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Effects of couple based coping intervention on self-efficacy and quality of life in patients with resected lung cancer
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Patient Education
Effects of couple based coping intervention on self-efficacy and quality of life in patients with resected lung cancer Hong-Lin Chena , Kun Liub,* , Qing-Sheng Youb a b
School of Nursing, Nantong University, Nantong City, Jiangsu Province, PR China Department of Thoracic Surgery, Affiliated Hospital of Nantong University, Nantong City, Jiangsu Province, PR China
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 July 2016 Received in revised form 19 June 2017 Accepted 3 July 2017
Objective: We aimed to assess the couple based coping intervention (CBCI) for self-efficacy and quality of life in patients with resected lung cancer, compared with individual coping intervention (ICI). Methods: From October to December 2015, 132 consecutive patients with resected lung cancer who were married/lived in a stable relationship were randomly assigned to the ICI group and the CBCI group. Results: The CBCI group had higher GSES compared with the ICI group at 2 month after operation, and at 6 month after operation (P < 0.05). The CBCI group had higher VT, SF, RE, and MH score of SF-36 compared with the ICI group at 2 month after operation, and at 6 month after operation (P < 0.05), but no significant differences were found in RP, PF, BP, and GH score of SF-36 compared between two groups (P > 0.05) in these 2 time points. Conclusion: Couple based coping intervention is more effective than individual coping intervention for improving the self-efficacy and the quality of life in patients with resected lung cancer. Practice implications: Practitioners might like to consider using couple based coping intervention strategy to improve self-efficacy and quality of life in patients with resected lung cancer. © 2017 Published by Elsevier Ireland Ltd.
Keywords: Lung cancer Couple based coping intervention Individual coping intervention Self-efficacy Quality of life
1. Introduction Lung cancer is the most common cancer in the world. According to GLOBOCAN estimates, about 1.8 million new lung cancer cases occurred in 2012 world widely, accounting for about 13% of total cancer diagnoses [1]. Surgical resection remains the single most consistent and successful option for early-stage lung cancer [2,3]. After surgery, stage I patients have the best survival with an average of a 71% 5-year disease specific survival, 60% of stage II patients will die during this period, and stage IIIA patients had a still worse prognosis with an average 5-year specific survival of only 24% [4]. More and more patients with resected lung cancer acquired prolonged postoperative survival. However, lung cancer survivors may suffer postoperatively from permanently reduced long-term quality of life (QOL) [5,6]. Retaining a good quality of life is of increasing importance and interest for lung cancer survivors [7]. Self-efficacy is the extent or strength of one's belief in one's own ability to complete tasks and reach goals. Many studies have found
* Corresponding author at: Department of Cardiothoracic Surgery, Affiliated Hospital of Nantong University, Xi Si Road 20# Nantong City, Jiangsu Province 226001, PR China. E-mail address: [email protected] (K. Liu).
self-efficacy was related with quality of life in patients with cancer, intervening to improve general self-efficacy for patients with cancer may improve their quality of life [8–11]. Recently, some of the randomized controlled trials assessing psychosocial intervention and self-efficacy-enhancing intervention were conducted in patients with cancer. Lee et al. reported a web-based program that targets changes in exercise and dietary behaviours had overall improvements in dietary quality, physical functioning and appetite loss (HRQOL) for breast cancer survivors [12]. Zhang et al. found the nurse-led self-efficacy enhancing intervention was effective in promoting self-efficacy and psychological well-being in patients with colorectal cancer [13]. Chambers et al. reported a multimodal supportive care intervention effectively promoted regular physical activity, and improved disease-specific and health-related QoL for prostate cancer survivors [14]. Buffart et al. reported a 12-week group-based exercise intervention imporved QoL, which was mediated by increased physical activity, general self-efficacy and mastery, and subsequent reductions in fatigue and distress [15]. However, these programs were all individual coping interventions. The patients with cancer also need for caregiving and emotional assistance from their spouses, and the spouses are generally the primary informal caregiver for cancer patients [16]. However, previous study showed that spousal caregivers of cancer patients perceived both negative and positive experiences in their
http://dx.doi.org/10.1016/j.pec.2017.07.002 0738-3991/© 2017 Published by Elsevier Ireland Ltd.
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coping throughout the cancer trajectory [17]. Therefore, we hypothesized that couple-coping intervention for cancer patients would significantly improve self-efficacy and quality of life compared to patient-coping intervention. We also found couplecoping intervention has not been reported in the resected lung cancer patients. The purpose of this paper is to verify this hypothesis and report the feasibility of couple-coping intervention for patients with resected lung cancer.
