotherapy=0.99±0.85)] [Table 8.8 (b); Figure 8.5 (b)], Criticism (χ2 = 10.01; df =

2; p<0.01) [Criticism increased from prior-to (0.92±0.71) to during (0.78±1.05), but

decreased at post-chemotherapy (0.82±0.88)] [Table 8.8 (b); Figure 8.5 (b)] and

Withdrawal (χ2 = 61.21; df = 2; p<0.001) [Withdrawal was indicated to reduce all the

way throughout the treatment phases (prior-to=0.99±0.67; during=0.79±1.06; post-

chemotherapy=0.76±0.85)] [Table 8.8 (b); Figure 8.5 (b)]. Nevertheless, Helpfulness

of Disclosure did not show the significant effect of time [F (1.90, 296.92) = 2.83; ns]

[Table 8.8 (a); Figure 8.5 (b)].

Table 8.8 (a): One-way Repeated Measure ANOVA: The Interpersonal Relationship Aspect of the Women with Breast Cancer

Sources of Variation ss df ms f Sign Perceived Husband’s Support 23507.478 1.759 13363.39 20.425 p<0.001 Level of Disclosure 363.890 1.764 206.237 151.468 p<0.001 Empathy 1559.096 2 779.548 25.111 p<0.001 Relationship Satisfaction (Separate table in the section of Breast Cancer: From the

Couples’ Perspective) Helpfulness of Disclosure 5.516 1.903 2.898 2.826 ns Holding Back* (Non-Parametric Table) Criticism* Withdrawal*

(Non-Parametric Table) (Non-Parametric Table)

*The non-parametric analysis was used as the assumptions for the parametric test were not met

Table 8.8 (b): Non-parametric Analysis (Friedman Test): The Interpersonal Relationship Aspect of the Women with Breast Cancer

χ2 df sign

Holding Back 33.29 2 p<0.001

Criticism 10.01 2 p<0.01

Withdrawal 16.21 2 p<0.001 Note: The non-parametric analysis was used as the assumptions for the parametric test were not met

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Figure 8.5 (a): Women's Interpersonal Relationship (Perceived Husband Support, Empathy & Level of Disclosure)

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Pre-Chemotherapy

During Chemotherapy

Post-Chemotherapy

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Helpfulness ofDisclosure

Holding Back Criticism Withdrawal

Figure 8.5 (b): Women's Interpersonal Relationship (Helpfulness of Disclosure, Holding Back, Criticism & Withdrawal)

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Pre-Chemotherapy

During Chemotherapy

Post-Chemotherapy

The Split Plot Repeated Measure ANOVA (with one within the subject’s factors

and one between the subjects’ factors) analysis was carried out to observe the effect of

the types of surgery on the women’s interpersonal relationship aspects. The results

gathered for this analysis showed that the types of surgery was not a major factor for all

aspects of the women’s interpersonal relationship such as Perceived Husband’s Support

[F (1, 155) = 1.30; ns] [Table 8.8 (c); Figure 8.5 (c)], Level of Disclosure [F (1, 155) =

p<0.001

p<0.001

p<0.001

ns

p<0.001 p<0.001 p<0.01

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0.30; ns] [Table 8.8 (c); Figure 8.5 (d)], Empathy [F (1, 155) = 0.88; ns] [Table 8.8 (c);

Figure 8.5 (e)] and Helpfulness of Disclosure [F (1, 155) = 1.60; ns] [Table 8.8 (c);

Figure 8.5 (f)].

Table 8.8 (c): Split Plot Repeated Measure ANOVA: The Effect of the Types of Surgery on the Interpersonal Relationship Aspects of the Women with Breast

Cancer Sources of variation ss df ms f sign

Perceived Husband’s Support Within Subjects Effect: Perceived Husband’s Support (Time)

26491.297 1.783 14861.30 23.688 p<0.001

Time x Types of Surgery 6199.442 1.783 3477.811 5.543 p<0.01 Between Subjects Effect: 2094.052 1 2094.052 1.300 ns (Effect of Types of surgery)

Level of Disclosure Within Subjects Effect: Level of Disclosure (Time) 231.157 1.794 128.884 97.897 p<0.001 Time x Types of Surgery 8.787 1.794 4.900 3.722 p<0.05 Between Subjects Effect: 22.016 1 22.016 0.296 ns (Effect of Types of Surgery)

Empathy Within Subjects Effect: Empathy (Time) 1247.180 2 623.590 20.253 p<0.001 Time x Types of Surgery 140.904 2 70.452 2.288 ns

Between Subjects Effect: 65.411 1 65.411 0.877 ns (Effect of Types of Surgery)

Helpfulness of Disclosure Within Subjects Effect: Helpfulness of Disclosure (Time)

5.663 1.948 2.908 3.068 p<0.05

Time x Types of Surgery 18.351 1.948 9.422 9.941 p<0.001

Between Subjects Effect: 3.056 1 3.056 1.602 ns (Effect of Types of Surgery)

Note: Holding Back, Withdrawal and Criticism were excluded from the analysis as the assumptions for the parametric test were not met

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Figure 8.5 (c): The Effect of Types of Surgery on Women's Interpersonal Relationship (Perceived Husband Support)

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Mastectomy(N=124)

Lumpectomy(N=33)

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Post-Chemotherapy

Figure 8.5 (d): The Effect of Types of Surgery on Women's Interpersonal Relationship (Empathy)

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Mastectomy (N=124)

Lumpectomy (N=33)

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Figure 8.5 (e): The Effect of Types of Surgery on Women's Interpersonal Relationship (Level of Disclosure)

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Mastectomy (N=124)

Lumpectomy (N=33)

Time: F (1.78, 276.30) = 23.69; p<0.001 Interaction Effects: F (1.78, 276.30) = 5.54; p<0.01 Between Subjects Effect: F (1, 55) = 1.30; ns (8.5-c)

Time: F (1.79, 278) = 97.90; p<0.001 Interaction Effects: F (1.79, 278) = 3.72; p<0.05 Between Subjects Effect: F (1, 55) = 0.30; ns (8.5-e)

Time: F (2, 310) = 20.25; p<0.001 Interaction Effects: F (2, 310) = 2.29; ns Between Subjects Effect: F (1, 55) = 0.88; ns (8.5-d)

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Figure 8.5 (f): The Effect of Types of Surgery on Women's Interpersonal Relationship (Helpfulness of Disclosure)

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Mastectomy(N=124)

Lumpectomy(N=33)

Likewise, no significant effect of breast cancer stages was found on the

women’s interpersonal relationship aspects, particularly on their Perceived Husband’s

Support [F (1, 142) = 0.18; ns] [Table 8.8 (d); Figure 8.5 (g)], Empathy [F (1, 142) =

0.13; ns] [Table 8.8 (d); Figure 8.5 (h)], Level of Disclosure [F (1, 142) = 0.03; ns]

[Table 8.8 (d); Figure 8.5 (i)] and Helpfulness of Disclosure [F (1, 142) = 0.13; ns]

[Table 8.8 (d); Figure 8.5 (j)].

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Figure 8.5 (g): The Effect of Breast Cancer Stages on Women's Interpersonal Relationship (Perceived Husband Support)

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Stage Two (N=89)

Stage Three(N=55)

Time: F (1.95, 301.91) = 3.07; p<0.05 Interaction Effects: F (1.95, 301.91) = 9.94; p<0.001 Between Subjects Effect: F (1, 55) = 1.60; ns (8.5-f)

Time: F (1.84, 261, 63) = 14.00; p<0.001 Interaction Effects: F (1.84, 261.63) = 3.05; ns Between Subjects Effect: F (1, 142) = 0.18; ns (8.5-g)

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Table 8.8 (d): Split Plot Repeated Measure ANOVA: The Effect of Breast Cancer Stages on the Interpersonal Relationship Aspects of the Women with Breast Cancer

Sources of variation ss df ms f sign

Perceived Husband’s Support Within Subjects Effect: Perceived Husband’s support (Time)

15157.204 1.842 8226.703 13.997 p<0.001

Time x Breast Cancer Stages 3303.741 1.842 1793.134 3.051 ns Between Subjects Effect: 300.044 1 300.044 0.176 ns (Effect of Breast Cancer Stages )

Level of Disclosure Within Subjects Effect: Level of Disclosure (Time) 324.402 1.822 178.053 135.925 p<0.001

Time x Breast Cancer Stages 4.476 1.822 2.457 1.875 ns Between Subjects Effect: 1.991 1 1.991 0.027 ns (Effect of Breast Cancer Stages)

Empathy Within Subjects Effect: Empathy (Time) 1025.698 2 512.849 16.399 p<0.001

Time x Breast Cancer Stages 51.281 2 25.641 0.820 ns

Between Subjects Effect: 9.130 1 9.130 0.127 ns (Effect of Breast Cancer Stages)

Helpfulness of Disclosure Within Subjects Effect: Helpfulness of Disclosure (Time) 6.846 2 3.423 3.413 p<0.05 Time x Breast Cancer Stages 5.901 2 2.951 2.942 ns

Between Subjects Effect: 0.246 1 0.246 0.129 ns (Effect of Breast Cancer Stages)

Note: Holding Back, Withdrawal and Criticism were excluded from the analysis as the assumptions for the parametric test were not met

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Figure 8.5 (h): The Effect of Breast Cancer Stages on Women's Interpersonal Relationship (Empathy)

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Stage Two (N=89)

Stage Three (N=55)

Time: F (2, 284) = 16.40; p<0.001 Interaction Effects: F (2, 284) = 0.82; ns Between Subjects Effect: F (1, 142) = 0.13; ns (8.5-h)

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Figure 8.5 (i): The Effect of Breast Cancer Stages on Women's Interpersonal Relationship (Level of Disclosure)

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Stage Three (N=55)

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Figure 8.5 (j): The Effect of Breast Cancer Stages on Women's Interpersonal Relationship (Helpfulness of Disclosure)

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Stage Two(N=89)

Stage Three(N=55)

Similarly, with the exception given to the patients’ Perceived Husband’s

Support [F (1, 142) = 5.7; p<0.05] [Pre-menopausal women perceived higher support

from their husbands in all occasions (prior-to=114.46±34.28; during=122.47±33.67;

post-chemotherapy=107.74±27.05), than the patients in the post-menopausal group

(prior-to=107.89±29.59; during=113.73±32.38; post-chemotherapy=95.67±20.06)]

[Table 8.8 (e); Figure 8.5 (k)], many aspects of the women’s interpersonal relationship

did not reveal any major effects from the menopausal status, such as Empathy [F (1,

142) = 0.30; ns] [Table 8.8 (e); Figure 8.6 (l)], Level of Disclosure [F (1, 142) = 2.38;

ns] [Table 8.8 (e); Figure 8.5 (m)] and Helpfulness of Disclosure [F (1, 142) = 0.31; ns]

[Table 8.8 (e); Figure 8.5 (n)].

Time: F (1.82, 258.72) = 135.93; p<0.001 Interaction Effects: F (1.82, 258.72) = 1.88; ns Between Subjects Effect: F (1, 142) = 0.03; ns (8.5-i)

Time: F (2, 284) = 3.41; p<0.05 Interaction Effects: F (2, 284) = 2.94; ns Between Subjects Effect: F (1, 142) = 0.13; ns (8.5-j)

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Table 8.8 (e): Split Plot Repeated Measure ANOVA: The Effect of the Menopausal Status on the Interpersonal Relationship Aspects of the Women with Breast Cancer

Sources of Variation ss df ms f sign

Perceived Husband’s Support Within Subjects Effect: Perceived Husband’s Support (Time)

19171.73 1.800 10649.75 16.641 p<0.001

Time x Menopausal Status 492.647 1.800 273.662 0.428 ns Between Subjects Effect: 9052.190 1 9052.190 5.742 p<0.05 (Effect of Menopausal Status)

Level of Disclosure Within Subjects Effect: Level of Disclosure (Time) 327.138 1.743 187.721 132.531 p<0.001

Time x Menopausal Status 3.990 1.743 2.289 1.616 ns Between Subjects Effect: 173.498 1 173.498 2.384 ns (Effect of Menopausal Status)

Empathy Within Subjects Effect: Empathy (Time) 1360.358 2 680.179 22.231 p<0.001

Time x Menopausal Status 28.303 2 14.151 0.463 ns

Between Subjects Effect: 22.758 1 22.758 0.304 ns (Effect of Menopausal Status)

Helpfulness of Disclosure Within Subjects Effect: Helpfulness of disclosure (Time) 6.355 2 3.177 3.427 p<0.05 Time x Menopausal Status 2.494 2 1.247 1.345 ns

Between Subjects Effect: 2.561 1 2.561 1.439 ns (Effect of Menopausal Status)

Note: Holding Back, Withdrawal and Criticism were excluded from the analysis because the assumptions for the parametric test were unmet

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Figure 8.5 (k): The Effect of Menopausal Status on Women's Interpersonal Relationship (Perceived Husband Support)

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Pre-Menopausal(N=81)

Post-Menopausal(N=63)

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Figure 8.5 (l): The Effect of Menopausal Status on Women's Interpersonal Relationship (Empathy)

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Pre-Menopausal(N=81)

Post-Menopausal(N=63)

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Figure 8.5 (m): The Effect of Menopausal Status on Women's Interpersonal Relationship (Level of Disclosure)

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Pre-Menopausal(N=81)

Post-Menopausal(N=63)

Time: F (1.80, 255.63) = 16.64; p<0.001 Interaction Effects: F (1.80, 255.63) = 0.43; ns Between Subjects Effect: F (1, 142) = 5.74; p<0.05 (8.5-k)

Time: F (2, 284) = 22.23; p<0.001 Interaction Effects: F (2, 284) = 0.46; ns Between Subjects Effect: F (1, 142) = 0.30; ns (8.5-l)

Time: F (1.74, 247.46) = 132.53; p<0.001 Interaction Effects: F (1.74, 247.46) = 1.62; ns Between Subjects Effect: F (1, 142) = 2.38; ns (8.5m)

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Figure 8.5 (n): The Effect of Menopausal Status on Women's Interpersonal Relationship (Helpfulness of Disclosure)

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Post-Menopausal(N=63)

The analysis of the Split Plot Repeated Measure ANOVA (with one within the

subjects’ factors and one between the subjects’ factors) also demonstrated the

insignificant effects of the patients’ ethnicity on all aspects of their interpersonal

relationship, such as the Perceived Husband’s Support [F (2, 154) = 2.12; ns] [Table

8.8 (f); Figure 8.5 (o)], Level of Disclosure [F (2, 154) = 0.84; ns] [Table 8.8 (f); Figure

8.5 (p)], Empathy [F (2, 154) = 0.06; ns] [Table 8.8 (f); Figure 8.5 (q)] and Helpfulness

of Disclosure [F (2, 154) = 2.70; ns] [Table 8.8 (f); Figure 8.5 (r)].

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Figure 8.5 (o): The Effect of Ethnicity on Women's Interpersonal Relationship (Perceived Husband Support)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (2, 284) = 3.43; p<0.05 Interaction Effects: F (2, 284) = 1.35; ns Between Subjects Effect: F (1, 142) = 1.44; ns (8.5-n)

Time: F (1.78, 275.080) = 17.47; p<0.001 Interaction Effects: F (3.57, 275.08) = 0.82; ns Between Subjects Effect: F (2, 154) = 2.12; ns (8.5-o)

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Table 8.8 (f): Split Plot Repeated Measure ANOVA: The Effect of Ethnicity on the Interpersonal Relationship Aspect of the Women with Breast Cancer

Sources of Variation ss df ms f sign

Perceived Husband’s Support Within Subjects Effect: Perceived Husband’s Support (Time)

20158.900 1.786 11285.68 17.474 p<0.001

Time x Ethnicity 1885.106 3.572 527.675 0.817 ns Between Subjects Effect: 6747.176 2 3373.588 2.121 ns (Effect of Ethnicity )

Level of Disclosure Within Subjects Effect: Level of Disclosure (Time) 320.750 1.788 179.396 132.47 p<0.001 Time x Ethnicity 1.908 3.576 0.533 0.394 ns Between Subjects Effect: 125.020 2 62.510 0.844 ns (Effect of Ethnicity)

Empathy Within Subjects Effect: Empathy (Time) 1128.170 2 564.085 18.260 p<0.001 Time x Ethnicity 170.950 4 42.737 1.383 ns

Between Subjects Effect: 8.635 2 4.318 0.057 ns (Effect of Ethnicity)

Helpfulness of Disclosure Within Subjects Effect: Helpfulness of disclosure (Time)

8.003 1.915 4.179 4.102 p<0.05

Time x Ethnicity 4.027 3.830 1.051 1.032 ns

Between Subjects Effect: 0.757 2 0.378 0.196 ns (Effect of Ethnicity)

Note: Holding Back, Withdrawal and Criticism were excluded from the analysis as the assumptions for the parametric test were not met

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Figure 8.5 (p): The Effect of Ethnicity on Women's Interpersonal Relationship (Empathy)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.5 (q): The Effect of Ethnicity on Women's Interpersonal Relationship (Level of Disclosure)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.5 (r): The Effect of Ethnicity on Women's Interpersonal Relationship (Helpfulness of Disclosure)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (2, 308) = 18.26; p<0.001 Interaction Effects: F (4, 308) = 1.38; ns Between Subjects Effect: F (2, 154) = 0.06; ns (8.5-p)

Time: F (1.79, 275.34) = 132.47; p<0.001 Interaction Effects: F (3.58, 275.34) = 0.39; ns Between Subjects Effect: F (2, 154) = 0.84; ns (8.5-q)

Time: F (1.92, 294.94) = 4.10; p<0.05 Interaction Effects: F (3.83, 294.94) = 1.03; ns Between Subjects Effect: F (2, 154) = 0.20; ns (8.5-r)

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8.2.3.1 Summary of the Results

With the exception of Helpfulness of Disclosure, a significant effect of time was

observed for all aspects of the women’s interpersonal relationship. These include their

Perceived Husband’s Support, Level of Disclosure, Empathy, Criticism and

Withdrawal, which confirms the study’s hypothesis that the treatment phases (prior-to,

during and post-chemotherapy) have different effects on the interpersonal relationship

aspect of the women with breast cancer. In particular, the women’s Perceived

Husband’s Support, Empathy and Criticism were found to increase from prior-to to

during chemotherapy, but diminished at post-chemotherapy. However, the Level of

Disclosure was notably improved, whereas Holding Back and Withdrawal were

indicated as declining throughout the treatment phases. As apposed to the postulated

hypothesis i.e. medical (types of surgery and breast cancer stages) and bio/socio-

demographic (ethnicity) aspects have significant effects on the interpersonal

relationship aspects of the women with breast cancer, these independent factors (breast

cancer stages, types of surgery and ethnicity) were not indicated as significant factors

for all aspects of the women’s interpersonal relationship. Likewise, all aspects of the

women’s interpersonal relationship were not affected by their menopausal status,

except for their Perceived Husband’s Support, which almost contrast with the proposed

hypothesis that menopausal status of the women with breast cancer has significant

effects to their interpersonal relationship aspects.

