A correlational survey to assess the level of stress, coping strategies, and quality of life of female cancer patients related to chemotherapy induced alopecia in Amala Cancer Hospital, Thrissur, Kerala

Mr. Athar Javeth¹ , Dr. R. G. Mathur², Dr. (Mrs.) Molly Babu³

¹Sr. Lecturer, Mother College of Nursing, Thrissur - 680012 Kerala.

²Ex Sr. Lecturer, Rajkumari Amrit Kaur College of Nursing, Lajpat Nagar, New Delhi - 110024

³Sr. Lecturer, Rajkumari Amrit Kaur College of Nursing, Lajpat Nagar, New Delhi - 110024

*Corresponding Author Email: javed.jannat@yahoo.com

ABSTRACT:

Background: Chemotherapy induced alopecia (hair loss) is a common side effect of the chemotherapy regimen. As hair is considered as an important aspect of human identity, loss of hair leads to development of stress and has negative consequences on various aspects of quality of life (QOL) and uses different coping strategies to deal with stress and improve the QOL. The aim of the study to assess the level of stress, coping strategies and QOL of female cancer patients due to chemotherapy induced alopecia and its relationship with each other and to determine association with selected demographic characteristics. Material and Methods: A correlational survey was carried out on 100 female cancer patients with chemotherapy induced alopecia who were admitted in the inpatient department of oncology. Structured rating scale and interview technique were used for assessing the level of stress, coping strategies and QOL of female cancer patients with chemotherapy induced alopecia. Results: The overall mean score of level of stress, coping strategies and QOL were 45.5±9.76, 41.32±5.89 and 42.49±7.38 respectively. Majority of patients (78%) had moderate level of stress, (94%) were using effective coping strategies and (83%) had good quality of life. Findings revealed that there was a significant negative correlation (r=-0.66) between level of stress and coping strategies, a significant high negative correlation (r=-0.91) between level of stress and quality of life at and a significant positive (r=+0.64) correlation between coping strategies and quality of life. There was a significant association between selected factors such as age (χ²= 36.08), education (χ²= 11.71), family support (χ²= 20.54), social support (χ²= 19.13) and marital status (χ²= 17.29) and level of stress. Coping strategies were significantly associated with economic status (χ²= 10.38), frequency of chemotherapy (χ²=17.28) and cycles of chemotherapy (χ²= 12.72) and a significant association between the QOL and age(χ²= 12.49) and education (χ²= 9.68) at p<0.05 level. Conclusion: Majority of patients had moderate level of stress and were using effective coping strategies and had good quality of life. Health professionals must provide health teaching about the side effects to the patients who were receiving chemotherapy so that they can be prevented from psychological stressors and cope with the symptoms effectively and improve the quality of life. Self care guide prepared by the researcher help the patient to deal with the problems of the chemotherapy induced alopecia.

KEYWORDS: Chemotherapy, alopecia, level of stress, coping strategies, quality of life..

INTRODUCTION:

“I almost feel silly saying it, but losing my hair was the hardest part about chemotherapy” - Reaves

Cancer is a disease of a cell caused by the genetic mutation of the cellular DNA. Cancer is a non communicable disease that accounts for the leading cause of death. Cancer afflicts different communities worldwide. It affects not only the single individual but also the entire family and society and thereby increases a substantial burden on the individual, family and society. Cancer is one of the most important community health problems in India. The three common malignancy seen in females are breast, followed by cervix and uterus accounts for a sizeable mortality and morbidity in India^(1).

Prolongation of survival, palliation of symptoms, preservation of quality of life are the main goals of chemotherapy. Even though chemotherapy can lead to nausea, vomiting, alopecia, fatigue, sexual dysfunction and reduction in quality of life ⁽²⁾. Oncology nurses play an important role in educating patients about the symptom experiences that distress women during the chemotherapy treatment. This will help the women to anticipate symptoms, adapting management strategies, and enable them to have better experiences through the cycles of treatment ^(3).

Chemotherapy induced alopecia is one of the most common and psychologically disturbing side effects of chemotherapy which may result in negative self mage, depression and anxiety ⁽⁴⁾. Individual’s perception and perception of others regarding self image play an important factor determining the emotional consequences of chemotherapy induced alopecia. Up to date information either in the verbal or written format helps them in dealing with chemotherapy induced alopecia ⁽⁵⁾.

Alopecia due to chemotherapy was considered as an assault by the postmenopausal women with breast cancer. They experienced that loss of their hair were more distressing than loss of breast which led to disharmony in their relationship due to lack of support. They considered that loss of hair was the worst experiences of chemotherapy ^(6). One of the strategies used by the female cancer patients to cope with alopecia by wearing wigs until their hair fully had grown back⁽⁷⁾.

Researcher’s own clinical experience and in view of these, the study was conducted to assess to assess the level of stress, coping strategies and quality of life of female cancer patients due to chemotherapy induced alopecia and its relationship with each other and to determine association with selected demographic characteristics.

