Self-efficacy beliefs and levels of anxiety in advanced cancer patients PDF

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Original article Self-efficacy beliefs and levels of anxiety in advanced cancer patients K. MYSTAKIDOU, md, phd, associate professor, Pain Relief and Palliative Care Unit, Areteion Hospital, University of Athens, School of Medicine, Athens, E. TSILIKA, bsc, msc, health psychologist, Pain Relief and ...

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Self-efficacy beliefs and levels of anxiety in advanced cancer patients Kyriaki Mystakidou European Journal of Cancer Care

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Original article

Self-efficacy beliefs and levels of anxiety in advanced cancer patients K. MYSTAKIDOU, md, phd, associate professor, Pain Relief and Palliative Care Unit, Areteion Hospital, University of Athens, School of Medicine, Athens, E. TSILIKA, bsc, msc, health psychologist, Pain Relief and Palliative Care Unit, Areteion Hospital, University of Athens, School of Medicine, Athens, E. PARPA, bsc, ma, clinical psychologist, Pain Relief and Palliative Care Unit, Areteion Hospital, University of Athens, School of Medicine, Athens, P. GOGOU, md, ma, trainee radiotherapist-oncologist, Radiology Department, Areteion Hospital, University of Athens, School of Medicine, Athens, P. THEODORAKIS, md, msc, dipl shtm, phd, National Counterpack in WHO for Mental Health, Municipality of Athens, Athens, & L. VLAHOS, md, phd, professor, Director in Radiology Department Areteion Hospital, University of Athens, School of Medicine, Athens, Greece MYSTAKIDOU K., TSILIKA E., PARPA E., GOGOU P., THEODORAKIS P. & VLAHOS L. (2010) European Journal of Cancer Care 19, 205–211 Self-efficacy beliefs and levels of anxiety in advanced cancer patients The aims of this study were to investigate the self-efficacy and anxiety in advanced cancer patients in a palliative care unit. The subject is some 99 advanced cancer patients, treated for pain relief and cancer-related symptoms. Patients completed the General Perceived Self-Efficacy Scale (GSE) and the Spielberger’s State-Trait Anxiety Inventory (STAI). The Eastern Cooperative Oncology Group was used to measure patients’ performance status. Statistically significant associations were found between GSE, patients’ gender, performance status, opioids and all the STAI scales. The multiple regression analysis revealed that self-efficacy was predicted by patients’ age, performance status, gender, as well as by their high levels on two STAI scales, in a model explaining 39.7% of the total variance. In advanced cancer patients, self-efficacy is significantly correlated with levels of anxiety, patients’ physical condition and demographic characteristics. Also, it seems to be influenced by components of the STAI, patients’ age, physical performance and gender.

Keywords: anxiety, cancer, palliative care, self-efficacy.

INTRODUCTION It is now recognized that medical status is not the only contributing factor in determining disease course, prognosis and quality of life. Viewed from a biopsychosocial perspective rather than a strictly biomedical model, it is acknowledged that biopsychosocial factors play vital role (Collie et al. 2005). Correspondence address: Kyriaki Mystakidou, Pain Relief and Palliative Care Unit, Areteion Hospital, University of Athens, School of Medicine, 27 Korinthias Steet, Athens 11526, Greece (e-mail: [email protected]).

Accepted 22 August 2008 DOI: 10.1111/j.1365-2354.2008.01039.x European Journal of Cancer Care, 2010, 19, 205–211

© 2009 The Authors Journal compilation © 2009 Blackwell Publishing Ltd

Social Cognitive Theory (SCT) proposes that personal factors, environmental (social) factors and behavioural factors all interact to determine behaviour (Bandura 1997). The central construct of the SCT is perceived self-efficacy, defined by Bandura (p. 21) as ‘a judgment of one’s ability to organize and execute given types of performances’. Highly efficacious people tend to think about positive outcomes associated with behaviours. In addition, low-selfefficacious people are prone to self-disparaging thought and demoralization that in turn lead to depressive ideation. Social Cognitive Theory proposes that beliefs about one’s abilities influence both thoughts and affective states. According to Bandura (1997), there are four hierarchical predictors of self-efficacy. They are past experiences with