2.3. Recruitment and randomization From October 2015 to December 2015, patients with resected lung cancer in our hospital were enrolled in our study. Patients were randomly assigned to the CBCI group and the ICI group. Simple randomization was accomplished by computer generated random number. Allocation was performed by third party personnel uninvolved in recruitment. 2.4. Interventions in two groups
2. Patients and methods 2.1. Study design This is a prospective, randomized, controlled intervention trial evaluating couple based coping intervention (CBCI) compared with individual coping intervention (ICI) for self-efficacy and quality of life in patients with resected lung cancer. The study design was approved by the Ethics Committee of our hospital. All patients or their partners gave written informed consent. 2.2. Eligibility criteria and exclusion criteria Eligibility criteria were: (1) patients with resected lung cancer; (2) lung cancer was initial diagnoses and not combined with other cancer; (3) age 18 years; (4) the life expectancy >6 months after surgery; (5) currently married, and their partners have ability to take care of them. Exclusion criteria were: (1) single, divorced, or widowed patients; (2) married, but their partners lived separately; (3) partner cannot reported their self-efficacy and quality of life, such as illiterate or psychological disorder; (4) not willing to participate CBCI or ICI.
All patients received 3 coping training sessions that were held at admission (before surgery), 2 months after discharge, and 6 months after discharge. The mean in hospital time after surgery was 9 1 day. In the ICI group, patients received cognitive intervention, behavioral intervention and psychological intervention. (1) Cognitive intervention: patients were educated the knowledge about lung cancer surgery, postoperative chemotherapy and postoperative radiotherapy; educated the knowledge about complications after surgery, chemotherapy and radiotherapy; educated about nutrition-related knowledge, including the basic principles of diet, and common eating problems; also educated the knowledge about common postoperative problems, including loss of appetite, nausea, vomiting, diarrhea, constipation, and insomnia. (2) Behavioral intervention: patients were educated how to take medication; how to establish good sleep habits; recommended exercise program, such as walking, climbing stairs and playing with the children and so on, for 6 to 7 days a week, each time carried out in three 10 min. (3) Psychological intervention: patients were educated how to adopt an active coping style; assisted to identify and challenge negative cancer-related cognitions; managing common concerns associated with lung cancer treatment.
Fig. 1. Flow of participants through each stage of the trial.
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In the CBCI group, patients received similar contents to ICI, which also included cognitive intervention, behavioral intervention and psychological intervention. Differently, they were couple based coping intervention. The patient's partners were asked: (1) also to attend the coping training sessions, and to learn knowledge about lung cancer; (2) accompany patients over 3 h a day, accompany patient walks more than 0.5 h a day; (3) understand patient's psychological changes, and help patients to adopt an active coping style. All of the 3 coping training sessions were held by a full-time nurse. Most of them were one to one training. But if two or more patients or couples came in at the same time, group-based trainings were used. All patients or couples received a handbook guiding them to train. 2.5. Outcomes The primary endpoints were self-efficacy and quality of life. These outcomes were assessed at 3 time points before 3 coping training sessions. 2.6. Instruments Self-efficacy was assessed by the General Self-Efficacy Scale (GSES). GSES is a 10-item psychometric scale that is designed to assess optimistic self-beliefs to cope with a variety of difficult demands in life. Each item is scored from 1 (not at all true) to 4 (completely true). The summary score ranges from 10 to 40, with the highest score indicating high self-efficacy. In samples from 23 nations, Cronbach’s alphas ranged from 0.76 to 0.90, with the majority in the high 0.80 s [18,19]. Quality of life was assessed by the 36-item Short Form Health Survey (SF-36). The SF-36 is a brief self administered questionnaire that generates scores across eight dimensions of health: physical functioning (PF), role limitations due to physical problems (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitations due to emotional problems (RE), and mental health (MH). Items are rated with respect to the individual’s experience over the past 7 days. Scores range from 0 to 100, with higher scores indicating better quality of life and functioning. The SF-36 has been shown to be both reliable and valid, with internal consistency coefficients exceeding 0.70 for all scales [20]. 2.7. Statistical analyses GSES and SF-36 scores in two groups were compared by repeated-measures analysis of variance. If sphericity could not be assumed, a Huynd-Feldt correction was used to produce a more critical F-value. Post-hoc tests were analyzed via student t-tests. We also conducted power analysis by outcome of GSES at 6 month. P < 0.05 was considered significant. Statistical analyses were performed using SPSS statistics software (version 19.0, IBM, Armonk, NY), and power analysis were performed using PS Power and Sample Size Calculations (Version 3.0, Copyright © 1997–2009 by William D. Dupont and Walton D. Plummer.) 3. Results 3.1. Baseline characteristics of participants From October 2015 to December 2015, 132 patients were enrolled in this trial. A recruitment and randomization flow chart is shown in Fig. 1. One patient assigned to the ICI group and eight patients assigned to the CBCI group withdrew immediately after
3
Table 1 Baseline characteristics of study participants by randomized group. Characteristics
CBCI (n = 58)
ICI (n = 65)
t/x2
P
Age Gender Male Female Smoking status Nonsmoker Smoker Type of lung cancer NSCLC SCLC Stage I II III Type of surgery Pneumonectomy Lobectomy or wedge resection Postoperative chemotherapy Yes No Postoperative radiotherapy Yes No
60.1 8.8
61.2 8.9
0.688 0.261
0.493 0.609
40 18
42 23 0.218
0.640
31 27
32 33 0.125
0.723
47 11
51 14 0.531
0.767
3 10 45
5 9 51 0.419
0.517
9 49
13 52 0.611
0.435
49 9
58 7 0.587
0.411
7 51
11 54
NSCLC: non-small cell lung cancer; SCLC: small cell lung cancer; CBCI: couple based coping intervention; ICI: individual coping intervention.
