Introduction
The incidence of breast cancer is rising and is now one of the most prevalent malignancies in women (W. Chen et al., 2016). Although the number of deaths from breast cancer is increasing, survival rates are rising (Berry et al., 2005). However, patients experience the physical and psychosocial impairments of the cancer diagnosis and systemic adjuvant therapy. Deformation of the breast during the treatment process not only destroys the integrity of the body but also reduces the unique charm of women (Boquiren, Esplen, Wong, Toner, & Warner, 2013). Meanwhile, chemotherapy-induced alopecia affects physical appearance and leads to mental burdens such as depression and social disorder (Choi et al., 2014). These results make it difficult to accept their disability and return to society.
As a second sexual organ in women, breasts play an important role in female bodily beauty. The occurrence of breast cancer not only affects body image but also causes psychosocial stress, including sadness, a sense of inferiority, misery, and shame from treatment (Moreira & Canavarro, 2010). An effective psychological intervention should be developed to assist patients to learn to cope with their physical situation and adapt to their disability (Chin et al., 2005). Disability acceptance is considered a pivotal factor in psychosocial adaptation (Groomes & Linkowski, 2007). Acceptance of disability (AOD) represents a process of change in values that is important for individuals to willingly accept themselves as intrinsically worthy (L. Li & Moore, 1998), which is a major factor in achieving psychological adjustment (Keany & Glueckauf, 1993). Several studies have found a high level of disability acceptance to be an important factor in the adjustment of physically disabled persons to their environments. On the basis of the acceptance of loss theory, Groomes and Linkowski (2007) developed a scale to measure the level of AOD with 32 items, adapted from an original 50-item scale (Wright, 1983). From then on, many studies have used this scale to assess AOD in patients with chronic disease, including survivors of stroke (Chai, Yuan, Jin, & Zhang, 2016), spinal cord injury (Nicholls et al., 2012), brachial plexus injury (N. Chen, Cheng, Sun, & Hu, 2009), and colostomy (Chao, Tsai, Livneh, Lee, & Hsieh, 2010). These results showed that patients with higher disability acceptance had better physical-defect coping behaviors, which promote psychosocial adaptation and rehabilitation. The results indicate that periodic assessment of AOD is necessary for persons with disability during the clinical recovery stage.
According to the literature review, several factors such as positive coping modalities, a higher level of education, and better social relations have been found to predict better AOD (Chiang, Livneh, Guo, Yen, & Tsai, 2015; Morozova, Shmeleva, Sorokoumova, Nikishina, & Abdalina, 2015). However, no published studies address the level of AOD in patients with breast cancer. Meanwhile, differences in AOD may exist among Chinese women with breast cancer. Thus, this cross-sectional descriptive study was designed to (a) evaluate disability acceptance in Chinese women with breast cancer and (b) determine the main variables associated with disability acceptance in this population. To our knowledge, this study is the first to try to determine AOD and its influencing factors in patients with breast cancer in a developing country. It is important to determine the main variables related to AOD to assist the development of interventions that are aimed at promoting AOD.
Methods
Study Design and Sample
This cross-sectional survey study used purposive sampling in the outpatient oncology unit of a teaching hospital in Tianjin to recruit 292 patients from January to April 2017. Inclusion criteria were (a) diagnosis of breast cancer and completion of related surgery, (b) age of 18 years or older, (c) being conscious and able to provide signed consent. Exclusion criteria were (a) history of breast cancer recurrence, (b) significant organ dysfunction, and (c) inability to understand or write Chinese.
Measures
Demographic questionnaire
The demographic variables included age, religion, educational level, marital status, job, income (per month), type of surgery, and time since diagnosis.
Acceptance of disability scale-revised
AOD was measured using the Acceptance of Disability Scale-Revised (ADS-R), a 32-item measure that is designed to assess four dimensions: enlargement of scope of values, transformation from comparative values to asset values, containment of disability effect, and subordination of physique (Groomes & Linkowski, 2007). The ADS-R is scored using a 4-point scale ranging from "strongly disagree" (1) to "strongly agree" (4), with higher scores indicating a higher level of AOD. The "low" acceptance level is 32-64, the "moderate" acceptance level is 65-96, and the "high" acceptance level is 97-128. The ADS-R was translated into Chinese by Chen to assess AOD in patients with brachial plexus injury (N. Chen, 2009), and the Cronbach's [alpha] value was measured as .83. The Cronbach's [alpha] value for the ADS-R in this study was .89.