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the behaviour, vicarious experiencing and verbal persuasion or encouragement (e.g. exposure to supportive abstinent role models that often occur in group therapy or self-help groups) and levels of arousal/impulsivity and distress. Actual ability or the result of the action is secondary to the perceived ability to affect the behaviour (Bandura 1997). Self-efficacy varies in dimensions of level, strength and generality (Bandura 1982; O’Leary 1985). Among the mechanisms of human agency, none is more central or pervasive than people’s beliefs in their efficacy do, to manage their own functioning and to exercise control over events that affect their lives (Bandura 2001). A sense of personal efficacy is the foundation of human agency. Self-efficacy is one factor that has been examined in relation to patient’s adjustment to cancer. Selfefficacy for managing pain, symptoms and function in particular may be critical to a patient’s ability to manage the physical and psychological challenges of cancer. Selfefficacy buffers the association between cancer, physical dysfunction, symptom management and psychological distress (Bisschop et al. 2004). Research supports the notion that cancer patients who feel more efficacious about their coping capacity are better adjusted (Lev et al. 1999a), enjoy a higher quality of life (Giese-Davis et al. 1999) and may live longer (Merluzzi & Nairn 1999) than those who feel inefficacious. Self-efficacy beliefs regulate human functioning through cognitive, motivational, affective and decisional processes. Those who have a high sense of coping efficacy adopt strategies and course of action designed to change hazardous environments into more benign ones. In this mode of affect regulation, efficacy beliefs alleviate anxiety by enabling individuals to mobilize and sustain coping efforts (Bandura et al. 1969, 1985; Locke & Latham 1990) People remain unperturbed while coping with potential threats they regard with high personal efficacy. But as they confront threats for which they distrust their coping efficacy their subjective distress and autonomic and catecholamine reactivity mount (Kent 1987; Kent & Gibbons 1987). People who report higher levels of stress tend to be less efficacious. Moreover, self-efficacy helps to account for such diverse phenomena as changes in different types of coping behaviour produced by different modes of treatment (Bandura 1982) and patterns and levels of physiological reactions to different threats (Bandura et al. 1982) among others. That self-efficacy operates as a cognitive regulator of stress and anxiety arousal is revealed in micro-level relations between different levels of instilled efficacy beliefs and corresponding subjective and biological 206

stress reactions while coping with phobic threats varying in levels of intimidation (Bandura et al. 1969, 1982, 1985). The self-regulation of thought processes plays a critical role in the maintenance of emotional well-being following the traumatic experience. It is not the sheer frequency of aversive cognitions per se that accounts for anxiety arousal but rather the sense of powerlessness to rid one’s mind of them (Kent 1987; Kent & Gibbons 1987). Different cultures may share similar aetiology and natural history of psychological distress among individuals, but patterns and manifestations of psychological distress can vary owing to the central characteristics socialized by these cultural traditions and their institutions. Hence, it is interesting in studying these dimensions in different cultures, in this study the Greek culture. Schwartz (1994) has adduced a domain of value variation across cultures; he labels mastery ‘active efforts to modify one’s surroundings and get ahead of other people’ (p. 102). Masterly action transforms the threatingness of the environment. Although there have been several studies on the predictive value of self-efficacy to anxiety and people’s coping self-efficacy on stressful tasks (Bandura et al. 1982; Maciejewski et al. 2000; Stiegelis et al. 2004; Shikai et al. 2007), there is not known study on the predictive value of anxiety to self-efficacy. Therefore, the aim of the present study is to assess this relationship as well as the influence of patients’ demographic and clinical characteristics on their self-efficacy beliefs.