randomization because they were no longer interested. The mean age of the enrolled patients was 60.7 8.8 years, 66.7% patients were male, and 51.2% patients were smokers. Among these patients, 79.7% patients were NSCLC, the rest of 20.3% patients were SCLC. After surgery, 87.0% patients received postoperative chemotherapy, and 14.6% patients received postoperative radiotherapy. Table 1 shows baseline data for the 123 patients after randomization. Baseline characteristics were well balanced between the two groups (P > 0.05). 3.2. Self-efficacy Repeated measures ANOVA revealed a significant main effect of training time (F = 3.761, P = 0.004) and group (F = 4.327, P = 0.002) on GSES. Post-hoc analysis revealed that the mean GSES were not significant different between the CBCI group and the ICI group (23.5 3.1 vs. 23.3 3.2; P > 0.05) preoperatively; the CBCI group had higher GSES compared with the ICI group (34.5 4.2 vs. 32.1 4.2, P < 0.05) at 2 months after operation; and the CBCI group also had higher GSES compared with the ICI group (34.7 5.7 vs. 31.6 5.5, P < 0.05) at 6 months after operation. Power analysis determined that a sample size of 49 vs. 53 at 6 month follow-up is needed for 79.0% power to establish significance. Table 2 and Fig. 2 show the self-efficacy comparison at 3 time points between the two groups. 3.3. Quality of life Repeated measures ANOVA revealed a significant main effect of training time (P < 0.05) and group (P < 0.05) on VT, SF, RE, and MH of SF-36. Post-hoc analysis revealed that the mean VT, SF, RE, and MH were not significant different between the CBCI group and the ICI group preoperatively; the CBCI group had higher VT, SF, RE, and MH compared with the ICI group at 2 months after operation; and the CBCI group also had higher GSES compared with the ICI group at 6 months after operation. But repeated measures ANOVA revealed no significant difference of training group (P > 0.05) relative to VT, SF, RE, and MH of SF-36. Table 2 and Fig. 3 show the quality of life comparison at 3 time points between the two groups.
Please cite this article in press as: H.-L. Chen, et al., Effects of couple based coping intervention on self-efficacy and quality of life in patients with resected lung cancer, Patient Educ Couns (2017), http://dx.doi.org/10.1016/j.pec.2017.07.002
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Table 2 Comparison of GSES and SF-36 between two groups in three time points. Group
Self-efficacy GSES Quality of Life SF-36 PF SF-36 RP SF-36 BP SF-36 GH SF-36 VT SF-36 SF SF-36 RE SF-36 MH
T0: Preoperative
T1: 2 month after operation
T2: 6 months after operation
n
mean (SD)
n
mean (SD)
n
mean (SD)
CBCI ICI
58 65
23.5 (3.1) 23.3 (3.2)
54 62
34.5 (4.2)* 32.1 (4.1)
49 53
34.7 (5.7)* 31.6 (5.5)
CBCI ICI CBCI ICI CBCI ICI CBCI ICI CBCI ICI CBCI ICI CBCI ICI CBCI ICI
58 65 58 65 58 65 58 65 58 65 58 65 58 65 58 65
61.2 (7.5) 63.1 (7.3) 67.5 (6.8) 68.9 (7.1) 62.5 (4.7) 63.1 (4.3) 63.4 (6.6) 62.1 (6.7) 70.2 (8.1) 68.2 (8.5) 58.3 (6.2) 59.6 (6.9) 55.3 (5.4) 53.7 (5.5) 67.4 (7.1) 65.4 (7.3)
54 62 54 62 54 62 54 62 54 62 54 62 54 62 54 62
48.6 (7.4) 47.1 (7.7) 46.2 (6.9) 45.6 (7.0) 51.3 (5.2) 52.2 (5.6) 51.4 (6.8) 50.1 (7.1) 45.3 (5.6)* 40.8 (6.1) 47.6 (7.5)* 42.6 (7.2) 45.6 (5.7)* 40.7 (5.2) 51.2 (7.5)* 42.4 (7.2)
49 53 49 53 49 53 49 53 49 53 49 53 49 53 49 53
48.4 (9.1) 46.8 (8.5) 45.6 (10.3) 44.8 (9.6) 48.1 (5.1) 47.8 (5.3) 45.8 (8.1) 43.6 (8.5) 45.1 (6.5)* 38.4 (7.2) 46.8 (7.6)* 41.5 (7.5) 44.7 (6.2)* 39.4 (5.7) 48.6 (7.6)* 42.3 (7.5)
GSES: general self-efficacy scale; SF-36: 36-item short form health survey; PF: physical functioning; RP: physical problems; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning; RE: emotional problems; MH: mental health. CBCI: couple based coping intervention; ICI: compared with individual coping intervention. * compared with ICI group P < 0.05.
