ASSOCIATION BETWEEN SOCIAL SUPPORT AND QUALITY OF LIFE IN PATIENTS WITH BREAST CANCER AT HIWA CANCER HOSPITAL IN SULAIMANI CITY/IRAQ

ORIGINAL ARTICLE

ASSOCIATION BETWEEN SOCIAL SUPPORT AND QUALITY OF LIFE IN PATIENTS WITH BREAST CANCER AT HIWA CANCER HOSPITAL IN SULAIMANI CITY/IRAQ

Avin Anwar Mahmood¹, Muhammad Rashid Amen ² *

1. University Nurse at Hiwa Cancer Hospital / General Directorate of Health in Sulaimani Governorate;
2. Department of Ault Nursing, College of Nursing, University of Sulaimani, City of Sulaimani, Iraq.

Corresponding author: Muhammad Rashid Amen

Email: muhammad.amen@univsul.edu.iq

ORCID

ABSTRACT

Received - 05-06-2021, Reviewed - 08/07/2021, Revised/ Accepted- 03/08/2021

INTRODUCTION

Being diagnosed with breast cancer is a very stressful event and has tremendous consequences for most persons who experience it, affecting all aspects of life and the temporary side effects associated with the treatment may influence the patients’ health related quality of life during and post treatment (Hassen et al 2019). The increase of morbidity in breast cancer afflicted patients, and aggravation for disease burden put a long-term impact on the physical and psychological health of patients, malignancies, especially in advanced stages, are associated with a compromised quality of life (QoL), which can be attributed to physical, psychological and social factors. While comparing cancer survivors with the control population, it is observed that they demonstrate a higher fatigue score and poorer quality of life (Wang et al, 2020). Simultaneously, physical impairment and psychological distress or emotional changes will have a negative influence on quality of life (QOL), its impact is not only confined to the treatment phase but also in the post treatment period (Oh and Cho 2020).

Social support is the interrelationships that protects individual from stress, reduces an illness distress and creating a sense of psychological and physical well-being and has a profound impact on quality of life in patients with chronic diseases, it has been found to be correlated with positive treatment outcomes for many chronic conditions including breast cancer, and it significantly reduces the stress emanating from cancer diagnosis as well as improves emotional wellbeing (Kim et al 2010) (Adam & Koranteng 2020).  Social support is usually provided by family members, relatives, friends and other relevant persons or facilities (Alshraifeen et al, 2020). Breast cancer and its treatment causes considerable harm to women in various life aspects including wellbeing, physical, psychological and social problems. Among breast cancer patients, inadequate social support is associated with a substantial increase in cancer-related mortality, increased social support, on the other hand, shows positive effects on breast cancer patients’ physical, psychological and social functioning and on their QoL. (Salakari et al, 2017)

Furthermore, Celik et al. (2021) found that social support might transform patients’ fear of progression and help them cope with uncertainty, in which way the patients had a better performance in adapting to society and in turn improved their QOL. Ban et al (2021) assessed the effect of social support by identifying the linkage between fear of progression and QOL for breast cancer patients, the result indicated that social support as an important factor in improving QOL.

As described previously, assessing the quality of life and perceived social support may have numerous benefits including the ability to provide clinicians and patients with accurate expectations about the likely impact of treatments on wellbeing and functioning, the ability to identify common problems that will need to be addressed, and the ability to identify therapies and interventions effective in addressing these problems. In addition, determine the association between QoL and social support may improve clinicians’ ability to predict treatment response and survival time in certain contexts. Besides, numerous studies have found that higher social support led to a better quality of life which may associate with longer survival of patients with breast cancer. Therefore, the aim of the present study was to assess QoL and perceived social support and find out the association between them in the women with breast cancer.

METHOD

Out of 413 breast cancer patients visited outpatients’ clinics at Hiwa Hospital, 342 patients were recruited into the study who met eligibility criteria, non-probability convenience sample technique was used. We included patients who were willing to participate, currently following up for any form of treatment and their last chemotherapy session was before at least 3 months. We excluded those patients who were diagnosed with any mood disorder before cancer, an uncontrolled chronic medical illness which not related to cancer or its treatment-related complications, and severe physical disability not related to cancer or its treatment.

The data for present cross-sectional study collected through constructed questionnaire which includes participants sociodemographic and clinical characteristics, Multidimensional Scale of Perceived Social Support (MSPSS), European Organization for Research and Treatment of Cancer Quality of Life questionnaire core 30 (EORTC QLQ C-30) and (EORTC QLQ BR-23).

The researcher collected data through direct face-to-face interview, a separate comfortable room was used for this reason, a brief explanation of the aim of the study was carried out prior to data collection. Moreover, pre-test was done on 25 patients to identify clarity and applicability of the tools, and to provide feedback about the questionnaire.