Further, in the next section, the result of the Breast Cancer: From the Husband’s

Perspective is presented.

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8.3 Breast Cancer: From the Husband’s Perspective

The two main results of the current study are presented in this section. These

include the sexuality and interpersonal relationship aspects, from the husband’s

perspective. Another two aspects, which are, the husbands’ psychological well-being

(anxiety and depression) and coping strategies have been reported in detail in the

previous section, entitled “Breast Cancer: From the Couple’s Perspective”. For this,

the results in every sub-section are presented in the following sequence:

(1) First level of analysis i.e. the One-way Repeated Measure ANOVA (parametric

test) and the Friedman analysis (non-parametric test), to examine the differences in the

husbands’ view on their wives’ sexuality and their husbands’ interpersonal relationship

aspects, throughout the treatment phases; prior to, during and post-chemotherapy,

following the breast cancer surgery. The whole sample size was used for this analysis,

as described in earlier section (see Table 8.1 in Section 8.1 – Breast Cancer: From the

Couples’ Perspective).

(2) Second level of analysis i.e. the Split Plot Repeated Measure ANOVA (one

within the subjects’ factors and one between the subjects’ factor), to examine the

differences in the sexuality and interpersonal relationship aspects at the different phases

of treatment (prior-to, during and post-chemotherapy) among the husbands, by looking

at the different effects of the surgery types, breast cancer stages, menopausal status and

ethnicity. However, this analysis was only carried out for the data which met the

assumptions for the parametric test. Different sample size of the independent factors

was preceded for this analysis (see Table 8.2 in Section 8.1 – Breast Cancer: From the

Couples’ Perspective). In this analysis, only the results gathered for Between Subjects

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Effect were highlighted because the findings of the time effect have already been

reported and described in the first level of the analysis, which was done based on the

whole sample. Therefore, the results for the time effects (from the second level of

analysis) are not reported in this particular section, but they will only be included in the

tables presented in the respective sections of this chapter. Moreover, the different

sample sizes of the independent factors (types of surgery, breast cancer stages,

menopausal status and ethnicity), used in the second level of the analysis (Split Plot

Repeated Measure ANOVA), revealed different results for the time and interaction

effects, respectively. Thus, the results of the time effect (from whole sample) were

focused on in the presentation of the research findings. Medical-related information

(type of surgery and breast cancer stages) was obtained from the patients’ medical

records, meanwhile, menopausal status of the women with breast cancer was defined

on the classification as proposed by Brambilla et al. (1994), as described in earlier

section (see Section 8.1 – Breast Cancer: From the Couples’ Perspective).

The results are also presented in such a sequence to answer the general and

specific hypotheses, as stated below:

General Hypothesis:

• Treatment phases (prior-to, during and post-chemotherapy) have different

effects on the husbands’ psychological aspects (anxiety and depression), their

view on the wives’ sexuality, interpersonal relationship and coping strategies.

Specific Hypotheses:

(a) Husbands’ psychological aspects (anxiety and depression) and their view on the

wives’ sexuality (wives’ body image and sexual attractiveness) are worst during

chemotherapy, as compared to prior-to and post-chemotherapy.

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[Note: The husband’s psychological aspects (anxiety and depression) have been

reported in detail in the section entitled, “Breast Cancer: From the Couple’s

Perspective].

(b) Husbands’ interpersonal relationship aspects (perceived providing support,

level of disclosure, empathy, relationship satisfaction, helpfulness of disclosure,

withdrawal, holding back and criticism) are better during chemotherapy, as

compared to prior-to and post-chemotherapy.

[Note: The husbands’ relationship satisfaction has been reported in the section

on “Breast Cancer: From the Couple’s Perspective”].

(c) Husbands use greater coping strategies during chemotherapy than prior-to and

post-chemotherapy.

[Note: The husbands’ coping strategies have been reported in detail in the

section on “Breast Cancer: From the Couple’s Perspective”].

(d) Medical (types of surgery and breast cancer stages) and bio/socio-demographic

aspects (wives’ menopausal status and ethnicity) have a significant impact on

the husbands’ psychological aspects, their view on the wives’ sexuality,

interpersonal relationship aspects and coping strategies.

[Note: The husband’s psychological aspects (anxiety and depression),

relationship satisfaction and coping strategies have been reported in detail in the

section on “Breast Cancer: From the Couple’s Perspective”].

Thus, the results gathered for the husbands’ views on the wives’ sexuality (body

image and sexual attractiveness) and their interpersonal relationship aspects are

presented in the next section.

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8.3.1 Husbands’ View on Their Wives’ Sexuality

In this section, two results are reported, namely, the husbands’ view on their

wives’ body image and the husbands’ view on their wives’ sexual attractiveness.

In the current study, the analysis of the One-way Repeated Measure ANOVA

indicated that a significant effect of time was detected for the husbands’ view on their

wives’ body image [F (2, 312) = 54.46; p<0.001] [The husbands’ negative view on their

wives’ body image was found to improve over time (prior-to=21.68±6.59;

during=18.13±7.64; post-chemotherapy=16.69±5.48)] [Table 8.9 (a); Figure 8.6 (a)]

and the husbands’ view on their wives’ sexual attractiveness [F (1.79, 279.37) = 3.90;

p<0.05] [The husbands’ positive view on their wives’ sexual attractiveness diminished

from prior-to (47.15±9.44) to during chemotherapy (45.96±8.88), but this was found to

improve at post-chemotherapy (48.26±8.03)] [Table 8.9 (a); Figure 8.6 (a)].

Table 8.9 (a): One-Way Repeated Measure ANOVA: Husbands’ Views on their Wives’ Sexuality

Sources of Variation ss df ms f sign Body Image-log 10 1.262 2 0.631 54.464 p<0.001 Sexual Attractiveness

417.490 1.791 233.126 3.896 p<0.05

Note: Transformation data (log 10) was used for Body Image score to allow the use of parametric analysis

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Wives' Body Image Wives' SexualAttractiveness

Figure 8.6 (a): Husbands' View on Their Wives' Body Image and Sexual Attractiveness

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Prior to Chemotherapy

During Chemotherapy

Post-Chemotherapy

p<0.001

p<0.05

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As indicated by the analysis of Split Plot Repeated Measure ANOVA (with one

within the subjects’ factors and one between the subjects’ factors), the effect of the

surgery types was found to be significant for the husbands’ view on their wives’ body

image [F (2, 155) = 71.33; p<0.001] [The husbands in the lumpectomy group indicated

better view of their wives’ body image in all the treatment phases (prior-

to=19.70±5.29; during=13.03±4.17; post-chemotherapy=11.45±3.04), as compared to

the patients’ husbands in the mastectomy group (prior-to=22.21±6.82;

during=19.48±7.80; post-chemotherapy=18.08±5.13)] [Table 8.9 (b); Figure 8.6 (b)].

However, no significant effect of the surgery types was observed for the husbands’

view on their wives’ sexual attractiveness [F (2, 312) = 0.02; ns] [Table 8.9 (b); Figure

8.6 (c)].

Table 8.9 (b): Split Plot Repeated Measure ANOVA: The Effect of the Types of Surgery on the Husbands’ Views on their Wives’ Sexuality

Sources of Variation ss df ms f sign

Wives’ Body Image Within Subjects Effect: Body Image-log 10 (Time) 1.524 2 0.762 71.333 p<0.001 Time x Types of Surgery 0.303 2 0.152 14.201 p<0.001 Between Subjects Effect: 1.374 1 1.374 39.447 p<0.001 (Effect of Types of Surgery)

Wives’ Sexual Attractiveness Within Subjects Effect: Sexual Attractiveness (Time)

366.342 1.802 203.332 3.402 p<0.05

Time x Types of Surgery 24.330 1.802 13.504 0.226 ns Between Subjects Effect: 1.836 1 1.836 0.015 ns (Effect of Types of Surgery)

Note: Transformation data (log 10) was used for Body Image score to allow the use of parametric analysis

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Figure 8.6 (b): The Effect of Types of Surgery on Husbands' View of their Wives' Body Image

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Figure 8.6 (c): The Effect of Types of Surgery on Husbands' View of their Wives' Sexual Attractiveness

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Mastectomy (N=124)

Lumpectomy (N=33)

Similarly, the effect of the breast cancer stages was significant for the husbands’

view on their wives’ body image [F (1, 142) = 13.43; p<0.001] [Husbands of the

women diagnosed at stage two of breast cancer indicated better views on their wives’

body image in all occasions (prior-to=21.65±6.65; during=16.70±7.29; post-

chemotherapy=15.72±5.32), as compared to the husbands of the patients at stage three

of breast cancer (prior-to=22.45±6.59; during=21.30±7.67; post-

chemotherapy=18.85±5.01)] [Table 8.9 (c); Figure 8.6 (d)], but it was found to be

insignificant for the husbands’ view on their wives’ sexual attractiveness [F (1, 142) =

0.02; ns] [Table 8.9 (c); Figure 8.6 (e)].

Time: F (2, 310) = 71.33; p<0.001 Interaction Effect: F (2, 310) =14.20; p<0.001 Between Subjects Effect: F (1, 155) = 39.45; p<0.001 (8.6 - b)

Time: F (1.80, 279.26) = 3.40; p<0.05 Interaction Effect: F (1.80, 279.26) = 0.23; ns Between Subjects Effect: F (1, 155) = 0.02; ns (8.6 -c)

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Table 8.9 (c): Split Plot Repeated Measure ANOVA: The Effect of the Breast Cancer Stages on the Husbands’ Views on their Wives’ Sexuality

Sources of Variation ss df ms f sign

Wives’ Body Image Within Subjects Effect: Body image-log 10 (Time) 0.892 2 0.446 41.088 p<0.001 Time x Breast Cancer Stages 0.171 2 0.085 7.878 p<0.001 Between Subjects Effect: 0.537 1 0.537 13.433 p<0.001 (Effect of Breast Cancer Stages)

Wives’ Sexual Attractiveness Within Subjects Effect: Sexual attractiveness (Time) 527.819 1.850 285.288 5.274 p<0.01 Time x Breast Cancer Stages 72.301 1.850 39.079 0.722 ns Between Subjects Effect: 1.987 1 1.987 0.016 ns (Effect of Breast Cancer Stages)

Note: Transformation data (log 10) was used for Body Image score to allow the use of parametric analysis

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Figure 8.6 (d): The Effect of Breast Cancer Stages on Husbands' View of their Wives' Body Image

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Stage Two (N=89)

Stage Three (N=55)

Time: F (2, 284) = 41.09; p<0.001 Interaction Effect: F (2, 284) =7.89; p<0.001 Between Subjects Effect: F (1, 155) = 13.34; p<0.001 (8.6-d)

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Figure 8.6 (e): The Effect of Breast Cancer Stages on Husbands' Views of their Wives' Sexual Attractiveness

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Stage Two (N=89)

Stage Three (N=55)

Nevertheless, the effect of the breast cancer patients’ menopausal status was not

detected for both the husbands’ view on their wives’ body image [F (1, 142) = 2.56; ns]

[Table 8.9 (d); Figure 8.6 (f)] and the husbands’ view on their wives’ sexual

attractiveness [F (1, 142) = 0.03; ns] [Table 8.9 (d); Figure 8.6 (g)].

Table 8.9 (d): Split Plot Repeated Measure ANOVA: The Effect of the Breast Cancer Patients’ Menopausal Status on their Husbands’ Views on the Wives’ Sexuality

Sources of Variation ss df ms f sign

Wives’ Body Image Within Subjects Effect: Body image-log 10 (Time) 1.043 2 0.522 45.771 p<0.001 Time x Menopausal Status 0.030 2 0.015 1.302 ns Between Subjects Effect: 0.107 1 0.107 2.563 ns (Effect of Menopausal Status )

Wives’ Sexual Attractiveness Within Subjects Effect: Sexual Attractiveness (Time) 235.387 1.793 131.248 2.169 ns Time x Menopausal Status 205.971 1.793 114.846 1.898 ns Between Subjects Effect: 4.248 1 4.248 0.033 ns (Effect of Menopausal Status )

Note: Transformation data (log 10) was used for Body Image score to allow the use of parametric analysis

Time: F (1.85, 262.72) = 5.27; p<0.01 Interaction Effect: F (1.85, 262.72) = 0.72; ns Between Subjects Effect: F (1, 155) = 0.02; ns (8.6-e)

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Figure 8.6 (f): The Effect of Menopausal Status on Husbands' Views of their Wives' Body Image

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Pre-Menopausal(N=81)

Post-Menopausal(N=63)

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Post Chemotherapy

Figure 8.6 (g): The Effect of Menopausal Status on Husbands' View of their Wives' Sexual Attractiveness

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Pre-Menopausal(N=81)

Post-Menopausal(N=63)

Similar results were also demonstrated for the effect of ethnicity on the

husbands’ view of their wives’ body image [F (2, 154) = 0.53; ns] [Table 8.9 (e);

Figure 8.6 (h)] and the husbands’ view on their wives’ sexual attractiveness [F (2, 154)

= 1.97; ns] [Table 8.9 (e); Figure 8.6 (i)].

Time: F (2, 284) = 45.77; p<0.001 Interaction Effect: F (2, 284) = 1.30; ns Between Subjects Effect: F (1, 142) = 2.56; ns (8.6-f)

Time: F (1.79, 254.67) = 2.17; ns Interaction Effect: F (1.79, 254.67) = 1.90; ns Between Subjects Effect: F (1, 142) = 0.03; ns (8.6-g)

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Table 8.9 (e): Split Plot Repeated Measure ANOVA: The Effect of Ethnicity on the Husbands’ Views of their Wives’ Sexuality

Sources of Variation ss df ms f sign

Wives’ Body Image Within Subjects Effect: Body Image-log 10 (Time) 1.333 2 0.667 58.450 p<0.001 Time x Ethnicity 0.102 4 0.025 2.231 ns Between Subjects Effect: 0.046 2 0.023 0.525 ns (Effect of Ethnicity)

Wives’ Sexual Attractiveness Within Subjects Effect: Sexual Attractiveness (Time)

397.891 1.814 219.315 3.679 p<0.05

Time x Ethnicity 62.656 3.628 17.268 0.290 ns Between Subjects Effect: 485.870 2 242.935 1.966 ns (Effect of Ethnicity)

Note: Transformation data (log 10) was used for Body Image score to allow the use of parametric analysis

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Post Chemotherapy

Figure 8.6 (h): The Effect of Ethnicity on Husbands' View of their Wives' Body Image

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Chinese (N=51)

Indian (N=30)

Time: F (2, 308) = 58.45; p<0.001 Interaction Effect: F (4, 308) = 2.23; ns Between Subjects Effect: F (2, 154) = 0.52; ns (8.6-h)

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Figure 8.6 (i): The Effect of Ethnicity on Husbands' View of their Wives' Sexual Attractiveness

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

8.3.1.1 Summary of the Results

Significant effect of time was observed for the husbands’ view on their wives’

sexual attractiveness and body image, which is parallel to the postulated hypothesis of

the study i.e. treatment phases (prior-to, during and post-chemotherapy) have different

effects on the husbands’ view on their wives’ sexual attractiveness and body image. In

this aspect, the husbands’ negative views on their wives body image were found to

improve over time; whereas, their positive views on their wives’ sexual attractiveness

diminished from prior-to to during chemotherapy, but improved at post-chemotherapy.

Similarly, the effects of the types of surgery and breast cancer stages were

indicated to be significant for the husbands’ view on their wives’ body image, but not

for their view on the wives’ sexual attractiveness. These findings are in line with the

study’s hypothesis which states that the medical aspects (types of surgery and breast

cancer stages) have significant effects on the husbands’ view on their wives’ body

image. However, the results were not in line with the hypothesis that medical aspects

(types of surgery and breast cancer stages) influence husbands’ view on their wives’

Time: F (1.81, 308) = 3.68; p<0.05 Interaction Effect: F (3.63, 279.39) = 0.29; ns Between Subjects Effect: F (2, 154) = 2.00; ns (8.6- i)

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sexual attractiveness. As for the wives’ menopausal status and ethnicity, both were

revealed as not important or insignificant for the husbands’ view on their wives’ body

image and sexual attractiveness, which totally reject the proposed hypothesis that the

bio/socio-demographic aspects (menopausal status and ethnicity) have significant effect

on husbands’ view on their wives’ body image and sexual attractiveness.