Medical Coping Modes Questionnaire
The Medical Coping Modes Questionnaire, which has been widely used to assess patient coping patterns, includes 19 items under the three dimensions of confrontation, avoidance, and acceptance-resignation (Wang, Wang, & Ma, 1999). Each item is scored using a 4-point Likert rating that ranges from 1 = never to 4 = very much. In terms of psychometric characteristics, the Cronbach's [alpha] values for the Medical Coping Modes Questionnaire in this study were as follows: confrontation = .803, avoidance = .723, and acceptance-resignation = .742.
Sense of Coherence Scale
This scale was used to investigate the sense of coherence in participants. The scale includes 13 items under the three subscales of comprehensibility, manageability, and meaning, with higher scores representing a higher level of sense of coherence. Each item is scored using a 7-point Likert scale. The Chinese version was translated by Ding, Bao, Xu, Hu, and Hallberg (2012), and the Cronbach's [alpha] value was measured as .76.
Social Relational Quality Scale
The Social Relational Quality Scale was designed by Hou, Lam, Law, Fu, and Fielding (2009) to assess the quality of social relationships in social processes. This 22-item scale is scored using a 4-point Likert scale that ranges from 1 = strongly disagree to 4 = strongly agree. It addresses the three dimensions of family intimacy, family commitment, and friendships, with higher scores representing higher levels of social relational quality. The Cronbach's [alpha] value was measured as .832 in Chinese patients.
Data Collection
The researcher identified eligible patients in a tertiary hospital in Tianjin by reviewing the medical records. The researcher explained the study purpose and the principle of confidentiality and obtained informed consent from all participants. Using uniform instructions, the researcher asked questions item by item and recorded answers objectively. Each survey took 10-15 minutes to complete. Three hundred ten participants were recruited; 18 had more than 30% of data missing from their questionnaires and were excluded from further analysis. Therefore, 292 (94.19%) questionnaires were included in the analysis.
Data analysis
Version 20.0 of IBM SPSS Statistics (IBM, Armonk, NY, USA) was used to analyze data. Descriptive analysis, including mean, standard deviation, and distribution statistics, was performed for the characteristics of participants and for each subscale in the survey. A one-sample t test was carried out to determine whether one or more patient characteristics significantly affected AOD scores. An independent samples t test was employed to compare group differences in terms of total AOD scores. Pearson correlation analysis was conducted to evaluate the correlations among continuous variables. Multiple linear stepwise regression was performed to find the factors influencing AOD among patients with breast cancer. The collinearity analysis of variable inflation factors was used to evaluate the possible multicollinearity effects among AOD predictive variables.
Ethical Considerations
This study was approved by the hospital ethics committee (Reference no. bc2016041) to protect the rights of participants. Participants were notified of the aim of the study and that research participation involved no harm. Patients who were willing to participate in the research completed written consent forms. They were assured of their anonymity and confidentiality.
Results
Participant Characteristics
Participant mean age was 53.24 (SD = 9.37) years. Regarding cancer- and treatment-related variables, 33.6% had been diagnosed for less than 1 year, 38.2% had been diagnosed 1-2 years ago, and 28.2% had been diagnosed 2-5 years ago. In terms of stage at diagnosis, 18.3% were diagnosed at Stage 3; 42.4%, at Stage 2; and 39.3%, at Stage 1. In addition, 25.7% had undergone breast-conserving therapy (BCT), and 74.3% had selected mastectomy.
Most participants were married (n = 242, 82.9%) and unemployed (n = 125, 42.8%) and professed no religious beliefs (n = 226, 77.4%). The largest percentage had educational levels higher than ninth grade (China has 9 years of compulsory education). In terms of income, 132 participants (45.2%) earned below [yen]2,500 RMB (Renminbi) per month, which is the average disposable income for Tianjin residents. In terms of surgery, 74.3% of the participants had undergone mastectomy. Meanwhile, the group differences in marital status were significant (t = 2.633, p = .009), and the AOD scores for participants who chose BCT were significantly higher than for those who chose mastectomy (t = 2.15, p = .032). These data are shown in Table 1.
