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Received: 5 April 2017

Revised: 9 October 2017

Accepted: 18 June 2018

DOI: 10.1111/ijn.12677

ORIGINAL RESEARCH PAPER

Illness perceptions of Chinese women with breast cancer and relationships with socio‐demographic and clinical characteristics Chunhua Ma MSc, Assistant1

| Jun Yan PhD, Associate Professor2 2 Yan Wu BSN, Doctor Degree Student | Wanbing Huang BSN, Master Degree Student 2 1 School of Medical Technology and Nursing, Shenzhen Polytechnic College, Shenzhen, China

|

Abstract Aims:

The aim of the study is to explore the illness perceptions of Chinese women

2

School of Nursing, Sun Yat‐Sen University, Guangzhou, China Correspondence Jun Yan, School of Nursing, Sun Yat ‐Sen University, 74 Zhongshan II Road, Guangzhou 510080, China. Email: [email protected] Funding information Science and Technology Department of Guangdong Province, Grant/Award Number: P‐045‐02; Health Department of Guangdong Province, Grant/Award Number: A2015088

with breast cancer and relationships with their socio‐demographic and clinical characteristics. Methods:

A descriptive, correlational, and exploratory design was used. The

Chinese version of the Revised Illness Perception Questionnaire was modified and used to collect data. Results:

Of the 16 common symptoms of breast cancer, the participants recognized

only 2.81 symptoms, on average. Of the 6 causal factors, “uncontrollable factors” had the highest mean score, while “behavioural factors” received the lowest score. Most of the participants knew little about the disease, perceived that this illness is cyclic in nature and would not last for a long time, believed that the illness could have serious consequences but could be controlled, and reported having negative emotional responses to this illness. Most of the dimensions of illness perception were significantly correlated with one another. Furthermore, some socio‐demographic and clinical characteristics were confirmed to be predictors of illness perceptions. Conclusions:

These findings suggest that illness perceptions should be regarded as

a whole to guide the coping process of Chinese women with breast cancer and provide new clinical information to support care for this group. KEYWOR DS

breast cancer, Chinese, illness perception, illness representations, nursing

SU M M ARY ST AT EM EN T

What this paper adds? • Of the 16 common symptoms of breast cancer, the participants

What is already known about this topic?

recognized only 2.81 symptoms, on average.

• Illness perceptions have been shown to explain a significant pro-

• Chinese women with breast cancer were more likely to believe that

portion of the variance in coping and quality of life among women

their illness was related to uncontrollable factors and did not under-

with breast cancer.

stand the association between behavioural factors and breast cancer.

• No research has focused on the illness perceptions of Chinese women with breast cancer.

Int J Nurs Pract. 2018;e12677. https://doi.org/10.1111/ijn.12677

• Most of the dimensions of illness perceptions were significantly correlated with one another.

wileyonlinelibrary.com/journal/ijn

© 2018 John Wiley & Sons Australia, Ltd

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• Some socio‐demographic and clinical characteristics were con-

perceiving less personal control and attributing cancer to a lack of

firmed to be predictors of the illness perceptions of Chinese

physical activity are important illness perceptions associated with

women with breast cancer.

lower levels of physical activity in breast cancer survivors (Charlier et al., 2012).

The implications of this paper:

Women with breast cancer differ in their subjective perceptions

• Findings can enrich the theoretical understanding of this group.

of their disease (Moss‐Morris et al., 2002; Rozema et al., 2014). Com-

• The findings provide new clinical information regarding care and rehabilitation for women with breast cancer.

pared with healthy people, women at increased risk of breast cancer view this illness as more chronic and severe and can identify more

• The use of a non‐Western patient sample adds to the understanding of the international cancer care burden.

symptoms (Moss‐Morris et al., 2002). Women newly diagnosed with breast cancer believe that this illness is a chronic illness with serious consequences but that it can be controlled with treatment (Kritpracha,

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IN T RODU CT ION

2004). Shabahang, Panahi, Noferesti, and Sahebghalam (2011) found that women with breast cancer undergoing chemotherapy perceived

Breast cancer is the most commonly diagnosed cancer among women

their illness to be acute, had better personal controllability, had opti-

in the majority (140/184) of countries worldwide (Ferlay et al., 2015)

mistic attitudes towards their illness, and exhibited less distress and

and remains the leading cause of cancer‐related deaths in women

less coherence regarding their illness.

(Servick, 2014). Compared with Western countries, China has a rela-

Furthermore, illness perceptions can be related to patients' socio‐

tively low incidence of breast cancer (Li, Mello‐Thoms, & Brennan,

demographic and clinical characteristics (Hopman & Rijken, 2015;

2016). However, this incidence has increased sharply since 1993

Postolica et al., 2017; Yan et al., 2011). Women with higher levels of

(DeSantis et al., 2015). Estimates suggest that in 2013, the number

education are more likely to believe that the duration of the illness will

of new breast cancer cases in China was 278 800 and the crude inci-

be short and that the illness will be controllable (Anagnostopoulos &

dence increased to 42.02 per 100 000 (Zuo, Zheng, Zeng, Zhang, &

Spanea, 2005; Kritpracha, 2004), while those with lower education

Chen, 2017). Meanwhile, as a result of increased survival rates (Chen

levels have less personal control and illness coherence and higher

et al., 2014; Li et al., 2016), an increasing number of Chinese women

emotional representation (Gosse, 2007; Kayaniyil et al., 2009).

must adapt to life following the diagnosis of breast cancer.