8.3.2 Husbands’ Interpersonal Relationship

In this section, the aspects of the husbands’ interpersonal relationship are

reported. These aspects were Perceived Providing Support, Level of Disclosure,

Empathy, Holding Back, Criticism, Withdrawal and Helpfulness of Disclosure.

However, the result gathered for the husbands’ Relationship Satisfaction is not

presented because this data has been reported in detail in the previous section entitled,

“Breast Cancer: From the Couple’s Perspective.”

The results collected from the analysis of the One-way Repeated Measure

ANOVA indicated a significant main effect of time on most of the husbands’

interpersonal relationship aspects, including Perceived Providing Support [F (1.93,

301.75) = 29.93; p<0.001] [Perceived Providing Support increased from prior-to

(117.99±27.31) to during (122.25±29.33), but decreased at post-chemotherapy

(104.06±21.32)] [Table 8.10 (a); Figure 8.7 (a)], Level of Disclosure [F (1.28, 199.66)

= 272.34; p<0.001] [Level of disclosure was found to increase from prior-to

(11.87±3.29) to during chemotherapy (13.14±3.76), but declined at post-chemotherapy

(11.90±3.27)] [Table 8.10 (a); Figure 8.7 (a)], Empathy [F (1.87, 292.08) = 8.70;

p<0.001] [Empathy was indicated to rise from prior-to (40.69±6.89) to during

chemotherapy (43.06±5.27), but diminished thereafter (post-

chemotherapy=42.08±4.99)] [Table 8.10 (a); Figure 8.7 (a)]. The important effect of

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time was also demonstrated in the results yielded in Friedman analysis for several

variables like Holding Back (χ2 = 12.34; df = 2; p<0.01) [Holding back was found to

decrease over time (prior-to=1.37±0.80; during=1.18±0.81; post-

chemotherapy=1.04±0.69)] [Table 8.10 (b); Figure 8.7 (b)], Criticism (χ2 = 39.90; df =

2; p<0.001) [Criticism clearly declined over time (prior-to=0.94±0.69;

during=0.55±0.66; post-chemotherapy=0.54±0.66)] [Table 8.10 (b); Figure 8.7 (b)]

and Withdrawal (χ2 = 27.38; df = 2; p<0.001) [Withdrawal increased from prior-to

(0.42±0.77) to during (0.66±0.90) and slightly decreased post-chemotherapy

(0.65±0.68)] [Table 8.10 (b); Figure 8.7 (b)]. However, the significant effect of time

was not observed for Helpfulness of Disclosure [F (2, 312) = 2.58; ns] [Table 8.10 (a);

Figure 8.7 (b)].

Table 8.10 (a): One-way Repeated Measure ANOVA: Interpersonal Relationship Aspects of the Husbands

Sources of Variation ss df ms f sign Perceived Providing Support 28416.628 1.934 14691.087 29.930 p<0.001 Level of Disclosure 164.038 1.280 128.165 272.344 p<0.001 Empathy 442.832 1.872 236.520 8.699 p<0.001 Relationship Satisfaction (Indicated in a separate table in the section entitled, “Breast

Cancer: From the Couples’ Perspective”) Helpfulness of Disclosure 4.845 2 2.423 2.578 ns Holding Back* (Non-Parametric Table) Criticism* (Non-Parametric Table) Withdrawal* (Non-Parametric Table)

*The non-parametric analysis was used as the assumptions for parametric test were not met

Table 8.10 (b): Non-parametric Analysis (Friedman Test): Interpersonal Relationship Aspects of the Husbands

χ2 df sign Holding Back 12.34 2 p<0.01 Criticism 39.90 2 p<0.001 Withdrawal

27.38 2 p<0.001

Note: The non-parametric analysis was used as the assumptions for parametric test were not met

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Support Empathy Level of DisclosureFigure 8.7 (a): Husbands' Interpersonal Relationship (Perceived Providing Support, Empathy & Level of

Disclosure)

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Pre-Chemotherapy

During Chemotherapy

Post-Chemotherapy

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Figure 8.7 (b): Husbands' Interpersonal Relationship (Criticism, Withdrawal, Holding Back &

Helpfulness of Disclosure)

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Pre-Chemotherapy

During Chemotherapy

Post-Chemotherapy

Further analysis with the Split Plot Repeated Measure ANOVA (with one

within the subjects’ factors and one between the subjects’ factors) indicated that the

types of surgery did not affect the husbands’ Perceived Providing Support [F (1, 155) =

0.90; ns] [Table 8.10 (c); Figure 8.7 (c)], Level of Disclosure [F (1, 155) = 0.03; ns]

[Table 8.10 (c); Figure 8.7 (d)], Empathy [F (1, 155) = 0.09; ns] [Table 8.10 (c); Figure

8.7 (e)] and Helpfulness of Disclosure [F (1, 155) = 0.10; ns] [Table 8.10 (f); Figure 8.7

(j)].

p<0.001

p<0.001

p<0.001

p<0.01 p<0.001 p<0.001

ns

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Table 8.10 (c): Split Plot Repeated Measure ANOVA: The Effect of the Types of Surgery on the Husbands’ Interpersonal Relationship Aspects

Sources of Variation ss df ms f sign

Perceived Providing Support Within Subjects Effect: Husband support (Time) 23565.895 1.956 12045.777 25.034 p<0.001

Time x Types of Surgery 220.341 1.956 1124.711 2.337 ns Between Subjects Effect: 1003.311 1 1003.311 0.903 ns (Effect of Types of Surgery)

Level of Disclosure Within Subjects Effect: Level of Disclosure (Time) 104.488 1.288 81.136 172.652 p<0.001

Time x Types of surgery 0.157 1.288 0.122 0.259 ns

Between Subjects Effect: 1.098 1 1.098 0.031 ns (Effect of Types of Surgery)

Empathy Within Subjects Effect: Empathy (Time) 272.789 1.882 144.932 5.334 p<0.01 Time x Types of Surgery 14.216 1.882 7.553 0.278 ns

Between Subjects Effect: 4.361 1 4.361 0.088 ns (Effect of Types of Surgery)

Helpfulness of Disclosure Within Subjects Effect: Helpfulness of Disclosure (Time)

3.489 2 1.744 1.849 ns

Time x Types of surgery 0.686 2 0.343 0.364 ns

Between Subjects Effect: 0.154 1 0.154 0.095 ns (Effect of Types of Surgery)

Note: Holding Back, Withdrawal and Criticism were excluded from the analysis as the assumptions for parametric test were not met

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Figure 8.7 (c): The Effect of Types of Surgery on Husbands' Interpersonal Relationship (Perceived Providing Support)

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Mastectomy(N=124)

Lumpectomy(N=33)

Time: F (1.96, 303.24) = 25.03; p<0.001 Interaction Effect: F (1.96, 303.24) = 2.34; ns Between Subjects Effect: F (1, 155) = 0.90; ns (8.7-c)

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Figure 8.7 (d): The Effect of Types of Surgery on Husbands' Interpersonal Relationship (Level of Disclosure)

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Mastectomy(N=124)Lumpectomy (N=33)

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Post-Chemotherapy

Figure 8.7 (e): The Effect of Types of Surgery on Husbands' Interpersonal Relationship (Empathy)

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Mastectomy (N=124)

Lumpectomy (N=38)

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Figure 8.7 (f): The Effect of Types of Surgery on Husbands' Interpersonal Relationship (Helpfulness of Disclosure)

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Mastectomy (N=124)

Lumpectomy (N=33)

Time: F (1.28, 199.61) = 172.65; p<0.001 Interaction Effect: F (1.29, 199.61) = 0.26; ns Between Subjects Effect: F (1, 155) = 0.03; ns (8.7-d)

Time: F (1.88, 291.74) = 5.33; p<0.01 Interaction Effect: F (1.88, 291.74) = 0.28; ns Between Subjects Effect: F (1, 155) = 0.09; ns (8.7-e)

Time: F (2, 310) = 1.85; ns Interaction Effect: F (2, 310) = 0.36; ns Between Subjects Effect: F (1, 155) = 0.10; ns (8.7 f)

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Similarly, breast cancer stages was not a significant factor affecting the

husbands’ Perceived Providing Support [F (1, 142) = 0.08; ns] [Table 8.10 (d); Figure

8.7 (g)], Level of Disclosure [F (1, 142) = 1.26; ns] [Table 8.10 (d); Figure 8.7 (h)],

Empathy [F (1, 142) = 2.86; ns] [Table 8.10 (d); Figure 8.7 (i)] and Helpfulness of

Disclosure [F (1, 142) = 0.60; ns] [Table 8.10 (d); Figure 8.7 (j)].

Table 8.10 (d): Split Plot Repeated Measure ANOVA: The Effect of Breast Cancer Stages on the Husbands’ Interpersonal Relationship Aspects

Source of Variation ss df ms f sign

Perceived Providing Support Within Subjects Effect: Husband support (Time) 22990.989 2 11495.49 24.056 p<0.001 Time x Breast Cancer Stages 1116.007 2 558.004 1.168 ns Between Subjects Effect: 97.692 1 97.692 0.084 ns (Effect of Breast Cancer Stages)

Level of Disclosure Within Subjects Effect: Level of Disclosure (Time) 148.105 2 74.052 240.680 p<0.001

Time x Breast Cancer Stages 1.031 2 0.515 1.675 ns Between Subjects Effect: 42.913 1 42.913 1.256 ns (Effect of Breast Cancer Stages)

Empathy Within Subjects Effect: Empathy (Time) 562.812 1.917 293.661 11.606 p<0.001

Time x Breast Cancer Stages 2.340 1.917 1.221 0.048 ns

Between Subjects Effect: 137.391 1 137.391 2.856 ns (Effect of Breast Cancer Stages)

Helpfulness of Disclosure Within Subjects Effect: Helpfulness of Disclosure (Time)

6.989 2 3.495 3.830 p<0.05

Time x Breast Cancer Stages 1.878 2 0.939 1.029 ns

Between Subjects Effect: 0.977 1 0.977 0.599 ns (Effect of Breast Cancer Stages)

Note: Holding Back, Withdrawal and Criticism were excluded from the analysis as the assumptions for parametric test were not met

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Figure 8.7 (g): The Effect of Breast Cancer Stages on Husbands' Interpersonal Relationship

(Perceived Providing Support)

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Stage Two (N=89)

Stage Three (N=55)

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Figure 8.7 (h): The Effect of Breast Cancer Stages on Husbands' Interpersonal Relationship (Level of Disclosure)

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Stage Two (N=89)

Stage Three (N=55)

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Post-Chemotherapy

Figure 8.7 (i): The Effect of Breast Cancer Stages on Husbands' Interpersonal Relationship (Empathy)

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Stage Two (N=89)

Stage Three (N=55)

Time: F (2, 284) = 24.06; p<0.001 Interaction Effect: F (2, 284) = 1.17; ns Between Subjects Effect: F (1, 142) = 0.08; ns (8.7 g)

Time: F (2, 284) = 240.68; p<0.001 Interaction Effect: F (2, 284) = 1.68; ns Between Subjects Effect: F (1, 142) = 1.26; ns (8.7- h)

Time: F (1.92, 272.15) = 11.61; p<0.001 Interaction Effect: F (1.92, 272.15) = 0.05; ns Between Subjects Effect: F (1, 142) = 2.86; ns (8.7-i)

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Figure 8.7 (j): The Effect of Breast Cancer Stages on Husbands' Interpersonal Relationship

(Helpfulness of Disclosure)

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Stage Two (N=89)

Stage Three (N=55)

Likewise, with the exception of the husbands’ Perceived Providing Support [F

(1, 142) = 9.40; p<0.01] [Husbands of the pre-menopausal women perceived providing

more support to their wives in all occasions (prior-to=121.78±28.06;

during=125.33±29.49; post-chemotherapy=108.30±21.92), as compared to the

husbands of the patients in the post-menopausal group (prior-to=112.46±25.57;

during=114.94±29.95; post-chemotherapy=98.75±18.48)] [Table 8.10 (e); Figure 8.7

(k)], there were no significant effects of the women’s menopausal status on the

husbands’ Level of Disclosure [F (1, 142) = 0.21; ns] [Table 8.10 (e); Figure 8.7 (l)],

Empathy [F (1, 142) = 0.07; ns] [Table 8.10 (e); Figure 8.7 (m)] and Helpfulness of

Disclosure [F (1, 142) = 0.94; ns] [Table 8.10 (e); Figure 8.7 (n)].

Time: F (2, 284) = 3.83; p<0.05 Interaction Effect: F (2, 284) = 1.03; ns Between Subjects Effect: F (1, 142) = 0.60; ns (8.7-j)

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Table 8.10 (e): Split Plot Repeated Measure ANOVA: The Effect of the Breast Patients’ Menopausal Status on the Husbands’ Interpersonal Relationship Aspects

Sources of Variation ss df ms f sign

Perceived Providing Support Within Subjects Effect: Husband’s support (Time) 22208.201 1.932 11495.86 23.278 p<0.01 Time x Menopausal Status 22.868 1.932 11.837 0.024 ns Between Subjects Effect: 10116.389 1 10116.39 9.398 p<0.01 (Effect of Menopausal Status)

Level of Disclosure Within Subjects Effect: Level of Disclosure (Time) 149.021 1.298 114.820 232.389 p<0.001 Time x Menopausal Status 2.298 1.298 1.771 3.584 p<0.05 Between Subjects Effect: 7.440 1 7.440 0.212 ns (Effect of Menopausal Status)

Empathy Within Subjects Effect: Empathy (Time) 426.749 1.921 222.196 8.616 p<0.01 Time x Menopausal Status 214.082 1.921 111.467 4.322 p<0.05

Between Subjects Effect: 3.508 1 3.508 0.069 ns (Effect of Menopausal Status)

Helpfulness of Disclosure Within Subjects Effect: Helpfulness of Disclosure (Time)

3.982 2 3.982 2.086 ns

Time x Menopausal Status 5.594 2 2.797 2.930 ns

Between Subjects Effect: 1.559 1 1.559 0.944 ns (Effect of Menopausal Status)

Note: Holding Back, Withdrawal and Criticism were excluded from the analysis as the assumptions for parametric test were not met

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Post-Chemotherapy

Figure 8.7 (k): The Effect of Menopausal Status on Husbands' Interpersonal Relationship (Perceived Providing Support)

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Pre-Menopausal(N=81)

Post-Menopausal(N=63)

Time: F (1.932, 274.322) = 23.278; p<0.01 Interaction Effect: F (1.932, 274.322) = 0.024; ns Between Subjects Effect: F (1, 142) = 9.398; p<0.01 (8.7-k)

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Figure 8.7 (l): The Effect of Menopausal Status on Husbands' Interpersonal Relationship (Level of Disclosure)

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Post-Menopausal(N=63)

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Post-Chemotherapy

Figure 8.7 (m): The Effect of Menopausal Status on Husbands' Interpersonal Relationship (Empathy)

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Pre-Menopausal(N=81)

Post-Menopausal(N=63)

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Post-Chemotherapy

Figure 8.7 (n): The Effect of Menopausal Status on Husbands' Interpersonal Relationship (Helpfulness of Disclosure)

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Pre-Menopausal(N=81)

Post-Menopausal(N=63)

Time: F (1.298, 184.296) = 232.389; p<0.001 Interaction Effect: F (1.298, 184.296) = 3.584; p<0.05 Between Subjects Effect: F (1, 142) = 0.212; ns (8.7- l)

Time: F (1.921, 272.724) = 8.616; p<0.01 Interaction Effect: F (1.921, 272.724) = 4.322; p<0.05 Between Subjects Effect: F (1, 142) = 0.069; ns (8.7m)

Time: F (2, 284) = 2.086; ns Interaction Effect: F (2, 284) = 2.930; ns Between Subjects Effect: F (1, 142) = 0.944; ns (8.7-n)

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Just like the findings gathered for other factors, the ethnicity factor also

indicated insignificant effects to all aspects of the husbands’ interpersonal relationship,

such as their Perceived Providing Support [F (2, 154) = 1.88; ns] [Table 8.10 (f); Figure

8.7 (o)], Level of Disclosure [F (2, 154) = 0.24; ns] [Table 8.10 (f); Figure 8.7 (p)],

Empathy [F (2, 154) = 0.14; ns] [Table 8.10 (f); Figure 8.7 (q)] and Helpfulness of

Disclosure [F (2, 154) = 2.70; ns] [Table 8.10 (f); Figure 8.7 (r)].