Acceptance of Disability Scores
The mean AOD score was 79.14 (SD = 8.49). The highest scores among subscales were for "enlargement of scope of values," followed by "subordination of physique," "transformation from comparative values to asset values," and "containment of disability effect." These results are shown in Table 2.
Correlates of Acceptance of Disability
The outcomes in Table 3 suggest that AOD is significantly and positively associated with age, a coping style involving confrontation, and sense of coherence and its dimensions (r = .115-.375, p < .05). AOD was significantly related to social relational quality and its subscales (r = .323-.561, p < .001). Moreover, the results found a significant and negative relationship between AOD and acceptance-resignation (r = -.253, p < .001).
Predictors of Acceptance of Disability
Multiple linear stepwise regression was applied to determine factors that influence the AOD of patients with breast cancer. The results in Table 4 highlight eight predictor variables, including family intimacy, friendships, confrontation, manageability, family commitment, marital status, surgery, and acceptance-resignation that, together, explained 49.1% of AOD. No collinearity issue was found in the model, because the variable inflation factor values were below 10.
Discussion
Scores of Acceptance of Disability and Its Subscales
In this study, the mean (SD) score for AOD in participants with breast cancer was 79.14 (8.49). This score is significantly higher than for survivors of stroke (mean = 74.15; t = 32.73, p < .001; Chai et al., 2016), which may be explained by intergroup differences in terms of physical condition, illness, and individual characteristics. The AOD score in this study is lower (mean = 82.10) than for patients with colorectal cancer (t = -5.96, p < .001; Zhao, Yang, Zou, Qian, & Shen, 2013). This lower score likely reflects a lower degree of acceptance due to physical condition, gender, psychological impairments, and experienced environmental barriers (Zhu et al., 2014).
The subscale with the highest score was enlargement of scope of values. As Wright stated in the acceptance of loss theory, individuals begin to recognize the importance of values other than those related to the disabilities that are presumed to have been lost (Wright, 1983). Simultaneously, the patients are rewarded for their own values and personal achievements in other areas, which reduces the impacts of physical disability and appearance impairment. This dimension is the basis for the transformation of values of the other three dimensions (Keany & Glueckauf, 1993).
Containment of disability effect was the subscale that earned the lowest score in this study. Possible explanations include the following: (a) Once the negative effects of disability are amplified, it may be regarded as a general weakness of the individual, which affects physical functions, emotions, and intelligence. (b) In the traditional society in China, patients experience serious loss and grief caused by disability discrimination (N. Chen et al., 2009). Thus, nurses should remain sensitive to patients with low levels of disability acceptance. Healthcare professionals should focus particular attention on patients with lower scores in the subscale "containment of disability" and assist patients to expand their values in other aspects. Postsurgery interventions should focus on helping patients with breast cancer accept their disabilities and learn how to cope and live with them (Livneh & Antonak, 2005).
Factors Influencing the Level of Acceptance of Disability
The results of this study suggested that the total score for social relational quality and the scores for each of its related subscales correlated positively with AOD, similar to findings by Zhang, Hu, Xu, Zheng, and Liang (2013). Social support from family and friends is one of the interpersonal resources that are helpful in coping with diseases. Theoretical models have determined that social support may function as an antecedent of personal growth by facilitating successful adaptation to diseases (Jim & Jacobsen, 2008). Furthermore, social support may help redefine perceptions about the potential harm of a situation and prevent a situation from being appraised as highly stressful (You & Lu, 2014). In addition, support from the community affords a regular exchange of information and a reduction in isolation, which makes life more understandable and helps patients adapt to their disability. Hence, clinical staff should facilitate the establishment of social support networks for patients with disabilities.
We found that confrontation and acceptance-resignation coping styles were two predictors of disability acceptance. Of these two variables, confrontation coping provided the larger contribution ([beta] = 0.225, p < .001) for predicting disability acceptance among patients. Acceptance-resignation coping was negatively associated with disability acceptance and was a statistically significant predictor ([beta] = -0.136, p = .002) of disability acceptance. The present research revealed that the scores for disability acceptance increased with the level of confrontation. A similar result was found in a previous study (Chai et al., 2016). Facing the reality of physical disability provides opportunities to view changes from different perspectives and to make positive adjustments to deal with diseases (Fu, Xu, Liu, & Haber, 2008; Smedema & Ebener, 2010). Meanwhile, confrontation may help patients understand their disability, alleviate mental stress, and thus achieve positive results such as disability acceptance (Pan, Zhang, & Gao, 2016). The negative association between acceptance-resignation coping and disability acceptance is consistent with previous research findings (Pan et al., 2016). A possible reason is that acceptance-resignation coping encourages patients to pay attention to physical defects and other negative effects of breast cancer. Chinese traditional culture encourages individuals with breast cancer to aspire to be "an excellent wife and kindly mother" with the role of maintaining family harmony (Simpson, 2005). Because they are unable to effectively solve existing problems, they feel uncertain and self-accusatory, which hinders positive patient health behaviors and thus reduces the scores for disability acceptance (Chin et al., 2005). The two coping strategies have different effects on disability acceptance. In the clinical environment, patients should be encouraged to adopt a positive coping style in the face of disability.