ME THODS Cancer patients are referred to the Pain Relief and Palliative Care Unit, for pain relief and cancer-related symptoms. Criteria for inclusion were: histologically confirmed malignancy, age >18 years, ability to communicate effectively with the healthcare professionals, patient signed informed consent and knowledge of the disease diagnosis. Patients were excluded if there was a diagnosis of a psychotic illness and a history of drug abuse. A representative sample of 110 patients suffering from incurable cancer (stage IV) was judged eligible to participate in the study. Of these patients, 11 (10%) refused to complete the assessment forms; thus the final sample consisted of 99 cancer patients. Research workers recorded data on patients’ clinical condition (disease status and treatment regimen). More specifically, disease status information included cancer diagnosis and performance status as defined by the Eastern Cooperative Oncology Group (ECOG) (0 = optimum performance status, 4 = worse © 2009 The Authors Journal compilation © 2009 Blackwell Publishing Ltd

Self-efficacy beliefs and levels of anxiety

performance status) (Oken et al. 1982). Patients with an ECOG score 0 or 1 were categorized as having ‘good’ performance status and those with score 2 or 3 as ‘moderate to poor’ performance status. Treatment regimen data consisted of any anti-cancer treatment (radiotherapy, chemotherapy) and also whether the patients were receiving any opioid analgesics. The study was performed in accordance to the Helsinki Declaration and according to European guidelines for good clinical practice, and it was approved by the institutional review board.

I N ST R U M E N T S Participants were asked to complete the General Perceived Self-Efficacy Scale (GSE) (Jerusalem & Schwarzer 1992; Schwarzer & Jerusalem 1995) as adapted to the Greek population (Glynou et al. 1992). It developed in German and has been translated into 28 different languages including English (Schwarzer & Jerusalem 1995) with internal consistencies (Cronbach 1951) between alpha = 0.75 and 0.91. The measure taps beliefs in one’s capability to handle new and difficult tasks in a variety of different domains. It consists of 10 items that are rated on a 4-point scale with the anchors not at all true and exactly true. Possible scores range from 10 to 40 with higher scores on this measure indicating higher levels of GSE. The Greek version of the GSE has also been validated in a sample of advanced cancer patients (Mystakidou et al. 2008) with Cronbach alpha = 0.927. The Spielberger’s State-Trait Anxiety Inventory (STAI) (Spielberger 1983) is a 40-item self-report. The StateAnxiety scale consists of 20 statements that evaluate how the respondent feels ‘right now, at this moment’. The Trait-Anxiety scale consists of 20 statements that evaluate how the respondent feels ‘generally’. In responding to the State-Anxiety scale, the subjects choose the number that best describes the intensity of their feelings: (1) not at all; (2) somewhat; (3) moderately; and (4) very much so. In responding to the Trait-Anxiety scale, subjects rate the frequency of their feelings on the following 4-point scale: (1) almost never; (2) sometimes; (3) often; and (4) almost always. Each STAI item is given a weighted score of 1–4. A high score means high anxiety, while a low score is translated as lower anxiety. The Spielberger’s State-Trait Anxiety Inventory is a brief, objective, self-report inventory. These two scoring systems have been previously validated and extensively used in patients with advanced cancer (Dugan et al. 1998). The scale has been translated into Greek by Fountoulakis et al. (2006). The authors have assessed the psychometric properties of STAI in advanced © 2009 The Authors Journal compilation © 2009 Blackwell Publishing Ltd

cancer patients (unpublished data) and revealed a threefactor structure with Cronbach alpha ranging 0.729–0.852.

Statistical analyses Basic descriptive statistics were computed for the sociodemographic variables, as well as means, standard deviations and ranges for all scale variables measured in the study (GSE, STAI) for patients. Pearson’s rank correlation coefficients were calculated for quantitative analysis between: (1) self-efficacy (GSE) with patient’s continuous characteristics (age, years of education, STAI factor I ‘emotionality’, STAI factor II ‘well-being mixed with worry’, STAI factor III ‘selfdeprecation’ and for qualitative analysis; and (2) GSE and the patients’ categorical characteristics (family status, gender, ECOG performance status and clinical characteristics: chemotherapy, radiotherapy, opioids, Non-Steroid Anti-Iflammatory Drugs and cancer location). Multiple regression model (method: stepwise) predicting self-efficacy was then constructed with sociodemographic, disease characteristics and anxiety (STAI) scales as predictor variables. All statistical analyses were performed using spss version 10.0 for windows.