Women who are married are more likely to believe that the illness will an

result in less serious consequences and to exhibit higher personal con-

“individual's integrated perceptual‐cognitive model of a health threat

trol (McCorry et al., 2013). Family history and illness severity have also

that guides the person's coping with health events as well as evalua-

been explored as factors that can influence illness perceptions

tion of treatment effects” (Leventhal, Leventhal, & Cameron, 2013)

(Postolica et al., 2017; Yan et al., 2011).

Self‐regulation

theory

defines

illness

perceptions

as

and asserts that there are 9 dimensions to the perception of illness:

Despite evidence suggesting that illness perceptions can influence

identity (the symptoms the patient associates with the illness), causal

coping and quality of life among women with breast cancer, no

(personal ideas about aetiology) (Postolica, Iorga, Petrariu, & Azoicai,

research has focused on the illness perceptions of Chinese women

2017), consequences (their view about the impact of the illness on

with breast cancer. Moreover, it has been demonstrated that women

his/her life) (Postolica et al., 2017), timeline acute/chronic (percep-

from different cultural backgrounds differ in illness perceptions

tions of duration of illness), timeline cyclical (the extent of illness

(Popov, Heruti, Levy, Lulav‐Grinwald, & Bar‐Sela, 2014); therefore,

variability and unpredictability) (Guler et al., 2017), personal control

results of previous studies conducted in Western societies cannot

(their belief about their personal ability to control the illness) (Eriksson,

reflect the characteristics of illness perceptions among Chinese

Fritzell, Rixon, Bjork, & Wettergren, 2015), treatment control (their

women with breast cancer. Thus, the present study aims to explore

belief about effective treatment to cure their illness) (Eriksson et al.,

the illness perceptions of Chinese women with breast cancer and

2015), illness coherence (their understanding of the illness and its

associations with their socio‐demographic and clinical characteristics.

implications), and emotional representation (their evaluation of the potential emotional impact of the illness) (Guler et al., 2017). Research has demonstrated that illness perceptions can explain a

2

M ET HODS

|

significant proportion of the variance in psychological distress, coping behaviours, and illness outcomes in women with breast cancer (Fan, Eiser, & Lin, 2013; Fischer et al., 2013; Iskandarsyah, de Klerk, Suardi, Sadarjoen, & Passchier, 2014; Richardson, Schuz, Sanderson, Scott, &

2.1

|

Study design

The study was carried out using the descriptive, correlational, and exploratory design.

Schuz, 2016); women with breast cancer who view their illness as a condition with serious symptoms and consequences and who consider their illness to be chronic and uncontrollable have been found to

2.2

|

Participants

report worse physical and mental health than those who believe the

A convenience sampling method was adopted. The participants were

opposite (Rozema, Vollink, & Lechner, 2014). Additionally, 43% of var-

recruited in the department of breast cancer of a tumour hospital in

iance in the distress of women with breast cancer is explained by their

Guangzhou City, Guangdong Province, China. To be eligible for the

illness perceptions, and the perception that the timeline is cyclical is

present study, women had to receive an initial diagnosis of breast can-

the strongest predictor of distress (Fischer et al., 2013). Moreover,

cer based on a biopsy, be able to communicate in Chinese, and be

MA

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ET AL .

mentally able to provide informed consent. Furthermore, to improve

perceptions were assessed with the Chinese version of the IPQ‐R, as

homogeneity, we chose postoperative women who were waiting for

modified by Ma et al. (2015).

chemotherapy. Women with a history of other malignant tumours, mental illness, or cognitive impairment were excluded.

The first part of the modified IPQ‐R for breast cancer is the identity subscale, which consists of 16 commonly experienced symptoms among women with breast cancer (Ma et al., 2015). The respondents

2.3

|

Sample size and power

were first asked if they had experienced these symptoms and then asked whether they believed the symptoms were related to their

The present study used the Chinese version of the Illness Perception

illness (Moss‐Morris et al., 2002). Both questions can be replied as

Questionnaire‐Revised (IPQ‐R) as the main measurement instrument.