Fig. 2. General Self-Efficacy Scale (GSES) comparison between the CBCI group and the ICI group. * P < 0.05.
4. Discussion and conclusion 4.1. Discussion In our study, we found couple based coping intervention improved the self-efficacy and the quality of life of the patients with resected lung cancer. Some studies have also found that couple-coping intervention was effective for other type of cancer patients. Baucom et al. reported the couple-based intervention improved the individual, medical, and relationship functioning for couples in which the woman is facing breast cancer [21]. Kayser et al. found breast cancer patients in the partners in coping program made the greatest gains in their quality of life, and concluded that the patients would benefit more from a couplebased approach to their illness [22]. Northouse et al. reported intervention spouses for prostate cancer patients reported higher quality of life, more self-efficacy, better communication, and less
negative appraisal of caregiving [23]. Giesler et al. also found patients with prostate cancer experienced long-term improvements in quality-of-life outcomes related to sexual functioning and cancer worry when received couple-based intervention [24]. The results of our study were similar like their studies. Some reasons can be explained why the self-efficacy and the quality of life can benefit form couple based coping intervention? First, spousal caregivers of cancer patients always not experienced coping throughout the cancer trajectory. Couple based coping intervention will increase the knowledge for caregiving and emotional assistance. Second, the diagnosis of cancer and its treatment can have an impact on both patients and their spouse. Previous study indicates that spouses of cancer patients even have more distress than patients, and spouses had a greater need for the intervention than patients [25]. Couple based coping intervention will decrease distress of the spouses, and then the spouses‘ caregiving and emotional assistance will be more effective. In our study, we also found couple based coping intervention improved the quality of life in the mental component summary (VT, SF, RE, and MH), but not in the physical component summary (PF, RP, BP, and GH). In the couple based coping intervention sessions, we asked the partners to understand patient's psychological changes, and help patients to adopt an active coping style. This active coping style improved the mental health of the patients with resected lung cancer. In the Isa MR et al’s deep muscle relaxation training program among prostate cancer patients, they also found training program imporved mental component summary (p = 0.032) and overall health related quality of life (p = 0.042) scores, but not physical component summary (p = 0.965) [26]. But in Adamsen L‘s high intensity exercise intervention in cancer patients undergoing chemotherapy, they found significant effects on vitality (effect size 0.55, 95% CI 0.27 to 0.82), physical functioning (0.37, 0.09 to 0.65), role physical (0.37, 0.10 to 0.64), role emotional (0.32, 0.05 to 0.59), and mental health (0.28, 0.02 to 0.56) scores fot the training program [27]. Mental component summary was impoved in all the studies, but not physical component summary. We think the reason is we enrolled different kinds of cancer patients. In our study, we assessed patients with resected lung cancer. Most of them were old, and
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Fig. 3. Quality of life (SF-36) comparison between the CBCI group and the ICI group. PF: physical functioning; RP: physical problems; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning; RE: emotional problems; MH: mental health * P < 0.05.
they have just received a major surgery. Even the intervention included a behavioral component, the physical component summary still can’t be improved. There are some limitations in this study. First, we followed participants for only 6 months after surgery. The long-term effectiveness of couple based coping intervention remains to be determined. Second, compliance of participant is a confounding factor in this research. We tried to improve the compliance of participant, but it can’t be completely eliminated, which will be result in bias. Third, we only assessed self-efficacy and the quality of life of the patients. Anxiety and/or depression maybe act as a covariate between the intervention and primary outcome variables.
4.2. Conclusion Our findings indicated couple based coping intervention is more effective than individual coping intervention in patients with resected lung cancer. Couple based coping intervention can improve the self-efficacy and the quality of life of the patients, especially for improving mental health of the quality of life. 4.3. Practice implications Practitioners might like to consider using couple based coping intervention strategy to improve mental health of the quality of life in patients with resected lung cancer.