Table 8.10 (f): Split Plot Repeated Measure ANOVA: The Effect of Ethnicity on the Husbands’ Interpersonal Relationship Aspects

Sources of Variation ss df ms f sign

Perceived Providing Support Within Subjects Effect: Husband’s support (Time) 24087.999 1.962 12276.934 25.398 p<0.001 Time x Ethnicity 2053.416 3.924 523.282 1.083 ns Between Subjects Effect: 4128.694 2 2064.347 1.879 ns (Effect of Ethnicity)

Level of Disclosure Within Subjects Effect: Level of Disclosure (Time) 144.235 1.299 111.014 241.65 p<0.001 Time x Ethnicity 2.043 2.598 0.786 1.711 ns Between Subjects Effect: 17.257 2 8.629 0.244 ns (Effect of Ethnicity)

Empathy Within Subjects Effect: Empathy (Time) 405.168 1.907 212.485 7.990 p<0.01 Time x Ethnicity 131.876 3.814 34.580 1.300 ns

Between Subjects Effect: 14.323 2 7.161 0.144 ns (Effect of Ethnicity)

Helpfulness of Disclosure Within Subjects Effect: Helpfulness of Disclosure (Time)

5.108 2 2.554 2.793 ns

Time x Ethnicity 11.548 4 2.887 3.158 p<0.05

Between Subjects Effect: 8.572 2 4.286 2.702 ns (Effect of Ethnicity)

Note: Holding Back, Withdrawal and Criticism were excluded from the analysis as the assumptions for parametric test were not unmet

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Figure 8.7 (o): The Effect of Ethnicity on Husbands' Interpersonal Relationship

(Perceived Providing Support)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.7 (p): The Effect of Ethnicity on Husbands' Interpersonal Relationship

(Level of Disclosure)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

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Figure 8.7 (q): The Effect of Ethnicity on Husbands' Interpersonal Relationship (Empathy)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

Time: F (1.96, 302.16) = 25.40; p<0.001 Interaction Effect: F (3.92, 302.16) = 1.08; ns Between Subjects Effect: F (2, 154) = 1.88; ns (8.7-o)

Time: F (1.30, 200.08) = 241.65; p<0.001 Interaction Effect: F (2.60, 200.084) = 1.71; ns Between Subjects Effect: F (2, 154) = 0.24; ns (8.7 p)

Time: F (1.91, 293.65) = 7.99; p<0.01 Interaction Effect: F (3.81, 293.65) = 1.30; ns Between Subjects Effect: F (2, 154) = 0.14; ns (8.7-q)

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Figure 8.7 (r): The Effect of Ethnicity on Husbands' Interpersonal Relationship (Helpfulness of Disclosure)

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Malay (N=76)

Chinese (N=51)

Indian (N=30)

8.3.2.1 Summary of the Results

Except for the husbands’ Helpfulness of Disclosure, the significant effect of

time was observed for all aspects of the husbands’ interpersonal relationship, which

included Perceived Providing Support, Level of Disclosure and Empathy. All these

parameters were observed to increase from prior-to to during, but decrease at post-

chemotherapy. These results confirm the hypothesis of the study which states that the

treatment phases (prior-to, during and post-chemotherapy) have different effects on the

interpersonal relationship aspects of the husbands. However, both the husbands’

Holding Back and Criticism were detected to decline over time.

The types of surgery, breast cancer stages and ethnicity did not have any

significant influence on all aspects of the husbands’ interpersonal relationship, which is

not in line with the postulated hypothesis i.e. medical (types of surgery and breast

cancer stages) and bio/socio-demographic aspects (ethnicity) have significant effects on

the interpersonal relationship aspects of the husbands. This situation is almost similar

for the effect of the menopausal status, whereby all aspects of the husbands’

interpersonal relationship (except for the husbands’ Perceived Providing Support) did

not reveal any significant differences across their wives’ menopausal status, as apposed

Time: F (2, 308) = 2.79; ns Interaction Effect: F (4, 308) = 3.16; p<0.05 Between Subjects Effect: F (2, 308) = 2.70; ns (8.7-r)

498

to the postulated hypothesis which states that the menopausal status of the women with

breast cancer has significant effect on the interpersonal relationship aspects of their

husbands.

Further, the results of the analyses of stepwise multivariate regression, which is

based on the various proposed regression models, are presented in the next section.

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8.4 Factors Predictive of the Women’s Quality of life, Relationship Satisfaction

and Coping Strategies

In this section, four regression models, namely Factors Predictive of Women’s

Global Health Status, Factors Predictive of Women’s Sexual Attractiveness, Factors

Predictive of Women’s Relationship Satisfaction and Factors Predictive of Women’s

Coping Strategy, are proposed. The justification of the model is guided by the

background literature documented previously (see Chapter Two, Three and Four).

Global Health Status, Sexual Attractiveness, Relationship Satisfaction and Coping

Strategy were selected as dependent variables because they made up the core variables

of the present study. In general, there are three groups of independent variables

proposed as predictors for the dependent variables in the models. These groups were

identified as women’s factors, husband’s factors and general factors. For the women’s

(patient’s) factors, the psychological aspect (anxiety and depression) was proposed as a

predictor for all the dependent variables in the proposed model, which included

Women’s Global Health Status, Sexual Attractiveness, Relationship Satisfaction and

their Coping Strategy. It has been shown that the psychological factor is crucial in all

aspects of the women’s life after breast cancer diagnosis. It is often incorporated as

one of the important components in the concept of quality of life and contributes to the

greater variance in the breast cancer patients’ global health. Similarly, patient’s

psychological aspect is important in predicting their sexuality aspect. It is observed

that the psychological aspect could be an important predictor for relationship

satisfaction and coping behaviour of the breast cancer patients. Besides the

psychological factors (anxiety and depression), relationship satisfaction is another

predictor suggested to be incorporated in the models of Global Health Status, Sexual

Attractiveness and Coping Strategies. In relation to coping strategy, the factor of

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marital relationship is important as a predictor for the adaptation behaviour. In the

model of women’s sexual attractiveness, apart from the psychological aspect and

relationship satisfaction, the predictors of body image and menopausal symptom have

also been incorporated in the model. Besides the psychological factor in the model of

women’s relationship satisfaction, all aspects of the women’s interpersonal

relationship, such as Perceived Husband’s Support, Level of Disclosure, Empathy and

Helpfulness of Disclosure were also integrated as predictors in this particular model.

Moreover, variables in marital communication (such as the Level of Disclosure,

Empathy and Helpfulness of Disclosure) are crucial in predicting the aspect of

interpersonal relationship. In the model of coping strategy, the predictor of the

perceived husband’s support was chosen to be incorporated in the model, in addition to

the psychological aspect and relationship satisfaction. This particular factor was

suggested (as a predictor) based on its significant effect on the way an individual

adjusted and adapted to the illness.

The husband’s factors are other important predictors incorporated in all the

regression models of the study as parts of the important predictors in the model. The

integration of these husband’s factors as predictors is very important because there are

scarcity of the studies that model the husband’s perspective(s) in the regression

equation. Furthermore, psychologists emphasized that interpersonal relations between

individuals could have a critical consequence for one’s health. In this study, the

duration of marriage, duration of breast cancer (included in the general predictors), as

well as the age of the women and their husbands were also integrated in the models of

the Women’s Global Health Status, Sexual Attractiveness, Relationship Satisfaction

and Coping Strategy. These variables were chosen based on their significant influences

on the dependent variables in the proposed models. Specifically, the duration or length

of marriage was hypothesized to have a positive correlation with all aspects of one’s

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life i.e. Global Health Status, Sexual Attractiveness, Relationship Satisfaction and

Coping Strategy. Similarly, the duration of breast cancer was hypothesized to cause a

significant effect to all aspects in the women’s life, which included their global health,

sexuality, relationship and coping behaviour. Finally, the age of the patients and their

husbands was suggested as another major predictor in the proposed models. The

significance of age as a vital predictor could be observed in many previous studies

conducted on the quality of life, sexuality, relationship issues and coping behaviour.

Therefore, the dependent and independent variables that were investigated in

each of the model proposed, are presented in Table 8.11 (a).

Thus, in this section, an analysis of multivariate regression (stepwise method)

was performed to prove the various hypotheses postulated in the current study.

8.4.1 Factors Predictive of the Women’s Global Health Status Post-

Chemotherapy

The hypothesis postulated in this section was:

• The women’s factors (greater age, lower level of anxiety and depression, higher

level of relationship satisfaction), the husbands’ factors (greater age, lower

level of anxiety and depression, higher level of relationship satisfaction) and the

general factors (the longer the duration of marriage, the longer the duration of

breast cancer) are factors predictive of the better global health status of the

women with breast cancer post-chemotherapy.

The stepwise regression analysis indicated that this factor, women’s depression

was the only factor predictive of global health status post-chemotherapy [R2 = 0.09, F

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(1, 155) = 14.96; p<0.05]. However, other women’s predictors (age, anxiety and

relationship satisfaction), the husbands’ predictors (age, anxiety, depression and

relationship satisfaction) and the general predictors (the duration of marriage and the

duration of breast cancer) did not appear as predictive of these women’s global health

status post chemotherapy [Table 8.11 (b)].

Table 8.11 (b): Stepwise Multiple Regression Analysis of the Global Health Status of Women with Breast Cancer Post-Chemotherapy: Women, husbands and General

Factors as Predictors Predictive Factors: Model 1

β p Women’s Predictors: Age Excluded Anxiety Excluded Depression -0.30 p<0.001 Relationship Satisfaction Excluded Husband’s Predictors: Age Excluded Anxiety Excluded Depression Excluded Relationship Satisfaction Excluded General Predictors: Duration of marriage Excluded Duration of breast cancer Excluded R Square : 0.09 (p<0.001) F Statistic : F (1, 155) = 14.96 β: Standardized Coefficient Beta

8.4.1.1 Summary of the Results

In the current study, the women’s global health status was predicted by their

depression. Other factors from the women (age, anxiety and relationship satisfaction)

and the husbands (age, anxiety, depression and relationship satisfaction) were found to

be unable to predict the global health status of the women with breast cancer who took

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part in this study. Similarly, general factors (duration of marriage and the duration of

breast cancer) were indicated as not predictive for the women’s global health status

post chemotherapy. Thus, the proposed hypothesis of the study which state that the

general factors (duration of marriage, duration of breast cancer), the women’s factors

(age, anxiety, depression, relationship satisfaction) and the husbands’ factors (age,

anxiety, depression, and relationship satisfaction) are the factors predictive of the

women’s global health status at post-chemotherapy, almost not in line with the study’s

finding.

8.4.2 Factors Predictive of the Women’s Sexual Attractiveness Post-

Chemotherapy

In this section, the hypothesis postulated was:

• The higher level of positive view on sexual attractiveness of the women with

breast cancer post-chemotherapy is predicted by the general factors (the longer

the duration of marriage, the longer the duration of breast cancer), the

women’s factors (greater age, lower level of anxiety and depression, less

menopausal symptoms, better global health status, higher level of relationship

satisfaction, less negative view on body image) and the husbands’ factors

(greater age, lower level of anxiety and depression, higher level of relationship

satisfaction, less negative view on wives’ body image and sexual

attractiveness).

Table 8.11 (c) presents the result of Stepwise Multivariate Regression Analysis.

The first model of the women’s sexual attractiveness suggested the women’s body

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image as a factor predictive of their sexual attractiveness at post-chemotherapy [R2 =

0.11, F (1, 155) = 19.0, p<0.001]. Women’s anxiety contributed to the significant R2

Change in the second model [R2 = 0.19, F (2, 154) = 17.48, p<0.001; R2 Change = 0.08,

p<0.001]. Meanwhile, the husbands’ view on their wives’ sexual attractiveness and the

husbands’ view on their wives’ body image also contributed to the R2 Change in the

third [R2 = 0.23, F (3, 153) = 14.84, p<0.001; R2 Change = 0.04, p<0.01] and fourth

models [R2 = 0.25, F (4, 152) = 12.81, p<0.001; R2 Change = 0.03, p<0.05],

respectively. The final model suggested that the women’s body image, the women’s

anxiety, the husbands’ view on their wives’ sexual attractiveness and the husbands’

view on their wives’ body image explained 25% of the variance of these breast cancer

patients’ sexual attractiveness at post-chemotherapy. However, other factors from the

women (age, depression, menopausal symptoms, global health status, relationship

satisfaction), the husbands (age, anxiety, depression, relationship satisfaction) and the

general (duration of marriage and duration of breast cancer) were not reveal as factors

predictive of the Women’s Sexual Attractiveness Post-Chemotherapy.

8.4.2.1 Summary of the Results

In this study, it was found that the women’s sexual attractiveness could be

predicted by their body image and anxiety, as well as their husbands’ view on the

wives’ sexual attractiveness and body image. On the contrary, the age of these women,

their depression, menopausal symptoms, global health status and relationship

satisfaction; as well as the age of the husbands, their anxiety, depression and

relationship satisfaction did not predict these women’s sexual attractiveness. At the

same time, the general factors (such as the duration of marriage and duration of breast

cancer) were also found to be not predictive of these women’s sexual attractiveness.

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Therefore, the study’s hypothesis which aims to prove that the women’s sexual

attractiveness at post-chemotherapy is predicted by the general factors (duration of

marriage, duration of breast cancer), the women’s factors (age, anxiety, depression,

menopausal symptoms, global health status, relationship satisfaction, body image) and

the husbands’ factors (age, anxiety, depression, relationship satisfaction, view on

wives’ body image, and view on wives’ sexual attractiveness), almost contrast with the

study’s finding.

8.4.3 Factors Predictive of the Women’s Relationship Satisfaction Post-

Chemotherapy

For this particular section, the hypothesis postulated was:

• The higher level of relationship satisfaction (with their husbands) of the women

with breast cancer post-chemotherapy is predicted by the general factors (the

longer the duration of marriage, the longer the duration of breast cancer), the

women’s factors (greater age, lower level of anxiety and depression, higher

level of perceived husband support, higher level of disclosure, higher level of

empathy, higher level of helpfulness of disclosure) and the husbands’ factors

(greater age, lower level of anxiety and depression, higher level of relationship

satisfaction, higher level of perceived providing support, higher level of

disclosure, higher level of empathy, higher level of helpfulness of disclosure).

The first model of the women’s relationship satisfaction at post-chemotherapy

indicated that the breast cancer patients’ perceived husband’s support explained 32% of

the variance of the women’s relationship satisfaction [R2 = 0.32; F (1, 155) = 71.67;

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p<0.001]. This model showed significant R2 changes when the women’s empathy was

included in model 2 [R2 = 0.42, F (2, 154) = 54.81, p<0.001; R2 Change = 0.04,

p<0.01]. In specific, the R2 value continued to increase when other predictors (such as

the husbands’ relationship satisfaction) were included in Model 3 [R2 = 0.46, F (3, 153)

= 43.30; p<0.001; R2 Change = 0.04; p<0.01], the perceived husband’s support in

Model 4 [R2 = 0.51, F (4, 152) = 40.01, p<0.001; R2 Change = 0.05; p<0.001], the

women’s helpfulness of disclosure in Model 5 [R2 = 0.54, F (5, 151) = 35.11, p<0.001;

R2 Change = 0.03; p<0.01] and the women’s depression in Model 6 [R2 = 0.57, F (6,

150) = 32.64, p<0.001; R2 Change = 0.03, p<0.01]. The final model indicated that the

women’s depression, their perceived husband’s support, the women’s empathy,

helpfulness of disclosure, their husbands’ relationship satisfaction and the husband

perceived providing support explained 57% of the variance of the women’s relationship

satisfaction. Other factors of the women (age, anxiety, level of disclosure), the

husbands (age, anxiety, depression, level of disclosure, empathy, helpfulness of

disclosure) and general factors (duration of marriage and duration of breast cancer)

were found to be not predictive of these Women’s Relationship Satisfaction Post-

Chemotherapy [Table 8.11 (d)].

8.4.3.1 Summary of the Results

The women’s relationship satisfaction was predicted by their depression,

perceived husband’s support, empathy and helpfulness of disclosure, as well as their

husbands’ relationship satisfaction and perceived providing support. Other factors such

as the age of the women, their anxiety, level of disclosure, and the age of the husbands,

their anxiety, depression, level of disclosure, empathy and helpfulness of disclosure did

not predict the women’s relationship satisfaction. A similar result was indicated for the

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general factors like the duration of marriage and duration of breast cancer, whereby

they were found to be not predictive of the women’s relationship satisfaction.

Therefore, based on this finding, the study’s hypothesis i.e. the women’s relationship

satisfaction with their husbands at post-chemotherapy is predicted by the general

factors (duration of marriage, duration of breast cancer), the women’s factors (age,

anxiety, depression, perceived husband’s support, level of disclosure, empathy,

helpfulness of disclosure) and the husbands’ factors (age, anxiety, depression,

relationship satisfaction, perceived providing support, level of disclosure, empathy,

helpfulness of disclosure), almost not in line with this study’s finding.

8.4.4 Factors Predictive of Women’s Problem-focused Coping Strategy Post-

Chemotherapy

For this particular section, the hypothesis postulated was:

• The greater use of problem-focused coping strategy of the women with breast

cancer post-chemotherapy is predicted by the general factors (the longer the

duration of marriage, the longer the duration of breast cancer), the women’s

factors (greater age, lower level of anxiety and depression, higher level of

relationship satisfaction, higher level of perceived husband’s support) and the

husbands’ factors (greater age, lower level of anxiety and depression, higher level

of relationship satisfaction, higher level of perceived providing support, greater

use of problem-focused strategy).

The model showed that the women’s perceived husband’s support was

predictive of the women’s problem-focused strategy post-chemotherapy [R2 = 0.23; F

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(1, 155) = 37.31; p<0.001]. The significant R2 Changes were observed when the

women’s age was included in the next model [R2 = 0.25, F (2, 154) = 26.11, p<0.001;

R2 Change = 0.06, p<0.01], indicating that their perceived husband’s support and age

explained 25% of the variance of these women’s problem-focused strategy at post

chemotherapy. Other predictors of the women (anxiety, depression, relationship

satisfaction) and husbands (age, anxiety, depression, perceived providing support,

relationship satisfaction, problem-focused strategy) as well as the general factors

(duration of marriage and duration of breast cancer) did not contribute to this particular

women’s coping model, as shown in Table 8.11 (e) below.