MATERIAL AND METHODS:

A correlational survey was carried out to assess the level of stress, coping strategies and quality of life of female cancer patients due to chemotherapy induced alopecia. Approval by the institutional ethical committee of Amala Institute of Medical Sciences was obtained prior to the study. A sample consisting of 100 female cancer patients with chemotherapy induced alopecia within age between 21- 55 years and underwent chemotherapy with chemotherapy induced alopecia was taken. Those female cancer patients satisfying the inclusion criteria and admitted in the inpatient department of Amala Cancer Hospital, Thrissur, were selected using purposive sampling. The structured rating scale with interview technique was used to collect the data. The tool was validated and pre-tested. It consists of section I: background information, section II: a structured rating scale on Level of stress, section III: coping strategies rating scale, section IV: quality of life rating scale. The level of stress was categorized as mild, moderate and severe based on the obtained scores. Coping was grouped as effective and ineffective coping whereas quality of life as good and poor quality of life. After obtaining the informed consent, the purpose of the study was explained and confidentiality was assured. The selected subjects was interviewed to fill the structured rating scale containing items to assess the level of stress, coping strategies used and quality of life. Thirty to forty five minutes were taken for the interview. The clinical aspects of cancer related information were obtained from the medical record.

Analysis of data was done with the help of descriptive and inferential statistics. Frequency and percentage distribution was computed to describe the sample characteristics. Frequency, percentage distribution, mean and standard deviation was calculated for total stress scores, coping strategies scores and quality of life scores. Pearson Product Moment correlation (r) was employed to determine the relationship between level of stress, coping strategies and quality of life. Chi-square was computed to analyse the association of the level of stress, coping strategies and quality of life with the selected factors such as age, education, marital status, occupation, economic status, family support, social support, cycles of chemotherapy completed, and frequency of chemotherapy.

RESULTS:

Socio demographic characteristics:

More than half of female cancer patients (56%) were in the age group of 41-50, a considerable number (36%) were having higher secondary education. Highest percent (47%) were Christians, majority (73%)of the female cancer patients were married, most (78%) belonged to nuclear family, maximum (76%) of the female cancer patients were house wife and 42% of patients were having the income in the range of 5001-10000.

TABLE 1: DEMOGRAPHIC CHARACTERISTICS OF FEMALE CANCER PATIENTS N=100

Sl.No

Sample Characteristics

Frequency

Percentage %

Age in years

a. 20 – 30

b. 31 – 40

c. 41 – 50

d. Above 50

Education

a. Primary (1-8)

b. Secondary (SSLC)

c. Higher Secondary (11-12)

d. Graduation

Religion

a. Hindu

b. Muslim

c. Christian

d. Others

Marital status

a. Unmarried

b. Married

c. Widow

d. Divorce/separated

Type of family

a. Joint family

b. Extended family

c. Nuclear family

Occupation

a. House wife

b. Govt job

c. Private job

d. Retired

e. Others

Income of the family per month in rupees

a. Below 5000

b. 5001-10000

c. 10001-20000

d. Above 20001

TABLE 2: DISEASE AND CHEMOTHERAPY OF FEMALE CANCER PATIENTS N=100

Sl.No

Sample Characteristics

Frequency

Percentage %

Body affected with cancer

a. Blood and Lymphatics

b. Uterus

c. Cervix

d. Breast

e. Ovary

f. Others specify

Stage of cancer

a. First stage

b. Second stage

c. Third stage

d. Fourth stage

Diagnosis time of cancer

a. 0-3 months

b. 4-6 months

c. 7-9 months

d. 10-12 months

e. Above 12 months

Person Helping in doing the house hold work

a. Spouse/children

b. Parents

c. Brothers/sisters

d. Friends

e. Others

Financial help for the family

a. Relatives/friends

b. Rotary club

c. Social service society

d. Loan from the bank

e. ESI

f. NIL

Cycles of chemotherapy completed

a. 1

b. 2

c. 3

d. 4

e. 5

f. 6

Frequency of administering chemotherapy

a. Once in two weeks

b. Once in three weeks

c. Once in a month

Social stressor is major stressor areas with mean standardised score of 1.9 followed by financial stressor with mean standardised score of 1.75 and the least stress area is sexual stressor with mean standardised score of 0.84

TABLE 4: COMPARISON OF PROBLEM FOCUSSED AND EMOTION FOCUSSED COPING N=100

Type of coping	Effective Coping	Ineffective Coping
Problem Focussed Coping	2.06*	1.36*
Emotion Focussed Coping	2.11*	1.51*

*Standardized Mean score

Table 3 shows that female cancer patients with effective coping were using more emotion focussed coping (standardized mean score=2.11) than the problem focussed coping (standardized mean score=2.06).

RELATIONSHIP BETWEEN LEVEL OF STRESS, COPING STRATEGIES AND QUALITY OF LIFE

There was a significant negative correlation (r=-0.66) between level of stress and coping strategies, a significant high negative correlation (r=-0.91)between level of stress and quality of life at and a significant positive (r=+0.64) correlation between coping strategies and quality of life.