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Patient Education
Effects of couple based coping intervention on self-efficacy and quality of life in patients with resected lung cancer Hong-Lin Chena , Kun Liub,* , Qing-Sheng Youb a b
School of Nursing, Nantong University, Nantong City, Jiangsu Province, PR China Department of Thoracic Surgery, Affiliated Hospital of Nantong University, Nantong City, Jiangsu Province, PR China
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 July 2016 Received in revised form 19 June 2017 Accepted 3 July 2017
Objective: We aimed to assess the couple based coping intervention (CBCI) for self-efficacy and quality of life in patients with resected lung cancer, compared with individual coping intervention (ICI). Methods: From October to December 2015, 132 consecutive patients with resected lung cancer who were married/lived in a stable relationship were randomly assigned to the ICI group and the CBCI group. Results: The CBCI group had higher GSES compared with the ICI group at 2 month after operation, and at 6 month after operation (P < 0.05). The CBCI group had higher VT, SF, RE, and MH score of SF-36 compared with the ICI group at 2 month after operation, and at 6 month after operation (P < 0.05), but no significant differences were found in RP, PF, BP, and GH score of SF-36 compared between two groups (P > 0.05) in these 2 time points. Conclusion: Couple based coping intervention is more effective than individual coping intervention for improving the self-efficacy and the quality of life in patients with resected lung cancer. Practice implications: Practitioners might like to consider using couple based coping intervention strategy to improve self-efficacy and quality of life in patients with resected lung cancer. © 2017 Published by Elsevier Ireland Ltd.
Keywords: Lung cancer Couple based coping intervention Individual coping intervention Self-efficacy Quality of life
1. Introduction Lung cancer is the most common cancer in the world. According to GLOBOCAN estimates, about 1.8 million new lung cancer cases occurred in 2012 world widely, accounting for about 13% of total cancer diagnoses [1]. Surgical resection remains the single most consistent and successful option for early-stage lung cancer [2,3]. After surgery, stage I patients have the best survival with an average of a 71% 5-year disease specific survival, 60% of stage II patients will die during this period, and stage IIIA patients had a still worse prognosis with an average 5-year specific survival of only 24% [4]. More and more patients with resected lung cancer acquired prolonged postoperative survival. However, lung cancer survivors may suffer postoperatively from permanently reduced long-term quality of life (QOL) [5,6]. Retaining a good quality of life is of increasing importance and interest for lung cancer survivors [7]. Self-efficacy is the extent or strength of one's belief in one's own ability to complete tasks and reach goals. Many studies have found
* Corresponding author at: Department of Cardiothoracic Surgery, Affiliated Hospital of Nantong University, Xi Si Road 20# Nantong City, Jiangsu Province 226001, PR China. E-mail address: [email protected] (K. Liu).
self-efficacy was related with quality of life in patients with cancer, intervening to improve general self-efficacy for patients with cancer may improve their quality of life [8–11]. Recently, some of the randomized controlled trials assessing psychosocial intervention and self-efficacy-enhancing intervention were conducted in patients with cancer. Lee et al. reported a web-based program that targets changes in exercise and dietary behaviours had overall improvements in dietary quality, physical functioning and appetite loss (HRQOL) for breast cancer survivors [12]. Zhang et al. found the nurse-led self-efficacy enhancing intervention was effective in promoting self-efficacy and psychological well-being in patients with colorectal cancer [13]. Chambers et al. reported a multimodal supportive care intervention effectively promoted regular physical activity, and improved disease-specific and health-related QoL for prostate cancer survivors [14]. Buffart et al. reported a 12-week group-based exercise intervention imporved QoL, which was mediated by increased physical activity, general self-efficacy and mastery, and subsequent reductions in fatigue and distress [15]. However, these programs were all individual coping interventions. The patients with cancer also need for caregiving and emotional assistance from their spouses, and the spouses are generally the primary informal caregiver for cancer patients [16]. However, previous study showed that spousal caregivers of cancer patients perceived both negative and positive experiences in their
http://dx.doi.org/10.1016/j.pec.2017.07.002 0738-3991/© 2017 Published by Elsevier Ireland Ltd.
Please cite this article in press as: H.-L. Chen, et al., Effects of couple based coping intervention on self-efficacy and quality of life in patients with resected lung cancer, Patient Educ Couns (2017), http://dx.doi.org/10.1016/j.pec.2017.07.002
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coping throughout the cancer trajectory [17]. Therefore, we hypothesized that couple-coping intervention for cancer patients would significantly improve self-efficacy and quality of life compared to patient-coping intervention. We also found couplecoping intervention has not been reported in the resected lung cancer patients. The purpose of this paper is to verify this hypothesis and report the feasibility of couple-coping intervention for patients with resected lung cancer.