The results of this study reveal that patients with higher manageability have a generally higher level of AOD, which concurs with previous findings (Berglund, Mattiasson, & Nordstrom, 2003). According to Wu, sense of coherence may be seen as a part of an individual's way of coping with stressful events (Wu, 2014). A greater capacity for self-management leads patients with breast cancer to seek additional resources to adjust to physical impairment, psychosocial problems, and daily life activities. As Antonovsky stated in the salutogenic model, individuals with high sense of coherence levels will take active steps to adapt to stressful situations (Antonovsky, 1987). Meanwhile, because of changes in body appearance, individuals expect to gain access to resources from others to escape the sorrow and loss that are involved in the acceptance process (J. Li, 2015). It will be necessary to develop effective interventions to improve the level of AOD and manageability.
Furthermore, the findings indicate that marital status is one of the factors that affect the AOD in patients with breast cancer. The AOD of married patients was higher than that of unmarried or divorced patients. Many studies have shown that being in a marital relationship is good for promoting empathic communication and adjusting to physical problems (Scott & Kayser, 2009). The emotional support that married patients receive from spouses buffers the negative emotion caused by disability (Jun et al., 2011). In addition, the companionship inherent in married relationships encourages patients to make life more understandable and to better acclimate to the current situation. Thus, a marital relationship should be considered a protective factor that buffers the adverse effects of disability.
Surgery type was identified as an independent predictor of disability acceptance in this study. Participants who had undergone mastectomy experienced higher levels of breast-specific concerns such as reduced sense of beauty, feelings of decreased attractiveness, and changes in appearance and sexuality, than did patients who chose BCT (Xue & Li, 2015). Meanwhile, the BCT patients had better cosmetic results and body image and fewer surgery-induced complications (Kim et al., 2015). Future studies may focus on the relation between body image and disability acceptance. Healthcare staff should provide adequate information at the time of surgery, which may affect AOD.
Limitations
There are several limitations to this study. First, only one hospital was used as the site of investigation. A multicenter survey will be necessary to extend the validity of the conclusions to the wider clinical practice environment. Second, the study used a cross-sectional approach. The factors that affect disability acceptance are dynamic, with different impacts at different stages. Thus, prospective and longitudinal studies should be conducted to examine the factors affecting AOD in patients with breast cancer over time. Third, the quantitative framework used in this study provides limited information regarding disability acceptance. Further qualitative research should be conducted to explore the meaning of disability acceptance and identify stimuli and inhibitors of disability acceptance in patients with breast cancer in the Chinese cultural context.
Conclusions and Implication
Survivors of breast cancer who participated in this study had "moderate" acceptance of their disability. Many factors were found to influence disability acceptance, including marital status, surgery, manageability, confrontation, acceptance-resignation, family intimacy, family commitment, and friendships. The results indicate that an effective psychological intervention model should be developed based on a theoretical foundation comprising different dimensions of the acceptance of loss theory and AOD predictors.
Relevance to Clinical Practice
In clinical practice, ward teams should pay special attention to patients with low disability acceptance scores and should organize support activities that involve family members, patient peers, friends, and clinical staff. Furthermore, nurses should take measures such as cognitive intervention (N. Chen, 2009), as appropriate, to improve disability acceptance. In addition, nurses should provide cognitive behavior therapy and group counseling to encourage patients to adopt positive coping strategies to relieve the posttraumatic stress response and return to society as soon as possible. Finally, study results suggest productive directions for further research and provide practical insight for the development of intervention programs in the future.
Acknowledgments
The authors gratefully acknowledge the assistance of the individuals who participated in this study.
References