Table 8.11 (e): Stepwise Multiple Regression Analysis of the Problem-focused Strategy of the Women with Breast Cancer Post-Chemotherapy: Women, husbands and General

Factors as Predictors Predictive Factors Model 1

β p Model 2 β p

Women’s Predictors: Age Excluded -0.246 p<0.01 Anxiety Excluded Excluded Depression Excluded Excluded Perceived Husband’s Support

0.440 p<0.001 0.045 p<0.001

Relationship Satisfaction Excluded Excluded Husband’s Predictors: Age Excluded Excluded Anxiety Excluded Excluded Depression Excluded Excluded Perceived Providing Support Excluded Excluded Relationship Satisfaction Excluded Excluded Problem-focused strategy Excluded Excluded General Predictors: Duration of marriage Excluded Excluded Duration of breast cancer Excluded Excluded R Square: (R2 = 0.19***) (R2 = 0.24***) R2 Change (R2 Change = 0.06**) F Statistic:

F (1, 155) = 37.31 F (2, 154) = 26.11

*** p<0.001; ** p<0.01; *p<0.05 β: Standardized Coefficient Beta

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8.4.4.1 Summary of the Results

The women’s problem-focused strategy was predicted by two factors - their age

and perceived husband’s support. Other predictors of the women such as anxiety,

depression and relationship satisfaction, as well as the husbands’ age, anxiety,

depression, perceived providing support, relationship satisfaction and problem-focused

strategy did not predict the women’s problem-focused strategy. It is important to

highlight that all the general factors proposed in this study (duration of marriage and

duration of breast cancer) were demonstrated as not predictive of the women’s

problem-focused strategy. Thus, it is suggested that the proposed hypothesis of the

study i.e. the women’s problem-focused coping strategy at post-chemotherapy is

predicted by the general factors (duration of marriage, duration of breast cancer), the

women’s factors (age, anxiety, depression, relationship satisfaction, perceived

husband’s support) and the husbands’ factors (age, anxiety, depression, relationship

satisfaction, perceived providing support, problem-focused strategy), almost not in line

with this study’s finding.

Based on the various results reported above, the discussion of these results will

therefore be discussed in the next chapter.

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CHAPTER NINE

DISCUSSION: PART TWO

QUALITY OF LIFE, INTERPERSONAL RELATIONSHIP AND COP ING

STRATEGIES OF THE WOMEN WITH BREAST CANCER AND THEI R

HUSBANDS

In this chapter, the main findings of the study are discussed. The discussion is

divided into three sub-sections, according to the various hypotheses postulated.

9.0 Pattern and Level of Quality of Life, Interpersonal Relationship, and Coping

Strategies of the Women with Breast Cancer and Their Husbands.

Several hypotheses, at both the couple and individual levels, were proposed as

below:

Hypotheses at the couple’s level:

• There are similarities in the patterns of the psychological aspect (anxiety and

depression), relationship satisfaction and coping strategies between the women and

their husbands overtime (prior-to, during and post-chemotherapy); however,

women indicated a higher level of psychological problem (anxiety and depression),

but a better relationship satisfaction, and greater use (higher level) of coping

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strategies as compared to their husbands in all occasions (prior-to, during and

post-chemotherapy).

[In addition to the above hypotheses (at the couple’s level), this discussion also addresses

the specific hypotheses postulated at the individual’s level, i.e. women and their husbands’ level.

More variables were also proposed for the women’s hypotheses: Health Related Quality of Life,

Sexuality (Body image and sexual Attractiveness) and Interpersonal Relationship (perceived

husbands’ support, level of disclosure, helpfulness of disclosure, empathy, holding back and

withdrawal). Similarly, more variables were proposed for the husbands’ hypotheses: Sexuality

(views on their wives’ body image and sexual attractiveness) and Interpersonal Relationship

(perceived providing support, level of disclosure, helpfulness of disclosure, empathy, holding back

and withdrawal)].

Therefore, in the next paragraph, the discussion is focused on the pattern of quality

of life, interpersonal relationship and coping strategies of the women and their husbands in

facing breast cancer. The discussion also emphasizes on the level of the psychosocial

aspects, which include the quality of life, interpersonal relationship and coping strategies

among the couples in confronting breast cancer and its treatment.

The hypothesis, which stated that patients experienced more psychosocial effects

when compared to their husbands, was proven by the findings of this research. This is in

line with many past researches, be it in the aspects of quality of life, interpersonal

relationship or coping strategy (e.g. Ben-Zur et al., 2001; Douglass, 1997; Northouse and

Swain, 1987). This condition is acceptable because it is obvious that women are the ones

who have to undergo chemotherapy, not their husbands. However, at the same time,

515

husbands can not be absolved from experiencing the effects, due to the critical situation of

the patients.

The results of this research are almost similar with the hypothesis of the research

which stated that the quality of life, interpersonal relationship and coping strategies of the

women and their husbands were affected by the phases of their treatment or certain periods

of time after the breast cancer surgery. The current research showed that the period during

chemotherapy as the most critical phase for the women suffering from breast cancer and

their husbands, as most aspects of their quality of life were shown to be affected. On the

contrary, their interpersonal relationship was improved during chemotherapy, the finding

which is similar to the ones gathered for the coping strategies, i.e. the patients and their

husbands were indicated as placing more emphasis on confronting with the crisis during

the treatment. This is also in line with the finding of several past research, which proved

the deterioration in the patients’ quality of life (e.g. Ozyilkan et al., 1998; Payne, 2002),

the importance of interpersonal relationship (e.g. Hilton et al., 2000) and coping strategies

(e.g. Zabalegui, 1999) in the phase of chemotherapy treatment for breast cancer. In this

study, the results of the different phases of the treatment (prior-to, during and post-

chemotherapy), which imposed different effects on the quality of life, interpersonal

relationship and coping strategy of the patients and their husbands, showed that:

1) Firstly, most aspects of the patients’ quality of life were found to decline, from

prior-to chemotherapy phase to during chemotherapy phase, but they were

improved after chemotherapy.

2) Secondly, the interpersonal relationship, between the patients and their husbands

was improved or became better the during the chemotherapy phase, as compared to

516

prior-to chemotherapy. However, the interpersonal relationship quality was found

to decline at post-chemotherapy phase.

3) Thirdly, more effort and focus was given to coping with the treatment, from the

prior-chemotherapy up to during-chemotherapy phase, which was shown to

decrease at post-chemotherapy.

A general conclusion which can be drawn from this situation is that most aspects of

the patients’ and their husbands’ quality of life, interpersonal relationship and coping

strategy are critical for their quality of life, improving interpersonal relationship and

increasing the focus for coping strategy, from prior-to chemotherapy phase right to during-

chemotherapy phase. An improvement in the patients’ quality of life and a decline in their

interpersonal relationship and coping strategy were also shown at post-chemotherapy.

To explain this situation, the philosophy of “Eliciting Meaning” (Degner et al.,

2003) and “Experience Perspective” (Jansen et al., 2005) are applied, as follows:

(1) Most aspects of quality of life of the women with breast cancer and their husbands were

found to decline during chemotherapy, but they improved after the treatment.

Rationally, the patients suffered from the short-term effects of chemotherapy during

this treatment, such as headaches, feeling unwell, dry mouths, nausea and vomiting,

fatigue and hair loss (National Institute of Health Consensus Development Conference

Statement Adjuvant Chemotherapy for breast Cancer, 1986). These usually happened

a few days at a time after every treatment (six cycles). However, after the sixth cycle

of chemotherapy, patients were able to adapt themselves to the negative effects of the

treatment. This adaptation contributed to the positive effect of the patients’ global

health status and their husbands. In the current study, this adaptation could be related

517

to the philosophy of “Elicit Meaning” (Degner et al., 2003) and “Experience

Perspective” (Jansen et al., 2005), as illustrated in Figure 9.0. According to Degner et

al., 2003), women who viewed breast cancer as a challenge or value would have

positive effects on their psychological aspect as compared to those who did not. The

philosophy of “Elicit Meaning” suggests that patients and their husbands practice

comparative process, life re-evaluation and life re-ordering. The comparative process

is where one has to deal with one’s own health and others close to them; thus, the

women evaluated the other hurdles which they had overcome before. These hurdles

might include other important events such as death, divorce, abusive situations or

serious problem in raising children. By describing these challenges, the women

indicated that the problems they had dealt with so far, as more important than their

breast cancer. Beside that, the women and their husbands also viewed breast cancer as

a ‘value,’ on which they re-evaluated their own lives. The most important factor in the

re-evaluation is taking into account how they relate themselves to God. Religion or

spirituality is a focus which leads these women and their husbands to view everyday as

precious. Although they were found to express it in different ways (such as expressing

each day as a bonus or trying to make each day count), the concept of life as precious

was central to these women. Among other things, breast cancer was also seen as a

‘challenge’. In this context, the women and their husbands performed ‘life re-ordering’

where the priority in their lives was re-ordering. They also made changes in their

interaction with others. By becoming more openly expressive in their interaction, the

women expressed that this had improved their relationships with their husbands and

other family members. In addition, they also believed that they had developed more

understanding and compassion towards others who were experiencing illnesses. As a

consequence of re-ordering, the women also spent more time focusing on themselves

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519

and what they wanted to do in a shift of priorities. The women shifted their focus to

their interests instead of material things. This adaptation process caused the women (as

well as their husbands) to be less passive, more assertive and confident and thus, they

obtained a better global health at post-chemotherapy.

(2) Conforming to the philosophy of “Elicit Meaning” could also explain the fluctuating

pattern of the interpersonal relationship aspect, which occurred along the course of

chemotherapy treatment, faced by the women with breast cancer (as well as their

husbands). These women indicated that the quality of their interpersonal relationship

became better during the during-chemotherapy phase as compared to pre-

chemotherapy and post-chemotherapy phases. Nevertheless, the quality was found to

decline at post-chemotherapy; this could be due to the adaptation of the patients and

their husbands in viewing breast cancer, i.e. as either a value or a challenge, where they

then applied the comparative process, life re-evaluation and re-ordering.

(3) Meanwhile, in the aspect of coping strategy, the philosophy of “Elicit Meaning”

could be used to explain the fluctuating pattern, where more focus was placed on

coping with the crisis of the treatment during the chemotherapy phase. Nevertheless,

this changed (decreased) during the post-chemotherapy phase. This is also a

manifestation of the comparative process, life self re-evaluation and re-ordering

actions.

The philosophy of “Experience Perspective,” as forwarded by Jansen et al. (2005),

also explains the adaptation actions by the patients and their husbands during-

chemotherapy phase to the post-chemotherapy phase. This philosophy, which is based on

520

the Theory of Planned Behaviour by Ajzen (1991), where the attitude towards certain

behaviour is based on the beliefs about the likelihood of the outcomes of that particular

behaviour and the evaluation of these outcomes, suggests that inexperienced patients (in

this study, “inexperienced patients” are referred to as the patients who were in during the

treatment phase) do not have a favourable attitude towards the treatment, as compared to

the experienced patients (in this study, “experienced patients” are those patients who were

in the post-chemotherapy phase). Similarly, according to Jansen et al. (2005), the beliefs

were different between the experienced and inexperienced patients with regards to the

likelihood and evaluation of the potential outcomes of the treatment. Another theoretical

perspective, which may also be accountable for this adaptive behaviour from the during-

chemotherapy to post-chemotherapy phases, is the Dissonance Reduction Theory

(Festinger, 1957). In this theory, dissonance (also referred to as inconsistency) is a

situation where an individual is motivated to try to reduce the inconsistency and achieve

consistency while living under psychological discomfort. In relation to this situation, as

indicated by Taylor et al. (1984), breast cancer patients might adapt to their situations by

cognitive, information and retrospective control, where they looked at others who were

worse off or by thinking about the positive aspects of their experiences, and focusing on

what they had scored well on. This is related to the crisis intervention model by Aguilera

and Messick (1974) which outlines that the factor such as “acceptance” has been found to

be important in order to be successful in overcoming the crisis. Here, acceptance is related

to the pain of the bereavement and destruction of part of the personality. Women and their

husbands also used what Taylor termed as ‘the process of self-enhancement’ (Taylor,

1983). This is a cognitive process where the patients compare themselves to the less

fortunate ones in order to feel that they are better off. Thus, where there is a threat to one’s

sense of control and self esteem, there are also a number of cognitive adaptations which

521

may allow one to psychologically cope in a situation such as breast cancer. Jensen et al.

(2000) are also of the opinion that women, who feel that they are in the period of ‘nearness

to death,’ are inspired to live in a valuable life, experiencing life more intensively, learning

to live more fully and appreciating life more completely. This is also in line with

Tominaga’s (1995) opinion that patients could control the situation by changing their

attitude; it is agreed that the aspects of quality of life, interpersonal relationship and coping

strategy of the women and their husbands are different during-chemotherapy and post-

chemotherapy phases, whereby this is in accordance with their evaluation on breast cancer,

which is certainly due to the change in their attitude and cognitive appraisal.

It is also felt that the period of approximately twenty weeks after surgery (after the

sixth cycle of chemotherapy) would give enough information to the patients to handle their

situation. According to Johnston and Vogele (1993), the information (such as procedural

information and behavioural instruction) may benefit the post-operative recovery.

Meanwhile, according to Ransom et al. (2005), those who reported more positive changes

in their physical quality of life were those who had reported to seek more information

about their illnesses. Beside that, it was also reported that the discussion about breast

cancer would normally decrease when the patients were outside the medical setting or

when their treatment had ended (Shapiro et al., 1997). This statement reflects that the

aspect of interpersonal relationship is less when the treatment has ended. Meanwhile, the

setting outside of the medical environment gives a more positive effect on the

psychological aspect of the patients, in which they do not think of the burden due to the

treatment they receive. In accordance to this scenario, a previous review on the crisis and

coping literature found that following the life crisis, three majors categories of positive

outcomes were identified (Schaefer and Moos, 1992); these are increased social resources,

increased personal resources and new approach in coping skills.

522

In relation to the issue of quality of life, Hoskin and Haber (2000) found facts

which supported the results of this research; these had a possibility in giving effects on the

psychological aspect of the patients, and their global health status, in which patients were

found to be concerned most frequently about their future, the possible recurrence of cancer

and their long-term prognosis, three months after diagnosis. Furthermore, several studies

found that the patients’ life quality deteriorated during the cancer treatment (Berger and

Far, 1999; Bernhard et al., 2004), and gradually improved after that (Ganz, 2004; Ozyilkan

et al., 1998). Other findings, such as by Dorval et al. (2005), suggested that the experience

of being ill and undergoing treatment could bring the patients and their spouses closer; the

fact which could also be used as a support for the findings of the current study. In addition

to this, the sense of marital closeness was found to increase at three months after diagnosis,

where breast cancer patients reported to receive more tenderness and affection from their

spouses. The facts proposed by Dorval could be used to explain the reason for the

improved interpersonal relationship aspect of breast cancer patients and their husbands

during chemotherapy as compared to prior-to and post-chemotherapy.

The phase during chemotherapy treatment is critical to a larger part of the women’s

quality of life. However, this treatment phase gives an advantage to the aspect of marital

relationship, i.e. it improves their relationship by elevating efforts in coping and

adjustment to overcome the crisis of breast cancer. As hypothesized, women with breast

cancer and their husbands showed almost a similar pattern of psychosocial morbidity

(quality of life, interpersonal relationship and coping strategy).

523

9.1 The Effect of Medical Factors (Types of Surgery and Stages of Breast Cancer)

and Selected Bio/Socio-demographic Variables (Menopausal Status and Ethnicity)

on the Quality of Life, Interpersonal Relationship and Coping Strategies of the

Women with Breast Cancer and Their Husbands

In this section, several hypotheses at the couple and individual’s levels are

proposed as below:

Hypotheses at the couple’s level:

• Medical factors (types of surgery and breast cancer stages) and selected bio/socio-

demographic aspects (ethnicity and menopausal status) have a significant effect on

the couples’ psychological aspects (anxiety and depression), relationship

satisfaction and coping strategies.

[In addition to the above hypothesis (the couple level), the discussion also addresses the

specific hypotheses postulated at the individual level: women and their husbands’ levels. More

variables are proposed for the women’s hypotheses: Health Related Quality of Life, Sexuality

(body image and sexual attractiveness) and Interpersonal Relationship (perceived husband’s

support, level of disclosure, helpfulness of disclosure, empathy, holding back and withdrawal).

Similarly, more variables are proposed for the husbands’ hypotheses: Sexuality (view on their

wives’ body image and sexual attractiveness) and Interpersonal Relationship (perceived providing

support, level of disclosure, helpfulness of disclosure, empathy, holding back and withdrawal)].