2.3. Recruitment and randomization From October 2015 to December 2015, patients with resected lung cancer in our hospital were enrolled in our study. Patients were randomly assigned to the CBCI group and the ICI group. Simple randomization was accomplished by computer generated random number. Allocation was performed by third party personnel uninvolved in recruitment. 2.4. Interventions in two groups
2. Patients and methods 2.1. Study design This is a prospective, randomized, controlled intervention trial evaluating couple based coping intervention (CBCI) compared with individual coping intervention (ICI) for self-efficacy and quality of life in patients with resected lung cancer. The study design was approved by the Ethics Committee of our hospital. All patients or their partners gave written informed consent. 2.2. Eligibility criteria and exclusion criteria Eligibility criteria were: (1) patients with resected lung cancer; (2) lung cancer was initial diagnoses and not combined with other cancer; (3) age 18 years; (4) the life expectancy >6 months after surgery; (5) currently married, and their partners have ability to take care of them. Exclusion criteria were: (1) single, divorced, or widowed patients; (2) married, but their partners lived separately; (3) partner cannot reported their self-efficacy and quality of life, such as illiterate or psychological disorder; (4) not willing to participate CBCI or ICI.
All patients received 3 coping training sessions that were held at admission (before surgery), 2 months after discharge, and 6 months after discharge. The mean in hospital time after surgery was 9 1 day. In the ICI group, patients received cognitive intervention, behavioral intervention and psychological intervention. (1) Cognitive intervention: patients were educated the knowledge about lung cancer surgery, postoperative chemotherapy and postoperative radiotherapy; educated the knowledge about complications after surgery, chemotherapy and radiotherapy; educated about nutrition-related knowledge, including the basic principles of diet, and common eating problems; also educated the knowledge about common postoperative problems, including loss of appetite, nausea, vomiting, diarrhea, constipation, and insomnia. (2) Behavioral intervention: patients were educated how to take medication; how to establish good sleep habits; recommended exercise program, such as walking, climbing stairs and playing with the children and so on, for 6 to 7 days a week, each time carried out in three 10 min. (3) Psychological intervention: patients were educated how to adopt an active coping style; assisted to identify and challenge negative cancer-related cognitions; managing common concerns associated with lung cancer treatment.
Fig. 1. Flow of participants through each stage of the trial.
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In the CBCI group, patients received similar contents to ICI, which also included cognitive intervention, behavioral intervention and psychological intervention. Differently, they were couple based coping intervention. The patient's partners were asked: (1) also to attend the coping training sessions, and to learn knowledge about lung cancer; (2) accompany patients over 3 h a day, accompany patient walks more than 0.5 h a day; (3) understand patient's psychological changes, and help patients to adopt an active coping style. All of the 3 coping training sessions were held by a full-time nurse. Most of them were one to one training. But if two or more patients or couples came in at the same time, group-based trainings were used. All patients or couples received a handbook guiding them to train. 2.5. Outcomes The primary endpoints were self-efficacy and quality of life. These outcomes were assessed at 3 time points before 3 coping training sessions. 2.6. Instruments Self-efficacy was assessed by the General Self-Efficacy Scale (GSES). GSES is a 10-item psychometric scale that is designed to assess optimistic self-beliefs to cope with a variety of difficult demands in life. Each item is scored from 1 (not at all true) to 4 (completely true). The summary score ranges from 10 to 40, with the highest score indicating high self-efficacy. In samples from 23 nations, Cronbach’s alphas ranged from 0.76 to 0.90, with the majority in the high 0.80 s [18,19]. Quality of life was assessed by the 36-item Short Form Health Survey (SF-36). The SF-36 is a brief self administered questionnaire that generates scores across eight dimensions of health: physical functioning (PF), role limitations due to physical problems (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitations due to emotional problems (RE), and mental health (MH). Items are rated with respect to the individual’s experience over the past 7 days. Scores range from 0 to 100, with higher scores indicating better quality of life and functioning. The SF-36 has been shown to be both reliable and valid, with internal consistency coefficients exceeding 0.70 for all scales [20]. 2.7. Statistical analyses GSES and SF-36 scores in two groups were compared by repeated-measures analysis of variance. If sphericity could not be assumed, a Huynd-Feldt correction was used to produce a more critical F-value. Post-hoc tests were analyzed via student t-tests. We also conducted power analysis by outcome of GSES at 6 month. P < 0.05 was considered significant. Statistical analyses were performed using SPSS statistics software (version 19.0, IBM, Armonk, NY), and power analysis were performed using PS Power and Sample Size Calculations (Version 3.0, Copyright © 1997–2009 by William D. Dupont and Walton D. Plummer.) 3. Results 3.1. Baseline characteristics of participants From October 2015 to December 2015, 132 patients were enrolled in this trial. A recruitment and randomization flow chart is shown in Fig. 1. One patient assigned to the ICI group and eight patients assigned to the CBCI group withdrew immediately after
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Table 1 Baseline characteristics of study participants by randomized group. Characteristics
CBCI (n = 58)
ICI (n = 65)
t/x2
P
Age Gender Male Female Smoking status Nonsmoker Smoker Type of lung cancer NSCLC SCLC Stage I II III Type of surgery Pneumonectomy Lobectomy or wedge resection Postoperative chemotherapy Yes No Postoperative radiotherapy Yes No
60.1 8.8
61.2 8.9
0.688 0.261
0.493 0.609
40 18
42 23 0.218
0.640
31 27
32 33 0.125
0.723
47 11
51 14 0.531
0.767
3 10 45
5 9 51 0.419
0.517
9 49
13 52 0.611
0.435
49 9
58 7 0.587
0.411
7 51
11 54
NSCLC: non-small cell lung cancer; SCLC: small cell lung cancer; CBCI: couple based coping intervention; ICI: individual coping intervention.