-Study instruments

Social support

Social support was measured by the Multidimensional Scale of Perceived Social Support (MSPSS). This 12-item measure is scored on a 7-point, Likert-type scale that ranges between 1 = very strongly disagree and 7 = very strongly agree (Canty-Mitchell & Zimet, 2000) and assessed the three sources of family, friends, and significant others support.

MSPSS sub-scales are composed of four items. Overall social support scores are calculated by summing the scores for each item, with higher scores indicating higher levels of social support. Subjects can be categorized according to the level of social support they receive as having low, medium, and high if they achieve total scores of (1–2.9), (3–5), and (5.1–7), respectively or for the total of MSPSS other format can be use (12-35) low, (36-60) medium, (61-84) high perceived social support (Zimet et al 1988). The reliability and validity of the MSPSS have been demonstrated across several different samples (Canty-Mitchell & Zimet, 2000). In the present study Cronbach's alpha coefficient of 0.90 was reported for the total scores and 0.92, 0.90, and 0.90 for the family, friends, and significant others subscales, respectively. At the time of development, the Cronbach’s α reliability was .91; Cronbach’s α for each subscale ranged from 0.90–0.95. In this study, the Cronbach’s α of the social support scale was 0.95.

Quality of Life

The validated European organization for research and treatment of cancer quality of life questionnaire core 30 (EORTC QLQ C-30) was used to measure breast cancer patients’ health-related quality of life in addition to European organization for research and treatment of cancer quality of life questionnaire specific for breast cancer (EORTC QLQ BR23) was used to assess specific factors of breast cancer patients’ QOL. Functional and symptom items of the EORTC QLQ-C30 and QLQ-BR23 questionnaires were rated on a 4-level response system from (1) not at all to (4) very much, while the Global health status/QOL (Question29, Question30) used a 7-point response scale.

The standardized tool EORTC QLQ-C30 was developed through a process of international joint study from multiple countries, and it is the most widely used standardized tool to measure the quality of life of cancer patients. This tool is composed of three subdomains and 30 items. It includes two items on Global health status/quality of life and five functional domains; physical, role, cognitive, emotional, and social functioning that include 15 items; three symptom domains; fatigue, pain, nausea/vomiting that include seven items; and one item for each of the symptoms commonly reported by cancer patients; dyspnea, loss of appetite, insomnia, constipation, diarrhea, and financial deficit. The EORTC QLQ-C30 is converted into a score ranging between (0 – 100) points; higher global health/quality of life scores, higher functional domain scores, and lower symptom domain scores indicate higher quality of life. Moreover, overall quality of life can be understood as a measurement of comprehensive quality of life (Fayers et al 2001).

Likewise, the QLQ- BR23, which assesses the QOL of breast cancer patients, has 23 items assessing disease symptoms and functions. The breast cancer module is designed for patients with different disease stages and treatment modalities. The module comprises 23 items, which incorporate 5 multi-item scales to assess systemic therapy side effects, arm symptoms, breast symptoms, body image, and sexual functioning. In addition, single items assess sexual enjoyment, hair loss, and future perspective (Sprangers et al, 1996).

Statistical analysis

Data analysis was performed using Statistical Package for Social Science (SPSS)-Version 24. All categorical data were presented in frequency and percentage and continuous data were presented in mean and standard deviation. Descriptive statistics were used to describe the participants’ demographics and cancer-related information. Pearson's correlation coefficients were used to examine the correlation between social support and QOL scores. Chi-square was used to determine the association between the level of perceived social support and the QOL subscale. The statistical significance level was set at p ≤ 0.05.

RESULTS

In total, 342 women were willing to participate in the study. The mean age was (42.65 ± 7.71) years, ranged from 25 to 79 years, almost (63%) less than 45 years. The distribution of marital status was almost as follows: married or living with a husband (79%), widowed/divorced (6%), and single (15%). Concerning education, more than (20.5%) with no formal education, (36.3%) completed primary school, and (33.3%) university graduated. Regarding participants' occupations, the majority almost (82%) were housewives. The income for more than (60%) of women was less than their expenditure and for (38%) was equal, Table (1).

The proportion of the obese and overweight as illustrated in table 2 was (57.3%) and (35.7%) respectively, a few (7%) were normal. The affected breast for more than half (51.5%) was the right side. The average age of diagnosis was (39.92 ± 7.27) years, almost (10%) were diagnoses with breast cancer earlier than the age of 30years, the proportion of patients diagnosed at (30 - 39) and (40 - 49years was (45.6%) and (38%) respectively, while the percentage of the participant diagnosed at 50 years and older was (6.4%) only.

The frequency of breast cancer treatments was; mastectomy (52.6%), lumpectomy (47.4%), radiotherapy (85.4%), biological (21.1%), and rehabilitation (27.5%) as shown in table (3).

Patients with breast cancer had a total MSPSS score of (12 - 84), with a mean score of (52.68 ± 20.09) (Table 4). It was found that (48.0%) of the patients had high social support, (31.5%) had medium social support, and (20.5%) had low social support (Table 5). The best mean source of social support on the MSPSS subscale was found to be family (4.97 ±1.96) and significant other (4.74 ± 1.86), however, the worst score was to the friend (3.47 ±102.8) on the scale of (1 - 7) (Table). The proportion of high social support received from family was highest (52.8%), when compared to significant other (48.2%) and friends (34.5%).