Based on the hypothesis of the study, aimed to evaluate the effect of medical

aspects (the surgical type and stages of breast cancer) and the selected bio/socio-

524

demographic factors (menopausal status and ethnicity), it was found that the medical

factors were not as vital as the selected bio/socio-demographic factors, in terms of the

psychosocial effects of breast cancer. In more specific, the discussion on the effects, as

stated above, is given below:

9.1.1 The Effect of the Medical Factors (Types of Surgery and Stages of Breast

Cancer) on the Quality of life, Interpersonal Relationship and Coping

Strategies of the Women with Breast Cancer and Their Husbands

As mentioned in the earlier section, the medical factors (the surgical type and

stages of breast cancer) were not found to be important in affecting the pattern of the

patients’ psychological aspect, relationship satisfaction and the coping strategy at the

couple’s level (interaction between the women and their husbands). In more details, the

types of breast cancer surgery did not impose much impact on these women’s life quality,

interpersonal relationship and a major part of their coping strategies. This situation is

almost similar to the one gathered in the previous research, i.e. they did not find the types

of surgery as one of the major factors contributing to the women’s psychosocial morbidity

(e.g. Bleiker et al., 2000; Ganz et al., 1992b; Monteiro-Grillo et al., 2005; Onen-Sertoz et

al., 2004). On the contrary, this study discovered that the types of surgery influenced the

views or perception of the women on their body image; this is in line with the findings of

other studies (e.g. Bukovic et al., 2005; Hartl et al., 2003). In the aspect of coping,

nevertheless, a number of strategies were found to be influenced by the types of surgery

(planning and using instrumental support), where women who went through lumpectomy

operation indicated to use more of the “planning” and “instrumental support” as compared

to those had mastectomy operation. The explanation to such a situation could be found in

525

the previous research which revealed that women who had gone through lumpectomy

might be more concerned about the recurrence of breast cancer, as compared to those who

had mastectomy (Arora et al., 2001; Bartelink et al., 1985; Fallowfield et al., 1986). Thus,

this might affect the “planning” and “using instrumental support” strategies of the patients

who went through lumpectomy.

A similar situation was also be found among the women’s spouses or husbands,

whereby the types of surgery did not affect the husbands’ psychological aspect,

interpersonal relation and coping strategies. Nonetheless, in the coping strategies of the

husbands of the women who had lumpectomy, they were found to engage in a more

“positive reframing” strategy as compared to those husbands of the women with

mastectomy. This was probably due to their susceptible feelings towards the recurrence of

breast cancer to their wives (e.g. Arora et al., 2001; Bartelink et al., 1985). On the other

hand, the husbands of the women who had mastectomy did not indicate susceptible

feelings because they might have thought that the cancer had entirely been removed from

their wives’ body. Similar to the situation of these women, their husbands were also found

to be influenced by the types of surgery. This coincides with to the findings of the

previous research which revealed the significant issue of body image after breast cancer

surgery (e.g. Margolis et al., 1990; Schou et al., 2005; Yeo et al., 2004).

This analogous situation was also found for the factor involving breast cancer

stages, whereby it was demonstrated that this particular factor did not play any important

role in affecting the aspect of quality life, interpersonal relationship and coping strategies

of the women with breast cancer and their husbands. Interestingly, it was surprising to

discover that breast cancer stages did impose any influence on the way these patients’

husbands viewed their wives’ body image. In this regard, the husbands whose wives were

diagnosed with stage three of breast cancer indicated a worse view on their wives’ body

526

image as compared to the husbands whose wives were diagnosed with stage two of breast

cancer. This situation is rather sensible as various stages of breast cancer can impose

different impacts on the husbands’ views on their wives’ body image.

9.1.2 The Effect of Selected Bio/Socio-demographic Factors (Menopausal Status

and Ethnicity) on Quality of life, Interpersonal Relationship and Coping

Strategies of Women with Breast Cancer and Their Husbands

In this study, the analysis conducted at the couple’s level indicated that ethnicity

was essential in influencing the relationship satisfaction and coping strategies of the

women with breast cancer and their husbands. However, this was found to be different for

the menopausal status, whereby this factor was observed to affect only the women and

their husbands’ coping strategies (most coping strategies), but not their relationship

satisfaction. Meanwhile, the menopausal status and ethnicity of the patients were

demonstrated to be not influencing the couples’ psychological aspect. In relation to this,

the current research also found that several aspects of quality of life (such as emotional

functioning, fatigue, and pain, body image, sexual functioning, future perspective, as well

as breast and arm symptoms) were affected by the patients’ menopausal status. For this,

pre-menopausal women were found to suffer, following the deterioration of their life

quality as compared to post-menopausal women. Hence, it was suggested that such a

difference might be due to the factor of age, i.e. between the pre-menopausal women and

the post-menopausal women [the age of the pre-menopausal group was statistically

different from the post-menopausal group: t (145) = 14.34; p<0.001]. This finding is

similar to the results of the previous research which indicated that the elder group of

patients had a better quality of life as compared to the younger group (e.g. Kenefick, 2006;

527

Kroenke et al., 2004). The finding of the current study is also in agreement with the

opinion by Carr et al. (2001) who suggest that “health expectation” plays a major role in an

individual’s health status, i.e. it is influenced by their self-appraisal. This also means that

the women in the elder group did not indicate a high expectation on the standard of their

health (as compared to younger group) when they receive the medical treatment related to

the age factor. Such low expectation causes the elder group to be easily contented with

any result of their medical treatment. This situation can be clearly distinguished from the

younger group of patients because their expectation towards their own health is relatively

higher. Therefore, the negative results of their medical treatment will definitely bring

negative effect to their appraisal of life’s quality.

Aging factor can be another reason why post-menopausal women indicated to have

a better quality of life than those in the pre-menopausal group. Based on the example from

a bowel cancer study, aging is observed to be negatively associated with the feeling of

“worry” about the development of the cancer (Collin et al., 2000). Furthermore, women in

the older group did not perceive cancer as enemy, punishment, weakness or irreparable

loss as compared to those in the younger group who were going through pre-menopausal

stage (Degner et al., 2003).

Surprisingly, the psychological and sexuality aspects of the patients’ husbands were

found to be not affected by the women’s menopausal status at all. In relation to this, it was

suggested that gender of the patients and their spouses could be the important factor which

influenced on the way the couples adapted to their health situations and responded to the

stress created by the illness (Peleg-Oren et al., 2003; Hagedoorn et al., 2000).

In terms of their interpersonal relationship, the patients’ need for their husband’s

support (husband’s support as rated by the patients or the husbands) was influenced by

their menopausal status. Pre-menopausal women were found to crave for more of their

528

husbands’ support than the post-menopausal women. It is also true that the pre-

menopausal women’s husbands (as rated by the husbands themselves) provided more

support to their wives, as compared to the husbands of the post-menopausal women.

These findings are comparable to that of other researchers (e.g. Seeman and Syme, 1987)

which proved the effect of age on the aspect of social support. There is also a finding

which reveals the association between aging and the decrease in the negative sentiment

(Guilford and Bengston, 1979). The finding of the present research is also similar to the

result of other study which proved that the difference between the pre-menopausal and

post-menopausal women was due to the difference in terms of the health expectations

between the younger and older people (Carr et al., 2001).

Meanwhile, in terms of their coping strategies (women: active, planning, positive

reframing, using emotional support, using instrumental support, self distraction, denial,

venting, self-blame; husbands: active, planning, positive reframing, religion, using

emotional support, using instrumental support, self-distraction, denial, venting), the same

situation could be observed where the pre-menopausal group (either the patients

themselves or their husbands) showed a higher level of coping than the post-menopausal

group (either the patients themselves or their husbands). This finding is in relation to

various factors such as health expectations (Carr et al., 2001) and perceptions of the

stressfulness of cancer (Dunkel-Schetter et al., 1992). The passive element in the coping

strategies employed by the women in the post-menopausal group was in line with the ones

documented by Cameron and Horsburgh (1998) who observed that older women were less

confident in seeking initial treatment, and they were also more likely to assume a passive

role in making decisions concerning their treatment. This situation might also be

associated with the life of the elderly, who were found to place lesser concerns over the

finances and work as compared to the younger women (Wang et al., 1999). However, both

529

the post-menopausal and the pre-menopausal groups (either the patients themselves or their

husbands) did not display any difference in terms of “acceptance” and “behavioural

disengagement” toward breast cancer. This shows that the women in the post- and pre-

menopausal groups (either the patients themselves or their husbands) have the same

attitude towards breast cancer. They may have accepted the reality of breast cancer in their

lives and taken the incident as a useful experience. Moreover, they may also have faced

their cancer crisis without any attitude of defeat.

However, the pre-menopausal patients demonstrated a stronger sense of “self-

blame” as compared to the post-menopausal women. Nonetheless, the “self-blame”

strategy (in which patients criticize and blame themselves for what has happened) seemed

to be insignificant when it came to their husbands. Thus, it was proposed that gender

might influence the social role of the women and their husbands (e.g. Hagedoorn et al.,

2000; Peleg-Oren et al., 2003). In relation to the gender factor, it was noted that women

always reacted to their situation more severely, and they frequently blamed themselves for

what was happening than men did (Ptacek et al., 1992).

Ethnicity was found to have little influence on the quality of patients’ life.

However, attention should be given to significant findings on several aspects of quality of

life in relation to patients’ ethnicity (pain, sexual functioning, future perspective, systemic

therapy side-effects and arm symptoms). The differences in the quality of life among the

Malay, Chinese and Indian ethnic groups were quite likely to be related to their respective

health traditions (Ariff and Beng, 2006). For instance, the understanding of the sources of

diseases is based on three different perspectives in the Chinese culture, namely ‘Ch’i’, ‘Yin

Yang’ and ‘Wu-hsing’. Ch’i is understood as a vital force that moves through the 12 main

channels in the human body. In this regard, an individual’s well-being is believed as a

consequence of the normal flow of ‘Ch’i’, and thus, the obstruction on any of the channels

530

can cause disease. ‘Yin Yang’ is a symbolic power which explains the phenomena of ‘hot

and cold’ in the human body. Meanwhile, ‘Wu-hsing’ is a traditional health belief which

relates human organs with the nature. For example, liver is associated with wood, heart

with fire, spleen with earth, lungs with metal, and kidneys with water. In the Chinese

culture, a perfect health is thought to be achieved when there is unobstructed ‘Ch’i’ flow

and a well-balanced ‘Yin-Yang’ in accordance with the five elements in the human body.

Dietary changes, traditional medicine, herbs and medical practices (coining, cupping,

pinching, steam baths, inhalation, balming and moxibustion) are among the ways which

have been used to restore balance. On the contrary, a different understanding of health is

adopted by the Indian community. The health system that they understand is known as

Ayurveda, which means ‘knowledge of life’. It concerns with three main things - Vata,

Pitta and Kapha; whereby, these three elements are known as ‘dosha’. Every

characteristic of the elements is symbolized in a dosha: space, air, fire, water and earth.

These elements represent the different organs of the body, and the equilibrium between the

dosha is perceived as a state of health and disease which occurs when there is a state of

imbalance.

The effect of ethnicity on the quality of the women with breast cancer might also be

observed indirectly. This is specifically referring to the different ideas of death among the

different ethnic groups. The Chinese honour spoken words and it is believed that talks of

death will invite an earlier death. They also go to a great length in ensuring that

individuals will die at home, as they believe that the soul of the deceased inhabits the site

of death (Berger, 1998). In the meantime, the Hindu and Buddhist devotees (Hinduism is a

religion which is largely followed by the Indians, whereas Buddhism is largely followed

by the Chinese) observe the life of reincarnation, where a person is thought to die and

reborn with a different identity, depending on their deeds. In the perspectives of the

531

Christians and Muslims (a small proportion of the Chinese and Indians in Malaysia are

Christian devotees; whereas Islam is a religion which is followed by the Malays), death is

viewed as a single occurrence; it is thought that the faithful decease will continue on (in the

form of spirit) in heaven (their reward) while the sinners will suffer in hell. In certain

religions, the characteristic of “affirming” in the understanding of death can influence an

individual’s well-being (Gire, 2002).

Generally, the findings of the current research showed that the quality of life of the

Chinese superseded those of the other ethnic groups. This finding is similar to a study

conducted on multi-ethnicity in Singapore (Thumboo et al., 2003); in that study, the

Chinese are indicated to have a better quality of life as compared to the Malays and

Indians. Other than the differences in the health philosophies among the ethnic groups, it

can be likened to opinions expressed by Lam and Fielding (2001) that the Chinese culture

gives utmost importance to staying healthy and keeping an ‘undamaged body’.

Other facts which could be relied on are the influence of ethnicity on the perception

of ‘susceptibility’ and ‘seriousness’ toward breast cancer among the Chinese and Indians.

The Chinese women showed a higher level of ‘susceptibility’ and ‘seriousness’ as

compared to the Indian women (Wu et al., 2006). Another factor which might have

contributed to the fact, that Chinese women have a better life’s quality than other races

(Indian and Malay), is the different proportions of the ethnic groups in the pre- and post-

menopausal groups. In this study, it was found that the proportion of the pre-menopausal

women was higher among the Malay and Indian ethnic groups as compared to the Chinese

[Malay (63%, n=49), Chinese (26%, n=13) and Indian (70%, n=21)]. As discussed in the

earlier sub-section, the pre-menopausal group of women was found to be experiencing the

psychosocial effects of breast cancer much more than those in the post-menopausal group.

532

Due to this fact, it was believed that the difference, in the quality of life among the

different ethnic groups, was partly caused by the menopausal status of these women.

Similarly, the ethnicity of these women was found to influence most of the

patients’ coping strategies such as active, planning, positive reframing, acceptance, using

emotional support, self-distraction and venting. In this study, the Malays and Indians

showed higher coping strategies than the Chinese. This was probably due to the lower

quality of life indicated for the Malays and Indians, as compared to the Chinese. Although

somewhat controversial from the previous findings, with regard to the association between

the patients’ coping strategies and quality of life (e.g. Fletcher et al., 2006; Kim et al.,

2003), it was suggested that the patients who were experiencing a decline in their quality

of life tended to put in more efforts in overcoming the crisis. This indirectly enabled them

to have high coping strategies in the midst of the declining quality in their life.

However, ethnicity was found to play a very minimal role among the husbands’

coping behaviour (venting, using emotional support, religion, positive reframing and

acceptance) as compared to the patients themselves (active, planning, positive reframing,

acceptance, using emotional support, using instrumental support, self-distraction, venting).

This difference was suggested to be caused more by the gender factor rather than the

cultural factor (e.g. Baider et al., 1995; Kessler and McLeod, 1985). According to Kessler

and McLeod (1985), women reacted more strongly than men during unfavourable events

which occurred in their lives. The differences in the coping strategies, between the women

with breast cancer and their husbands, were also related to the way they viewed or

evaluated these unfavourable events. As indicated by Ptacek et al. (1992), women rated

their situation as more severe than men and more often blamed themselves for their

difficulties. This difference was also associated to the fact that men appraised themselves

as having more control over their lives than women did (Lefcourt, 1981; Pearlin and

533

Schooler, 1978; Wheaton, 1980). Perhaps, the most consistent gender-related difference in

coping behaviour is the greater tendency of the women than men in seeking social support

from others (Ptacek et al., 1992; Rosario et al., 1988; Stone and Neale, 1984; Thoits,

1991). This is parallel to the finding by Cutrona (1996) who indicated that women always

seek counsel and comfort from other persons when they encounter stressful events. In the

current study, the differences in the coping strategies between the women with breast

cancer and their husbands could also be in the aspect of emotional expression. This fact is

supported by Gottlieb and Wagner (1991) who suggested that women usually have intense

emotions related to their family members’ suffering, as compared to men who are more

impassive. This situation could also be due to the different strategies used by men and

women in dealing with their emotions. Men usually control their emotion through

physical-related activities such as exercises, sports, drinking and smoking (Rosario et al.,

1988; Thoits, 1991). Furthermore, men are also associated with the characteristic of

withdrawal in their response to the situation, as compared to women (Repetti, 1989;

Rosario et al., 1988). On the contrary, women usually respond to the situation by directing

their expression of feeling such as talking to another person or writing about their emotions

(Stone and Neale, 1984; Thoits, 1991). As it was found among the women, the husbands

of the women with breast cancer from the Malay and Indian ethnic groups showed better

coping strategies as compared to the Chinese; the fact which is related to their quality of

life, as explained in the earlier sub-section.

Selected bio/socio-demographic factors, like menopausal status and ethnicity, were

found to be influential on the psychosocial aspects (quality of life, interpersonal

relationship and coping strategies) of the patients and their husbands. On the other hand,

the medical factors, such as the types of surgery and breast cancer stages, were indicated as

not important.

534

9.2 Factors Predictive of the Women’s Global Health Status, Sexual

Attractiveness, Relationship Satisfaction and Coping Strategies

For this particular section, the discussion is based on the hypotheses proposed in

the previous chapter (Chapter Four). Thus, in the subsequent paragraphs, this elaboration

is further divided into five sub-sections on the findings of the study.

9.2.1 Factors Predictive of the Global Health Status of the Women with Breast

Cancer

The hypothesis proposed that:

• The women’s factors (higher age, less anxiety, less depression, higher level of

relationship satisfaction), the husbands’ factors (higher age, less anxiety, less

depression, higher level of relationship satisfaction), and the general factors (the

longer the duration of marriage, the longer the duration of breast cancer) are factors

predictive of the better global health status of the women with breast cancer post-

chemotherapy.

By examining the factors related to the women, their husbands and general factors

as predictive factors of the women’s global health status, it was indicated that only the

women’s psychological factors were found to be influential on the health status. Based on

this finding, this research could not completely prove the hypothesis which stated that the

global health status of the women could be predicted by the women’s factors (age, anxiety

535

and depression, relationship satisfaction), husbands’ factor (age, anxiety, depression,

relationship satisfaction) and general factors (duration of marriage and duration of breast

cancer). Although the global health status of the women was indicated as affected by their

psychological factors, depression was revealed to be the only predictive factor on the

global health status of the women; hence, anxiety was not vital. This could be caused by

the patients’ appraisal of their global health status, which was more influenced by the

elements of depression (like the state of loss of interest and decreased pleasure response)

rather than the elements of anxiety, such as anxious mood, feeling of restlessness and

anxious thoughts (Zigmond and Snaith, 1983). This is also similar to the report by

Wellisch (1988) and Petty and Noyes (1981), as quoted by Moyer and Salovey (1996), that

the loss of interest, feelings of worthlessness, diminished ability to concentrate, recurrent

thoughts of suicide and death, extreme irritability, and sleep disturbances were the key

symptoms of depression which might be considered as purely psychological in breast

cancer patients.