randomization because they were no longer interested. The mean age of the enrolled patients was 60.7 8.8 years, 66.7% patients were male, and 51.2% patients were smokers. Among these patients, 79.7% patients were NSCLC, the rest of 20.3% patients were SCLC. After surgery, 87.0% patients received postoperative chemotherapy, and 14.6% patients received postoperative radiotherapy. Table 1 shows baseline data for the 123 patients after randomization. Baseline characteristics were well balanced between the two groups (P > 0.05). 3.2. Self-efficacy Repeated measures ANOVA revealed a significant main effect of training time (F = 3.761, P = 0.004) and group (F = 4.327, P = 0.002) on GSES. Post-hoc analysis revealed that the mean GSES were not significant different between the CBCI group and the ICI group (23.5 3.1 vs. 23.3 3.2; P > 0.05) preoperatively; the CBCI group had higher GSES compared with the ICI group (34.5 4.2 vs. 32.1 4.2, P < 0.05) at 2 months after operation; and the CBCI group also had higher GSES compared with the ICI group (34.7 5.7 vs. 31.6 5.5, P < 0.05) at 6 months after operation. Power analysis determined that a sample size of 49 vs. 53 at 6 month follow-up is needed for 79.0% power to establish significance. Table 2 and Fig. 2 show the self-efficacy comparison at 3 time points between the two groups. 3.3. Quality of life Repeated measures ANOVA revealed a significant main effect of training time (P < 0.05) and group (P < 0.05) on VT, SF, RE, and MH of SF-36. Post-hoc analysis revealed that the mean VT, SF, RE, and MH were not significant different between the CBCI group and the ICI group preoperatively; the CBCI group had higher VT, SF, RE, and MH compared with the ICI group at 2 months after operation; and the CBCI group also had higher GSES compared with the ICI group at 6 months after operation. But repeated measures ANOVA revealed no significant difference of training group (P > 0.05) relative to VT, SF, RE, and MH of SF-36. Table 2 and Fig. 3 show the quality of life comparison at 3 time points between the two groups.
Please cite this article in press as: H.-L. Chen, et al., Effects of couple based coping intervention on self-efficacy and quality of life in patients with resected lung cancer, Patient Educ Couns (2017), http://dx.doi.org/10.1016/j.pec.2017.07.002
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Table 2 Comparison of GSES and SF-36 between two groups in three time points. Group
Self-efficacy GSES Quality of Life SF-36 PF SF-36 RP SF-36 BP SF-36 GH SF-36 VT SF-36 SF SF-36 RE SF-36 MH
T0: Preoperative
T1: 2 month after operation
T2: 6 months after operation
n
mean (SD)
n
mean (SD)
n
mean (SD)
CBCI ICI
58 65
23.5 (3.1) 23.3 (3.2)
54 62
34.5 (4.2)* 32.1 (4.1)
49 53
34.7 (5.7)* 31.6 (5.5)
CBCI ICI CBCI ICI CBCI ICI CBCI ICI CBCI ICI CBCI ICI CBCI ICI CBCI ICI
58 65 58 65 58 65 58 65 58 65 58 65 58 65 58 65
61.2 (7.5) 63.1 (7.3) 67.5 (6.8) 68.9 (7.1) 62.5 (4.7) 63.1 (4.3) 63.4 (6.6) 62.1 (6.7) 70.2 (8.1) 68.2 (8.5) 58.3 (6.2) 59.6 (6.9) 55.3 (5.4) 53.7 (5.5) 67.4 (7.1) 65.4 (7.3)
54 62 54 62 54 62 54 62 54 62 54 62 54 62 54 62
48.6 (7.4) 47.1 (7.7) 46.2 (6.9) 45.6 (7.0) 51.3 (5.2) 52.2 (5.6) 51.4 (6.8) 50.1 (7.1) 45.3 (5.6)* 40.8 (6.1) 47.6 (7.5)* 42.6 (7.2) 45.6 (5.7)* 40.7 (5.2) 51.2 (7.5)* 42.4 (7.2)
49 53 49 53 49 53 49 53 49 53 49 53 49 53 49 53
48.4 (9.1) 46.8 (8.5) 45.6 (10.3) 44.8 (9.6) 48.1 (5.1) 47.8 (5.3) 45.8 (8.1) 43.6 (8.5) 45.1 (6.5)* 38.4 (7.2) 46.8 (7.6)* 41.5 (7.5) 44.7 (6.2)* 39.4 (5.7) 48.6 (7.6)* 42.3 (7.5)
GSES: general self-efficacy scale; SF-36: 36-item short form health survey; PF: physical functioning; RP: physical problems; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning; RE: emotional problems; MH: mental health. CBCI: couple based coping intervention; ICI: compared with individual coping intervention. * compared with ICI group P < 0.05.