     The result of present study reveals that the family was greater social support source, more than half (52.1%) received high social support from family, followed by significant others (48%) for participant reported that had high social support from physicians, nurses and other health care professionals. The proportion of high social support provided by friend was (34.5%) only. Regarding total social support (31%) perceived high social support, the proportion of medium social support was (47.4%) and (21.6%) of them perceived low social support level, as shown in Table (5).

Overall, for EORTC-C30 table (6), the mean of global health status was (68.52 ± 19.80); the functional scale was low especially in emotional functioning and cognitive functioning (52.10 ± 26.60) and (54.97 ± 26.99) respectively. The role functioning had the highest score (68.42 ± 25.87) followed by social functioning and physical functioning (67.54 ± 28.31) and (66.12 ± 20.11) respectively and the total functional scale score was (61.83 ± 17.61). While symptom scales were moderate-to-low for most items, the higher score was for financial deficit (55.95 ± 33.07) and the lowest score was (3.70 ± 11.11) diarrhea, other symptoms which have high scores were fatigue, pain, and insomnia (43.60 ± 19.80), (39.96 ± 24.15), and (29.24 ± 27.82) respectively, and total symptoms scores were (25.37 ± 14.08).

     The scores of QoL according to QLQ-BR23, patients exhibited higher scores for future perspective and body image (5.83 ± 19.97) and (52.87 ± 29.44) respectively, while the least score was for sexual functioning (32.99 ± 28.79) and total functional scale score was (45.81 ± 17.83). Regarding symptom scales, hair loss, arm symptoms, and systemic therapy’s side effects were more disturbing (59.84 ± 18.53), (43.27 ± 20.05), and (41.35 ± 18.53) respectively, followed by breast symptoms (32.36 ± 22.27) and the score of total symptoms subscale was (44.21 ± 19.76) as presented in Table (7). The higher scores in global health status showed better QoL. Similarly, higher scores in functional scales indicate better QoL. On the other hand, higher scores in symptom scales show worse QoL.

The correlations between the quality of life measured using EROTC QOL-C30 EROTC QOL-BR23 and social support are presented in Table 8. A most strong positive correlation was found between MSPSS and each of QOL-C30 and QOL-BR23 functional subscales, (r:548; p:0.001) and (r:502; p:0.001) respectively. In addition, a negative correlation was found between MSPSS and each of QOL-C30 and QOL-BR23 symptoms subscales (r: - 454; p:0.001) and (r: - 372; p:0.001) respectively. Moreover, MSPSS correlated significantly to global health status/QOL (r:436; p:0.001). All reported significant correlations to show a positive relationship between the quality of life and social support, which mean the more social support an individual receives, the higher his or her quality of life is. Table (8).

As demonstrated in tables (9 & 10) the scores of global health status/QoL (77.83 ± 15.32) and QOL-C30 functions (71.31 ± 10.42) were significantly higher among patients received high social support when compared to those who received low social support (57.66 ± 24.95) and (48.85 ± 15.08) respectively. Whereas, it was the opposite regarding symptom subscales scores in both QoL scales. This reflects better QoL among patients who perceived higher social support. Social function in the QOL-C30 and future perspective in the QOL-BR23 had greater scores (83.02 ± 17.75) and (67.93 ± 25.29) respectively among patients who perceived high social support when compared to other functions.

A significant association was found between social support with all functions in both QOL- C30 and QOL-BR23 except sexual enjoyment. In addition, high social support is associated with lower symptoms of most QOL-30 and QOL-BR23 symptom subscales. Fatigue, pain, dyspnea, insomnia, appetite loss, and financial deficit scores on the QOL-C30 scale were decreased with increasing social support, on another hand systematic treatment adverse effect, arm, and breast symptoms decreased among high perceived social support patients, (p ˂ 0.05).

Table (1) Distribution of sample according to socio-demographic characteristics

Table (2) Distribution of sample according clinical characteristics

Table (3) Distribution of sample according type of treatments

Table (4) Distribution of MSPSS and its subscale scores

MSPSS: Multidimensional Scale of Perceived Social Support, SD: standard deviation

Table (5) Distribution of levels of total social support and subscales.

Table (6) Distribution the scores of EORTC QoL C-30.

Table (7) Distribution the scores of EORTC QoL BR-23.

Table (8) Distribution of correlation among study dependent variables.

   MSPSS: Multidimensional Scale of Perceived Social Support, QoL: Quality of Life

  *. Correlation is significant at the 0.05 level., **. Correlation is significant at the 0.01 level.

Table (9) The difference of QOL-C30 scores according to levels of social support. 

Table (10) The difference of QOL-BR23 scores according to levels of social support.