The result of this study is also in line with the one found by Newman et al. (1994),

i.e., individuals with major depressive episodes tend to have a greater burden of stressful

life events than those with general anxiety disorder. In addition to this, Sneeuw et al.

(1992) also stated that the physical changes and functioning were of lesser importance for

the psychological adjustments of the patients with breast cancer compared to their concerns

over the recurrence of disease and future health. This finding suggests that the

psychological elements are far more important in influencing the quality of life for the

patients with breast cancer as compared to their physical elements.

The relationship satisfaction (as rated by both the breast cancer patients/women and

their husbands) was not predictive of their global health status; this result contradicts with

the ones found in the previous research (e.g. Lewis et al., 1993; Pistrang and Barker, 1995;

536

Stroud and Turner, 2006). This situation probably indicated that the patients and their

husbands did not give priority to the aspect of relationship satisfaction as they were both

too busy concentrating on the outcome of the breast cancer treatment. This finding is

almost similar to the one gauged by Hodgson et al. (2003), whereby, no connection was

found between the psychological aspect and disengaged statements of the couples with

breast cancer.

Meanwhile, the psychological aspect of the patients’ husbands was also found to be

not predictive of the women’s global health status. One could speculate that the aspect of

the women’s health might largely be affected by their own psychological state (i.e.

depression) and not by others such as their husbands’.

[Note: The predictive factors of age, duration of marriage and breast cancer would be discussed

together in the final sub-section as all these factors were observed to be insignificant for the

women’s global health status, sexual attractiveness and relationship satisfaction].

9.2.2 Factors Predictive of the Sexual Attractiveness of the Women With Breast

Cancer

The hypothesis proposed that:

• The higher positive view on sexual attractiveness of the women with breast cancer

post-chemotherapy is predicted by the general factors (the longer the duration of

marriage, the longer the duration of breast cancer), the women’s factors (higher age,

less anxiety, less depression, less menopausal symptoms, better global health status,

higher level of relationship satisfaction, less negative view on body image) and the

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husbands’ factors (higher age, less anxiety, less depression, higher level of

relationship satisfaction, less negative view on wives’ body image, and less negative

view on wives’ sexual attractiveness).

The factors of women (age, anxiety, depression, menopausal symptoms, global

health status, relationship satisfaction and body image), husbands (age, anxiety,

depression, relationship satisfaction, view on wives’ body image and view on wives’

sexual attractiveness) and the general factors (duration of marriage, duration of breast

cancer) were proposed as predictive of the women’s sexual attractiveness. It was found

that women’s anxiety, views on their body image, husbands’ views on their wives’ body

image and sexual attractiveness were predictive of the women’s sexual attractiveness.

When compared to depression, the women’s anxiety was found to be related to their sexual

attractiveness. This could be due to the fact that sexuality is influenced by anxious mood,

restlessness and anxious thoughts. This is almost similar to what Moyer and Salovey

(1996) proposed in their study, i.e. that possibly mood-related factors and not physical

mutilation which had caused sexual dysfunction followings mastectomy. In addition to

this, the relationship between the psychological aspect and the loss of the breasts was noted

when women who went through modified radical mastectomy were found to suffer more

distress as compared to those who had cholecystectomy for gall bladder and biopsy for

benign breast disease (Psychological Aspects of Breast Cancer Study Group, 1987). This

is also in line with the opinion of Schover (1986) who stresses that among all the

psychological factors leading to sexual problems in the cancer patients, the most common

ones are stress and anxiety. Friedman and Chernen (1987), Frued (1938) and Masters and

Johnson (1970), as quoted by Edelmann (1992) suggested that anxiety played a crucial role

in the sexuality problem which could prevent the satisfaction and enjoyment in the sexual

538

activity. This is also similar to the finding by Master and Jonhson (1970), as quoted by

Edelmann, (1992) who pointed out that anxiety could interrupt the sexual stimuli and

inhibit the psychological response, leading to sexual dysfunction. In addition, Holmberg et

al. (2001) reported that the psychological distress could be caused by the feelings of

shame, loss of dignity, embarrassment about their body changes, low self-esteem, and the

difficulty of looking at their bodies, as well as the guilt which stemmed from the belief that

they had somehow brought the illness to themselves. This is also in line with what

McKinney and Sprecher (1991) found in their study, i.e. the sexuality difficulties which

some couples encountered (referring to the case of the breast cancer in this study) could be

the result of the feeling of anxious because of their fear of intimacy, concerned about the

partner’s commitment to the relationship or fear of rejection. The feeling of anxiety,

among the breast cancer patients, could be contributed by their uncertainty about the

partners’ expectation and how to initiate physical intimacy. Similarly, the relationship

between the women’s anxiety and the loss of their breasts was also connected to the

women’s view on their breast cancer. In this study, the breast cancer patients’ level of

anxiety was found to be significantly lower for those who viewed breast cancer as a

challenge or a value, compared to the women who held on to the negative aspect of this

disease at the follow-up assessment (Degner et al., 2003).

As expected, the women’s views on their body image as well as their husbands’

views on their wives’ body image and sexual attractiveness are predictive of the sexual

attractiveness of these patients. This finding stresses the importance of body image change

and the husbands’ view towards the women’s sexuality. According to Yurek et al. (2000),

women who indicated more negative impressions about their sexual self, in relation to the

loosing of their breasts, were more apt to engage less in their sexual activities and be

vulnerable to the heightened body changes stress, as well as difficulties in the sexual

539

responsiveness. Lower sexual arousal and greater sexual embarrassment and negativity

were common characteristics of the women with negative schema (Yurek et al., 2000).

Similarly, Holmberg et al. (2001) indicated their agreement that the symbols of sexuality

and attractiveness (such as wearing feminine clothes and having long hair, which are the

core features of women’s self identity) were no longer considered as possible. The results

of this study also supported the finding by Andersen and Jochimsen (1985) who proposed

that female cancer patients exhibited disruptions in their sexual activity and arousal.

Among others, headaches, feeling unwell, experiencing problem with dry mouths, nausea

and vomiting, fatigue and hair loss (National Institute of Health Consensus Development

Conference Statement Adjuvant Chemotherapy for Breast Cancer, 1986) could cause

negative effects on the women’s sexual attractiveness and appearances, which further

affect the husbands’ view on their wives’ sexuality. In addition to these, chemotherapy

treatment has been found to cause intermittent vaginal irritation during the treatment and

several weeks after. In relation to this, symptoms related to sexuality are commonly

experienced such as hot flashes, reduced libido, dryness and atrophy of the vagina and

vulva, as well as the fragility and thinness of the mucosa in vagina (Holmberg et al., 2001;

Hordern, 2000). The situations described above were suggested to disrupt the sexual

relationship between the women and their husbands; thus, explaining the importance of the

husbands’ or spouses’ views as predictive of the women’s sexuality. The importance of

the husbands’ (or partners’) factor as predictive of the women’s sexuality was also

indicated by Holmberg et al. (2001) who found that the sexual desires, among the male

partners of the patients in their study, were found to decrease following breast cancer.

Another study indicated that the breast cancer patients’ husbands reported the need for

information on intimacy and sexuality (Woloski-Wruble and Kadmon, 2002).

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Unexpectedly, the results of this study did not reveal relationship satisfaction (be it

of the women or their husbands) as predictive of the women’s sexuality. Nevertheless, this

was not surprising as the sexual aspects sometimes could not predict the relationship

satisfaction. This fact was proven and supported by Leiber et al. (1976) who found and

suggested that cancer patients needed more comforting and reassurance from their spouses,

rather than sexual stimulation. Moreover, an increase in the desire for sexual intercourse,

after cancer diagnosis, was less reported as compared to the wish for more physical

closeness (Leiber et al., 1976). One could argue that breast cancer is not a chronic illness

that is solely based on sex and sexual satisfaction only, hence it does not cause marital

breakdown as stated by other researchers (e.g. Dorval et al., 1999; Dorval et al., 2005).

Woloski-Wruble and Kadmon (2002) are among other researchers who put forward the

argument which shows that sexuality does not necessarily connect to the aspect of

interpersonal relationship; instead, they state that husbands rated their marriage as ‘happy’

and ‘very happy’ even if they had sexual problems at the time (i. e. changes in libido,

sexual interest, and sexual functioning) in relation to their wives’ breast cancer. Another

relevant finding points out that the exact satisfaction with relationship is developed from

the element of love, interdependence, trust and commitment (Cutrona, 1996). These seem

to suggest that there is a possibility that sexual attractiveness and relationship satisfaction

are not necessarily dependent on each other, whereby the relationship satisfaction itself has

covered the broad meaning which does not merely focus on sexual attractiveness. This is

also proven by Iwao (1993) and Kondo (1980) who found a difference in the sexual issues

between the Asian and the Western people. They observed that American women raised

sex-related topics more often as compared to Japanese women; similarly they expected a

lot more from their marriage, while the Japanese women put less emphasis on the sexual

and romantic aspects of their marriage.

541

Other predictive factor which could not be proven by the model of the women’s

sexual attractiveness is the psychological aspect of the husbands. This situation is

acceptable because, perhaps, the psychological aspect of the husbands tends to be related

to the potential loss (death) of their wives due to breast cancer and not to the aspect of their

wives’ sexuality, as also noted by Holmberg et al (2001). Beside that, Mantani et al

(2007) found that the husbands’ psychological aspect (i.e. anxiety) had no significant

relation to their wives’ psychological aspect (i.e. anxiety), explaining why women’s

anxiety is predictive of their sexual attractiveness, as compared to their husbands’ anxiety.

The insignificance of menopausal symptoms and global health status of the women as

predictive of their sexual attractiveness could be explained by the loss of their breasts, and

not by other elements (such as global health, menopausal symptoms, etc.). This means that

the issue of sexuality (in the case of breast cancer) is unique, in which it is not related to

the women’s appraisal of their health status (be it from the aspect of functioning or

symptomatology).

[Note: The predictive factors of age, duration of marriage and duration of breast cancer are

discussed together in the final sub-section as all these factors have been observed to be

insignificant for the women’s global health status, sexual attractiveness and relationship

satisfaction].

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9.2.3 Factors Predictive of the Relationship Satisfaction of the Women With Breast

Cancer

The hypothesis proposed that:

• The higher relationship satisfaction (with their husbands) of the women with breast

cancer post-chemotherapy is predicted by the general factors (the longer the duration

of marriage, the longer the duration of breast cancer), the women’s factors (higher

age, less anxiety, less depression, higher perceived husband support, higher level of

disclosure, higher level of empathy, higher level of helpfulness of disclosure) and the

husbands’ factors (higher age, less anxiety, less depression, higher level of

relationship satisfaction, higher level of perceived providing support, higher level of

disclosure, higher level of empathy, higher level of helpfulness of disclosure).

In this study, it was found that the women’s factors (i.e. depression, perceived

husband’s support, empathy and helpfulness of disclosure) and the husbands’ factors

(relationship satisfaction and perceived providing support) were predictive of the women’s

relationship satisfaction. In particular, women’s depression was found to predict their

relationship satisfaction with their husbands, just as the women’s depression predicted

their global health status. This finding suggests that the women’s relationship satisfaction

is affected by the symptoms of depression (such as the loss of interest and a decreased

pleasure response). The connection between “depression, health status and relationship

satisfaction” could be related to the bio-behavioural model which stated that an

individual’s health could be affected by the positive emotions resulting from a close

543

relationship with the spouse (e.g. Pistrang and Barker, 1995), whether directly (e.g.

alterations in the functioning of the central nervous system, immune, endocrine and

cardiovascular systems) or indirectly (e.g. through better health behaviors or compliance

with medical regimens) (Kiecolt-Glaser et al., 2002; Andersen et al., 1994). Andersen et

al. (1994), in their approach to the bio-behavioural perspective, added that an individual

who was involved with the events characterized by the interpersonal component, had a

greater alteration of the natural killer cell activity. The finding of this study is also similar

to the research by Leiber et al. (1976) who indicated that breast cancer patients suffering

from depression exhibited symptoms such as openly expressing their fears, worries, needs

and desires. The prediction of the women’s perceived husband support, empathy and

helpfulness of disclosure, as well as their husbands’ relationship satisfaction and providing

support (on the women’s relationship satisfaction) was expected. This discovery had also

been emphasized by Manne et al. (1999b) who stated patients might look more at the

positive aspects of cancer and its treatment when they perceived greater support from their

spouses. In other words, women with breast cancer might look at their situation more

positively when they received support and encouragement from their spouses. Dorval et

al. (2005) also support the finding of this study, i.e. spouse provided tangible support to the

patients in the forms of tenderness and affection. This is also similar to opinion of others,

which suggested that the spouse went through difficult times by communicating concerns,

reassurance, understanding and willingness to help (Cutrona, 1996), which then fostered

intimacy and closeness with the patients. The prediction of their interpersonal support, on

the women’s relationship satisfaction, was also noted by Dorval et al (2005), who stated

that the sense of marital closeness increased after the women were diagnosed with breast

cancer. Responses such as giving advice to the patients, accompanying the patients for

their consultations, and showing tenderness and affection were found to be the source of

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interpersonal support which brought the couples together. However, this situation was

found to be different for couples’ empathy and helpfulness of disclosure. It was

demonstrated that women’s empathy and helpfulness of disclosure were predictive of their

relationship satisfaction; nevertheless husbands’ empathy and helpfulness of disclosure

were to be not predictive.

The husbands’ psychological aspect was found to be not predictive of the women’s

relationship satisfaction. Perhaps, gender-related difference in the social and instrumental

roles could be a rational reason to explain this situation, i.e. it might influence the way the

couples adapted to their situations (e.g. Hagedoorn et al., 2000; Peleg-Oren, 2001). In

relation to the gender factor, men were observed to attain more benefits from the marital

relationship on their physical health (Berkman and Syme, 1979), whereas, women were

more likely be concerned with the quality of marriage (Gove et al., 1983; Husaini et al.,

1982). Moreover, this can also be related to the fact that the association between the

mental health and marital satisfaction is stronger for women than men (Gove et al., 1983;

Husaini et al., 1982). The role of gender was also proposed by Weihs et al. (2002) who

emphasized that the dynamics of the family system, their cultural norms and the social

context in which the family is embedded, might influence the subjective perception of the

association between the family support and the spouses’ psychological distress, which

differed among males and females. In addition, the husbands’ psychological aspect (which

did not predict their wives’ relationship satisfaction) was not surprising at all because there

had been studies in the past which discovered that it was not predictive of ‘getting closer’

to the patients (e.g. Dorval et al., 2005). It was also speculated that the husbands’

psychological aspect was more influenced by the fear of the patients’ death (due to cancer)

rather than by the aspect of relationship satisfaction (Holmberg et al., 2001). In explaining

why women’s depression was predictive of their relationship satisfaction (whereas,

545

husbands’ depression was not), Mantani et al. (2007) elaborated that there was a possibility

of no mutually dependent of psychological aspect between the women with breast cancer

and their husbands, even though it was rare for this to happen.

Surprisingly, the level of disclosure (as rated by both patients and their husbands)

did not predict the women’s relationship satisfaction. Based on this discovery, one could

speculate that the patients had decided not to share all their problems with their spouse, as

compared to the spouse who might prefer to avoid initiating a discussion about the disease

and would rather not talking about it at all for fear of upsetting or distressing the patients

(Halford et al., 2000). Besides, the cultural background of the patients could also affect

the way these women communicated with their husbands. The connection between the

women’s depression, empathy, and helpfulness of disclosure, as important predictors of

their relationship satisfaction could also be seen in a few other studies. For example,

Mantani et al. (2007) demonstrated that insufficient empathic response from the family

member during times of distress might heighten one’s depression. Another instance was

taken from Pistrang et al. (1997) who found that a lack of empathy seemed to be the

characteristic of several unhelpful responses.

[Note: The predictive factors of age, duration of marriage and duration of breast cancer are

discussed together in the final sub-section, as all these factors were observed to be insignificant for

the women’s global health status, sexual attractiveness and relationship satisfaction].

546

9.2.4 Factors Predictive of the Coping Strategy of the Women With Breast Cancer

The hypothesis proposed that:

• The greater use of problem-focused coping strategy of the women with breast cancer

post-chemotherapy is predicted by the general factors (the longer the duration of

marriage, the longer the duration of breast cancer), the women’s factors (higher age,

less anxiety, less depression, higher level of relationship satisfaction, higher level of

perceived husband’s support) and the husbands’ factors (higher age, less anxiety,

less depression, higher level of relationship satisfaction, higher level of perceived

providing support, greater use of problem-focused strategy).

This study demonstrated that only the women’s perceived husband support and the

women’s age were predictive of the women’s coping strategy, while other factors such as

anxiety, depression and relationship satisfaction did not predict the coping strategy of these

patients. This is similar to the husbands’ factors, where all the factors anticipated as

predictive of the coping strategy (age, anxiety, depression, providing support, relationship

satisfaction and coping strategy) were found to be actually not predictive at all. The

discovery of the connection between the women’s problem-focused strategy and their

perceived husband support was anticipated; this finding is in line with the results of past

research which stated that support supplements individual with the capacity to cope with

“problem solving” (e.g. Edgar et al., 2000). In addition, the responses of the spouses

might serve as coping deterrents or coping assistance (Manne, 1999; Manne and Zautra,

1989).