“yes” or “no”, and the sum of the yes answers of the second question

Moss‐Morris et al. (2002) divided all the items in the IPQ‐R into 3 cat-

comprised the identity score.

egories: identity, causal, and the remaining 7 subscales, which had

The second part is the causal subscale with 33 items, with a

more items than the first 2 subscales. Hence, the sample size was

response format of a 5‐point Likert‐type scale that ranged from

determined based on the equation n ≥ (5‐10) × m (where m is the

“strongly disagree” (1) to “strongly agree” (5). According to the results

number of items in the scale (Jia, He, & Jing, 2015), with 38 items,

of the factor analysis in the study by Ma et al. (2015), these items have

at least 190 participants (5 × 38) had to be recruited for the study.

been organized in 6 factors: “psychological factors”, “gene and hormonal factors”, “immune and environmental factors”, “behavioural

2.4

|

Data collection

factors”, “uncontrollable factors”, and “metabolic factors”. The mean of each factor is calculated by summing the scores of each item and

The data were collected from July 2014 to July 2015. All the data col-

dividing by the number of items in the factor. High scores on a factor

lection was conducted by 2 master's degree students who had been

indicate that participants strongly believe that this factor contributes

trained as research assistants. The participants' medical records were

to the development of breast cancer.

used to confirm the eligibility of the participants, and participants who

The third part of the revised IPQ‐R is a 38‐item questionnaire

met the inclusion criteria were recruited prior to their discharge follow-

rated on a 5‐point Likert scale comprised of 7 subscales: “timeline

ing surgery. If the women agreed to participate, they were asked to

acute/chronic”, “timeline cyclical”, “consequences”, “personal control”,

complete the study tool package. For those who could not complete

“treatment control”, “illness coherence”, and “emotional representa-

the questionnaire independently (ie, 12 women felt fatigue), the research assistants read the items to them and recorded their answers. The study tool package included the following:

tion”. Subscale means are calculated by summing the scores of each item and dividing by the number of items in the subscale. High scores on the timeline acute/chronic, timeline cyclical, consequences, and emotional representation subscales indicate that respondents have

Socio‐demographic and clinical characteristics form:

strongly held beliefs about the chronicity, the cyclical nature, the

A standard socio‐demographic form was used to collect self ‐report

negative consequences of the illness, and the psychological causes

data on age, education level, marital status, employment status, and

of the illness. High scores on the personal control, treatment control,

monthly family income per person. Participants' medical records were

and illness coherence subscales represent the respondents' positive

reviewed to obtain clinical data, including the stage of the tumour

beliefs about the controllability of the illness and a personal

and family history of breast cancer.

understanding of the condition (Postolica et al., 2017).

The Illness Perception Questionnaire‐Revised (IPQ‐R):

In the present study, the internal consistency reliability (Cronbach

The IPQ‐R by Moss‐Morris et al. (2002) consists of 9 subscales mea-

alpha) values for these subscales were as follows: timeline acute/

suring identity, timeline acute/chronic, timeline cyclical, causal, con-

chronic (α = .80), consequences (α = .86), personal control (α = .75),

sequences, personal control, treatment control, illness coherence,

treatment control (α = .78), illness coherence (α = .76), timeline cyclical

and emotional representation. The development of the Chinese ver-

(α = .73), and emotional representation (α = .92). For the causal

sion of the IPQ‐R, together with its validity and reliability study, was

subscale, the internal consistency reliability of the 6 factors was as

performed by Song et al. in 2007 among Chinese women with myo-

follows: psychological factors (α = .75), gene and hormonal factors

cardial infarction. In that study, the Chinese version of the IPQ‐R

(α = .80), immune and environmental factors (α = .65), behavioural

demonstrated acceptable content validity, internal consistency, and

factors (α = .74), uncontrollable factors (α = .66), and metabolic factors

test‐retest reliability (Song et al., 2007).

(α = .83). Because the identity subscale consists of items with a dichotomous variable response (yes/no), it was not possible to calculate its

The original IPQ‐R was not disease‐specific, and Moss‐Morris

internal consistency reliability (Moss‐Morris et al., 2002).

et al. (2002) encouraged researchers to adapt the identity subscale and the causal subscale to the particular illness. Ma, Zhang, Yan, and Tang (2015) modified these 2 subscales of the Chinese version of

2.5

|

Ethical considerations

IPQ‐R to make them suitable for women with breast cancer, and

Ethical approval was obtained from the hospital's research ethics com-

tested it with Chinese women with breast cancer. The modified IPQ‐

mittee (L2015ZSLYEC‐003). All participants were assured that their

R for breast cancer has demonstrated acceptable to good face and

involvement or noninvolvement would not affect the care they

content validity, internal consistency, and test‐retest reliability (Ma

received and that the information they provided would be kept

et al., 2015). Therefore, in the present study, the participants' illness

confidential.

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Data analysis

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ET AL .

mean age of 47.6 years (SD = 10.48). Only 25.4% of the participants

The data entry and analysis were performed using the Statistical Package for the Social Sciences, version 20.0 (Chicago, IL, USA). Descriptive statistics were computed to describe the sample characteristics and IPQ‐R scores. Pearson correlations, 2‐sample t tests, and 1‐way ANOVAs were used to investigate associations between

had a college education or higher. The participants were predominantly married (92.2%) and employed (72.0%). More than 80% of the participants were in the early stages of breast cancer (stage I = 18.7%, stage II = 69.9%); 9.3% of the respondents had a family history of breast cancer.

participants' socio‐demographic and illness characteristics, and illness perceptions. Finally, variables that correlated with illness perceptions

3.2

were put into a multiple linear regression model using the stepwise

The findings of the identity dimension are presented in Table 2. The

method to explore th...