RE SUL TS Descriptive statistics The mean age of the participants was 63.5 years (SD, 13.2, range 33–90). Of the 99 patients, the majority were female (59.6%), and most (90.9%) had a partner. Regarding their disease all of them were at stage IV (advanced cancer) (Table 1). Means, standard deviations and ranges for GSE and STAI scales are shown in Table 2. The average score on the GSE for this sample was 28.29 ⫾ 6.90 (range, 12–40), and STAI scales mean scores ranged 23.44–34.46 (standard deviations range from ⫾5.65 to ⫾6.77).

Univariate analysis Results indicated statistically significant associations between GSE with the categorical variables of gender (P = 0.042), ECOG (P = 0.001) and opioids (P = 0.055) (Table 3). Concerning the relationship between GSE and the continuous variables (age, years of education and STAI scales) (Table 4), statistically significant negative correlations were found between self-efficacy (GSE) and the scores of ‘emotionality’ (r = -0.305, P = 0.002), ‘well-being mixed 207

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Table 1. Demographic characteristics

and

disease-related

patient’s %

n

Table 3. Comparison between General Perceived Self-Efficacy Scale and demographic, disease related patient’s categorical characteristics Self-efficacy

Age 63.5 ⫾ 13.2 years Education 10.7 ⫾ 3.8 years Gender Male Female Diagnosis Breast Lung Gastrointestinal Urogenital Other Family status Married Unmarried

Mean

Standard deviation

Range (33–90) Range (1–16) 40 59

40.4 59.6

12 15 27 35 10

12.1 15.2 27.3 35.4 10.1

90 9

90.9 9.1

Eastern Cooperative Oncology Group score 0–1 75 2–3 24 Chemotherapy No 56 Yes 43 Radiotherapy No 17 Yes 82 Metastasis No 56 Yes 43 Opioids No 53 Yes 46

75.8 24.2 56.6 43.4 17.2 82.8

P-value

Family status

Partner No partner

28.37 27.56

6.91 7.16

0.738

Gender

Male Female

30.00 27.14

6.14 7.19

0.042

Eastern Cooperative Oncology Group

0–1

29.59

6.35

0.001

2–3

24.25

7.08

Metastasis

No Yes

29.34 26.93

6.65 7.05

0.085

Chemotherapy

No Yes

29.16 27.16

6.47 7.34

0.154

Radiotherapy

No Yes

26.29 28.71

6.44 6.95

0.191

Opioids

No Yes

29.53 26.87

6.97 6.60

0.055

Cancer location

Gastrointestinal Lung Urogenital Breast Other

27.25 29.20 29.24 26.46 27.40

6.90 5.51 6.66 7.39 5.97

0.580

56.6 43.4 53.5 46.5

Table 4. Relation between General Perceived Self-Efficacy Scale, demographic and State-Trait Anxiety Inventory Scales Self-efficacy

Table 2. Descriptive statistics of the assessed measurements

Self-efficacy Emotionality Well-being mixed with worry Self-deprecation

Mean

Standard deviation

Minimum

Maximum

28.29 30.09 34.46

6.90 5.65 6.77

12.00 19.00 17.00

40.00 48.00 51.00

23.44

6.07

12.00

39.00

with worry’ (r = -0.465, P < 0.0005) and ‘self-deprecation’ (r = -0.645, P < 0.0005).

Multivariate analyses The stepwise method was used in order to examine which of the variables in the univariate analyses could be the strongest predictors of patients’ self-efficacy beliefs. Results demonstrated that 39.7% of the variance (adjusted R2) in predicting GSE was accounted for by ‘well-being mixed with worry’ (B = -0.35, P = 0.0005), ‘self-deprecation’ (B = -0.31, P = 0.002), age (B = -0.12, P = 0.005), ECOG performance status (B = -2.88, P = 208

Age Years of education Emotionality Well-being mixed with worry Self-deprecation

Pearson’s r

P-value

-0.143 0.183 -0.305 -0.464 -0.407

0.157 0.072 0.002...