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This finding is supported by Broman (1993) and Umberson (1992) who indicated

that the reduction of risky behaviour and the increase of preventative behaviour might be

contributed by the social ties, such as marriage and friendship (Broman, 1993; Umberson,

1992). In the same vein, the interpersonal support from the spouses, such as the

involvement of the spouses in decision-making concerning matters of their wives’

treatments (e.g. Smitt and Heltzel, 1997) might also contribute to the way of coping in

women with breast cancer. This statement is similar to the finding by Thoits (1986) who

pointed out that “social resources” (could be spousal support) might be helpful for coping

as it could facilitate managing or changing a stressful situation. The finding of the current

research is also in line with the social support theories proposed by Kuuppelomaki (1999)

and Nichols (1995), i.e. social support is important to be conceptualized in enhancing

coping ability in stressful situations. In addition and as indicated in the earlier sub-section,

patients were observed to be more likely to focus on the positive aspects of their cancer

and treatment when they received more support. The patients also might alter their

appraisal of their condition and they faced it more positively with the emotional

encouragement and support from their spouses (Manne et al., 1999b). The main reason of

the need for the interpersonal support, among the women in this research sample, was the

fact that it was rather difficult for these women to maintain the role of a parent during the

cancer treatments. This was mainly crucial for the women with younger children or

teenagers, as they might be exhausted from their treatment and the energy that they would

need to cope with their cancer reduced their capacity for emotionally supporting their

family (Holmberg et al., 2001). Moreover, Holmberg et al. (2001) explained that the

patients in this study, perceived support from their husbands (based on certain actions such

as taking over household chores, i.e. doing the dishes, cooking and cleaning) as providing

instrumental support. Their husband’s support is considered important for these women;

548

these include providing transportation to the clinic and being present during their

consultations with the doctors and the treatment. In addition, husbands may also help their

wives by taking note of the questions to be asked to the staff involved in the treatment, and

making sure that the questions are answered, taking the initiative to record the responses

and to review the findings with their wives.

Nevertheless, the psychological aspect of the women themselves did not affect their

problem-focused coping strategy. This reflects the real situation as the psychological

aspect is more related to the emotion-focused coping strategy than the problem-focused

strategy (e.g. Ben-Zur et al., 2001; Manne and Zautra, 1989). Furthermore, the women’s

relationship satisfaction did not predict their coping strategy. Although this finding

contradicts with the previous findings, it was suggested that the women’s coping strategy

did not depend on their relationship satisfaction with their husbands, but instead on the

interpersonal support from their husbands. In this context, the relationship satisfaction and

interpersonal support from their spouses are not mutually dependant.

It is a little surprising that the women’s coping strategies were not predicted by

their husbands’ factors at all; be it from the psychological aspect, the interpersonal

relationship or coping strategy. In terms of the husbands’ perceived providing support, it

was found to be in opposition with the aspect of the women’s perceived husbands’ support

(in this study, women’s perceived husband’s support was found to be predictive of their

coping strategy). Hence, it was speculated that the patients acknowledged their husbands’

support in coping with the crisis of cancer and its treatments, but at the same time, the

husbands did not feel that they had adequately provided their wives with the required

support in the difficult situations. This could be associated with the factor of gender,

where receiving help (or might be interpreted as receiving support) was indicated to be

closely related to the women than men (Bull and Stevens, 1981; as quoted by Edelman,

549

1984; Edelman 1984). It was also speculated that in certain circumstances, the issue of

helping (or support) was not much crucial for men. Similarly, the husbands’ problem-

focused coping strategy did not predict their wives’ coping strategy. Therefore, it is

suggested that the issue of coping strategy, among the couples in the breast cancer

research, is unique in that, perhaps, patients’ coping strategy is solely predicted by the

factors from their own selves, not by any other individuals (i.e. husbands). Rather similar

to the women’s relationship satisfaction, the husbands’ relationship satisfaction also did

not predict the women’s problem-focused coping strategy. As already discussed in the

earlier sub-section, the coping strategy of the women did not depend on their relationship

satisfaction and those of their husbands’.

The psychological factor, interpersonal relationship and coping strategy of the

husbands, which were not related to the women’s coping strategy, might also be influenced

by their culture. This is to highlight that the difference in the culture, surrounding the

marital issue between the Asian and Western populations, might have influenced the

results gathered in this study. The cultural influences have also been reported by Kagawa-

Singer and Wellisch (2003), where Asian men (as perceived by their women) were

indicated to view their wives as ‘role filler’, comforter and supporter; thus, they did not

treat their beloved spouses as one who needed to be comforted and supported. The major

differences between the Asian and Euro-American men, in relation to this study, could be

found in terms of expressing needs and obtaining supports. In particular, Asian men were

indicated to find support from other persons (if they needed it), rather than their wives, or

they would just keep it to themselves. This is obviously different among Euro-American

men who were found to be more direct in their expression of needs. The differences

between the Asian and Euro-American populations could also be observed through their

social network. In the Euro-American culture, husbands or men are usually the place for

550

women who crave for support, whereas in the Asian culture, husbands are not ranked as

the most important person in seeking for support. In addition to the above differences, the

pattern in the marital communication could also be affected by the cultural factor; in

which, this is another point explaining why there was a difference finding obtained in this

study as compared to the western context (Kagawa-Singer and Wellisch, 2003). As stated

in the earlier sub-section, in relation to cultural difference, and based on the example taken

from Kagawa-Singer and Wellisch (2003), Asian men (as perceived by their women) were

expected to have harmony rather than intimacy in the couple relationship, the fact which

contradicted the Euro-American population. Yet another fact which should be taken into

consideration pertaining to this situation, is the sexual issue among the Asian and non-

Asian populations. Based on the examples given by Meston et al. (1998), the Asian

population living in Canada held more conservative sexual attitudes and had less

knowledge in the sexual issues as compared to the non-Asian Canadians. Similarly, the

Asian population was also reported to have lower level of communication with their

doctor, pertaining to issues surrounding sexual behaviour and risk prevention (Schuster et

al., 1996).

[Note: The predictive factors of age, duration of marriage and duration of breast cancer are

discussed together in the final sub-section, as all these factors were observed to be insignificant for

the women’s global health status, sexual attractiveness and relationship satisfaction].

551

9.2.5 Age, Duration of Marriage and Duration of Breast Cancer as the Factors

Predictive of the Women’s Global Health Status, Sexual Attractiveness,

Relationship Satisfaction and Coping Strategy

The age of both the breast cancer patients and their husbands was not found to be

predictive of the women’s global health status, sexual attractiveness and relationship

satisfaction. However, the women’s age was observed as a predictive of their problem-

focused strategy.

In this study, age was found to be an insignificance factor on various dependent

variables, may relates to the unique situation during the treatment (for this discussion, the

author classified ‘post-chemotherapy’ as the treatment phase where patients had just

completed six sessions of chemotherapy. In addition to this phase, these patients had to

continue with the radiotherapy treatment (after four weeks of rest), following the

chemotherapy treatment).

Both the durations of marriage and breast cancer after diagnosis were indicated as

not predictive of the women’s global health status, sexual attractiveness, relationship

satisfaction and coping strategy. This might be related to the uniqueness of the

chemotherapy treatment itself, where almost all the dependent variables (women’s global

health status, sexual attractiveness and interpersonal relationship) were influenced by the

women’s psychological factors (anxiety and depression), but not by their socio-

demographic factors (age and duration of marriage) and the medical factor (duration of

breast cancer).

However, the relationship between the age of the women and the problem-focused

coping strategy during the treatment might be true, particularly in attaining information

about coping with breast cancer. For this, Avis et al. (2005) explained that younger

552

women seemed to be more in need for information about the psychological abnormalities

emerging from breast cancer and were less satisfied with the information they received.

The rationality behind the association between the age and problem-focused strategies was

also indicated by Compas et al. (1999) who stated that the older patients engaged in a more

adaptive way of coping as compared to the younger ones. On the contrary, older women

were found to be more passive during the decision making for their treatment, leave the

decision making to their doctors, and more hesitant in seeking out for initial treatment

(Cameron and Horsburg, 1998). This situation might also be due to the fact of the older

women’s life, in which they demonstrated less concerns over finances and work as

compared to the younger women (Wang et al., 1999).

As predicted, psychological factor is important in predicting the quality of life,

sexuality aspects and the relationship satisfaction of the women with breast cancer.

Meanwhile, interpersonal support and age are major factors in predicting their coping

strategy. Women’s empathy, helpfulness of disclosure and perceived husband’s support

are the most significant predictors for the women’s relationship satisfaction. Similarly,

husbands’ view on their wives’ sexuality, their relationship satisfaction and perceived

providing support, are concluded to be crucial factors in predicting their wives’ sexuality

and relationship satisfaction, respectively.

9.3 Limitations of the Study

There are several limitations to this study which should be taken into consideration,

such as the sample randomization. The selection of the cases (women with breast cancer

and their husbands) in this study was not done randomly; it should be cautious in terms of

the representative on the population of women with breast cancer. This non-randomization

553

of the sample selection was because a few cases of the breast cancer which met the

inclusion criteria of the current study. However, this sampling method is accepted and has

widely been applied in other related cancer research, in order to meet the sample size

required for the study (e.g. Ben-Zur et al., 2001; Wimberly et al., 2005; Yeo et al., 2004).

Other constraints lie in the location of the current research, which focused only on the

government hospitals [Kuala Lumpur General Hospital (KLGH), Kuala Lumpur,

Malaysia) and semi-government hospitals [University of Malaya Medical Centre

(UMMC), Kuala Lumpur, and the Hospital Universiti Kebangsaan Malaysia, Kuala

Lumpur]. This could also have affected the representative of the sample as most of the

patients seeking treatment at these hospitals are those from the lower to middle socio-

economic class. Most patients from the higher socio-economic class usually seek

treatment for cancer from private hospitals (among others, Cancer Institute in Nilai, Negeri

Sembilan, Malaysia) which are known to offer high-class medical services. This further

caused the research sample to be non-representative for the whole population of the cancer

patients from the higher socio-economic background.

Another limitation, in relation to the context of this research, is the aspect of

interpersonal relationship. It was suggested that the situation of the women’s marital

relationship, before the diagnosis of breast cancer, should be given attention due to its

possibility in affecting the marital situation at post-diagnosis of breast cancer. However, in

this research, their marital situation before the diagnosis of breast cancer was not evaluated

as the methodology of the study was only designed for the treatment phases following the

breast cancer surgery. This could have also influenced the findings in terms of the

interpersonal relationship aspect of the women with breast cancer and their spouses.

554

Therefore, the sample representativeness, geographical location of the hospital

selected and the methodological issue should be addressed and considered in interpreting

the findings of this study.

Based on this discussion, the conclusions and implications of the study will be

discussed in the final chapter (Chapter 10).

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CHAPTER TEN

CONCLUSIONS AND IMPLICATIONS

This study has highlighted several important findings in relation to breast cancer

and its psychosocial aspect. The major discovery of this research is that chemotherapy for

breast cancer treatment was found to negatively affect the many aspects of the patients’

(women’s, as well as their husbands’) quality of life. On the contrary, the psychosocial

crisis, resulting from the chemotherapy treatment of breast cancer, has enabled breast

cancer patients to become closer with their husbands. This crisis has also caused these

women and their husbands to opt for or devise more strategies in their effort to overcome

the psychological and social problems due to breast cancer. Nevertheless, it is important to

highlight that these psychosocial effects were found to be more often felt and suffered by

the patients rather than their spouses, in this study.

Another finding of this research, which is crucial in the field of oncology, is that

the medical factors (types of breast cancer surgery and stages of breast cancer) do not have

much effect on the psychosocial aspect of the women and their spouses, as compared to the

bio/socio-demographic factors (menopausal status and ethnicity).

In line with its contribution to the current practice of oncology, the patients’

psychological state was found to be of importance in predicting their global health status,

sexual attractiveness and relationship satisfaction. In specific, women’s depression is

predictive of their global health status and relationship satisfaction, whereas their anxiety is

predictive of their sexual attractiveness. In addition, women’s perceived husband’s

support and helpfulness of disclosure were observed to be of importance to attain

satisfaction in their relationship. Nonetheless, the husbands’ psychological factors

556

(depression and anxiety) were found to be of no importance to their wives’ global health

status, sexual attractiveness, relationship satisfaction and coping strategy. In terms of the

sexual attractiveness of the patients, it was found that their views (women and their

husbands’) on the body image, were predictive of these women’s sexual attractiveness.

Other than that, the husbands’ views on their wives’ sexual attractiveness were also

indicated as predictive of their wives’ sexual attractiveness.

Furthermore, the study also revealed that the women’s relationship satisfaction was

not predictive of their global health status, sexual attractiveness and coping strategy. The

same is also true for the husbands, where their relationship satisfaction was indicated as

not predictive of their wives’ global heath status, sexual attractiveness, coping strategy and

relationship satisfaction. However, it was found that the husbands’ relationship

satisfaction could be used to predict the relationship satisfaction of their wives. In other

words, the husbands’ relationship satisfaction is closely related to the satisfaction of their

wives in their relationship.

In reference to the relationship satisfaction of the women with breast cancer,

women’s helpfulness of disclosure and their empathy was also found to be another

important predictor in the current study. This, on the contrary, is different from the

empathy and helpfulness of disclosure of the husbands, whereby both these factors were

not able to predict their wives’ relationship satisfaction.

In term of the level of disclosure (as rated by women with breast cancer and their

husbands), this aspect did not predict the women’s relationship satisfaction (with their

husbands) at all.

In this study, the husbands’ support (as rated by the patients and their husbands)

was found to be an important predictor of the women’s relationship satisfaction. However,

557

it was found that the breast cancer patients’ perception of their husband’s support (as rated

by the women) was the only predictive of their coping strategy.

Among the medical and bio/socio-demographic variables, the age of these women

was indicated as an important predictor for their problem-focused coping strategy.

Meanwhile, the menopausal status and ethnicity of the patients might also play essential

roles in these women’s psychosocial aspect (as well as their husbands’) in relation to breast

cancer.

Therefore, several implications are put forward, based on the findings of this research:

1. Every hospital which provides chemotherapy treatment should hold “chemotherapy

education” sessions for breast cancer patients as not every hospital provides it. At the

moment, only University of Malaya Medical Centre (UMMC) is offering this

education class for their breast cancer patients (as well as their family), prior to the

chemotherapy treatment. However, it is aimed only at the practical aspects of and

teaching the patients the work process involved (i.e. how to come for their

chemotherapy treatment, get the blood tests done, knowledge on the side-effects of the

treatment, etc.), but this is not a psychological support programme. Thus, it is

suggested that, besides giving detailed explanations on the treatment, this education

should aim to benefit patients in terms of reducing their psychological deterioration

due to the treatment. For these reasons, it is therefore proposed that psychologists

should take part in the chemotherapy education as they play major roles in helping

breast cancer patients and their family members, particularly in preparing them for

impairment of quality of life during chemotherapy.

558

2. Doctors and paramedics (e.g. nurses, counsellors, and non-government organizations)

have to be more exposed to and be updated with the current psychosocial issues

concerning breast cancer. This is especially so with counsellors and the counselling

module, so as to meet the psychosocial needs of the patients. Hence, it is crucial to

encourage them to actively take part in any programs, workshops, seminars and the

like, which are related to breast cancer whether in or outside the country, in order to

render a better service for breast cancer patients and their immediate family members.

3. Besides patients with breast cancer, special attention should also be given to their

family members, particularly their spouses. Spouses of breast cancer patients should

be encouraged to get themselves involved in the consultation and treatment sessions

which are attended by their wives. This is to ensure that the spouses will be able to

provide the necessary support needed by their wives in dealing with either the disease

or the treatment. It was clearly indicated in the findings of the study, i.e. patients

perceived that they needed support from their husbands in coping with breast cancer.

Thus, it is suggested that a specific training program be implemented for the spouses of

breast cancer patients. For instance, special program modules and comprehensive

training sessions should be provided to train breast cancer patients’ spouses to become

good supporters to their wives.

4. An “Information Resource Centre” for breast cancer and its treatment should be setup

in every hospital as not every hospital provides it. This centre could be a place for the

patients to obtain updated information pertaining to all aspects of breast cancer.

5. The findings of this study could be used as a model for the implementation of any

future health programs related to breast cancer in Malaysia, especially in rural areas

where women tend to present with late stages of breast cancer. Therefore, support

from family members especially spouses is critical for them.

559

6. Future researchers are encouraged to delve further into the psychosocial issues of

breast cancer, particularly the ones concerning the treatment phase. Based on the

literature review given in previous chapter, past researchers have given little attention

to the psychosocial aspect of the treatment (e.g. Arora et al., 2001; Ashing-Giwa et al.,

1999; Bergh et al., 2001). This could be due to difficulties which may occur during the

data collection at the treatment phase. The psychosocial data of cancer (in the

treatment phase) is important as references for the health professionals (e.g. doctors,

nurses, counsellors) in administering and managing their patients. Furthermore, studies

on the psychosocial issues of breast cancer should be encouraged, especially among the

Asian population (i.e. Malaysia), as there is still a scarcity of data in this field.

In conclusion, the policies of health institutions (both government and non-

government organizations) are important in improving the quality of life of patients,

particularly patients with breast cancer. Healthcare providers (doctors, nurses and allied

health professionals) are the main source for patients with cancer and their family members

to get information relevant to their treatment and health situation. In other words, they are

the ones who should fully equip themselves with the necessary knowledge.

560

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