Fig. 2. General Self-Efficacy Scale (GSES) comparison between the CBCI group and the ICI group. * P < 0.05.
4. Discussion and conclusion 4.1. Discussion In our study, we found couple based coping intervention improved the self-efficacy and the quality of life of the patients with resected lung cancer. Some studies have also found that couple-coping intervention was effective for other type of cancer patients. Baucom et al. reported the couple-based intervention improved the individual, medical, and relationship functioning for couples in which the woman is facing breast cancer [21]. Kayser et al. found breast cancer patients in the partners in coping program made the greatest gains in their quality of life, and concluded that the patients would benefit more from a couplebased approach to their illness [22]. Northouse et al. reported intervention spouses for prostate cancer patients reported higher quality of life, more self-efficacy, better communication, and less
negative appraisal of caregiving [23]. Giesler et al. also found patients with prostate cancer experienced long-term improvements in quality-of-life outcomes related to sexual functioning and cancer worry when received couple-based intervention [24]. The results of our study were similar like their studies. Some reasons can be explained why the self-efficacy and the quality of life can benefit form couple based coping intervention? First, spousal caregivers of cancer patients always not experienced coping throughout the cancer trajectory. Couple based coping intervention will increase the knowledge for caregiving and emotional assistance. Second, the diagnosis of cancer and its treatment can have an impact on both patients and their spouse. Previous study indicates that spouses of cancer patients even have more distress than patients, and spouses had a greater need for the intervention than patients [25]. Couple based coping intervention will decrease distress of the spouses, and then the spouses‘ caregiving and emotional assistance will be more effective. In our study, we also found couple based coping intervention improved the quality of life in the mental component summary (VT, SF, RE, and MH), but not in the physical component summary (PF, RP, BP, and GH). In the couple based coping intervention sessions, we asked the partners to understand patient's psychological changes, and help patients to adopt an active coping style. This active coping style improved the mental health of the patients with resected lung cancer. In the Isa MR et al’s deep muscle relaxation training program among prostate cancer patients, they also found training program imporved mental component summary (p = 0.032) and overall health related quality of life (p = 0.042) scores, but not physical component summary (p = 0.965) [26]. But in Adamsen L‘s high intensity exercise intervention in cancer patients undergoing chemotherapy, they found significant effects on vitality (effect size 0.55, 95% CI 0.27 to 0.82), physical functioning (0.37, 0.09 to 0.65), role physical (0.37, 0.10 to 0.64), role emotional (0.32, 0.05 to 0.59), and mental health (0.28, 0.02 to 0.56) scores fot the training program [27]. Mental component summary was impoved in all the studies, but not physical component summary. We think the reason is we enrolled different kinds of cancer patients. In our study, we assessed patients with resected lung cancer. Most of them were old, and
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Fig. 3. Quality of life (SF-36) comparison between the CBCI group and the ICI group. PF: physical functioning; RP: physical problems; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning; RE: emotional problems; MH: mental health * P < 0.05.
they have just received a major surgery. Even the intervention included a behavioral component, the physical component summary still can’t be improved. There are some limitations in this study. First, we followed participants for only 6 months after surgery. The long-term effectiveness of couple based coping intervention remains to be determined. Second, compliance of participant is a confounding factor in this research. We tried to improve the compliance of participant, but it can’t be completely eliminated, which will be result in bias. Third, we only assessed self-efficacy and the quality of life of the patients. Anxiety and/or depression maybe act as a covariate between the intervention and primary outcome variables.
4.2. Conclusion Our findings indicated couple based coping intervention is more effective than individual coping intervention in patients with resected lung cancer. Couple based coping intervention can improve the self-efficacy and the quality of life of the patients, especially for improving mental health of the quality of life. 4.3. Practice implications Practitioners might like to consider using couple based coping intervention strategy to improve mental health of the quality of life in patients with resected lung cancer.
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