TABLE 5: RELATIONSHIP BETWEEN LEVELS OF STRESS, COPING STRATEGIES AND QOL N=100

Scale

Mean

S.D

Correlation (r)

Level of stress

Coping strategies

45.50

41.32

9.76

5.89

-0.66*

Coping strategies

Quality of life

41.32

42.49

5.89

7.38

+0.64*

Level of stress

Quality of life

45.50

42.49

9.76

7.38

-0.91*

*r = 0.195 for df (98) at 0.05 level of significance.

ASSOCIATION OF LEVEL OF STRESS, COPING STRATEGIES AND QOL WITH SELECTED FACTORS

There was a significant association between selected factors such as age (χ²= 36.08), education (χ²= 11.71), family support (χ²= 20.54), social support (χ²= 19.13) and marital status (χ²= 17.29) and level of stress. Coping strategies were significantly associated with economic status (χ²= 10.38), frequency of chemotherapy (χ²=17.28) and cycles of chemotherapy (χ²= 12.72) and a significant association between the quality of life and age(χ²= 12.49) and education (χ²= 9.68) at p<0.05 level. (Table 6)

TABLE 6: ASSOCIATION BETWEEN VARIABLES AND SELECTED FACTORS N=100

Sl. No

Selected Variables

Level of stress

Coping strategies

Quality of life

χ²Value

χ² value

Age in years

20 – 30

31 – 40

41 – 50

Above 50

36.08*

5.02^NS

12.49*

Education

Primary (1-8)

Secondary (SSLC)

Higher Secondary (11-12)

Graduation

11.71*

1.41^NS

9.68*

Marital status

Unmarried

Married

Widow

Divorce/separated

17.29*

2.36^NS

0.39^NS

Occupation

House wife

Govt job

Private job

Retired

Others

9.82^NS

8.32^NS

3.38^NS

Economic Status

Below 5000

5001-10000

10001-20000

Above 20001

6.218^NS

10.38*

2.02^NS

Family Support

Spouse/children

Parents

Brothers/sisters

Friends

Others

20.54*

1.35^NS

5.46^NS

Social Support

Relatives/friends

Rotary club

Social service society

Loan from the bank

ESI

NIL

19.13*

1.83^NS

5.43^NS

Cycles of chemotherapy completed

8.86^NS

12.72*

8.47^NS

Frequency of administering chemotherapy

Once in two weeks

Once in three weeks

Once in a month

4.08^NS

17.28*

2.10^NS

*significant at p(0.05), NS – Not significant at p(0.05)

DISCUSSION:

Researcher could not locate literature covering all the three aspects such as level of stress, coping strategies and quality of life. Chemotherapy induced hair loss was ranked among the transient and unavoidable side effect and it affects the body image and described it as troublesome and distressing. Some of aspects of the study are consistent with the study carried out by Limieux J et al ⁽⁸⁾.

Experiencing chemotherapy induced alopecia produces marked physical, psychological and social distress. Alopecia related distress increases with lack of information, negative perception, and limited social support. Educational programmes and adequate social support reduce the burden laid by the alopecia in cancer patients. Level of stress was significantly associated with education, family and social support which was consistent with study done by Kim I R et al ⁽⁹⁾.

Findings revealed that majority of the patient were using effective coping which mainly involve emotional focussed coping which was consistent with study of Borsellino M et al ⁽¹⁰⁾ and Frith H et al ⁽¹¹⁾. Anticipatory coping was the strategy which was used by the alopecia patient for an expected altered appearance. It provides a greater sense of control over their changing appearance and better coping.

CONCLUSION:

Nurses are required to be accountable for the quality of the patient care they deliver. Nurses act as an educator for educating the client regarding the management of the chemotherapy induced alopecia both physically and psychologically and enhance effective stress management techniques and improved coping strategies. A more holistic approach to the patient care is believed to improve health outcomes, to increase patient and team satisfaction, to reduce the stress and to help patients to cope to better terms with their treatment experiences. Nurse-client interactions provide opportunities to express the feelings, to offer psychosocial support and empathy, to reinforce coping skills and to promote the optimal level of health.

Nurses have the potential to directly influence QOL through interventions that may help female cancer patients rebalance their lives. Innovative therapies include meditation, music therapy, support groups, and spiritual counselling that use holistic approaches to healing may promote healthier adaptations to chemotherapy induced alopecia.

Self care guide prepared by the researcher help the patient to deal with the problems of the chemotherapy induced alopecia. There is a need for well-designed intensive information for female cancer patients; so that they can be prevented from the psychological stressor and to cope with the symptoms effectively and thereby improving the quality of life.

The aspect of identifying the level of stress, coping strategies and quality of life has not been given sufficient thought so far. Research studies conducted by the Indian nurses in this aspect are very few. The need for the hour is that nursing personnel provide scientifically tested materials or programs towards the assessment of the problems and provide psychosocial support accordingly.

ACKNOWLEDGEMENT:

The authors express our sincere gratitude to Amala Cancer Hospital, AIMS, Thrissur, Director, HOD, Medical Oncology Dept, Principal, Amala Institute of Medical Sciences and the female cancer patients for their kind support and co-operation during the course of study.

ETHICAL CLEARANCE:

AIMSIEC/01/2013

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Received on 09.03.2016 Modified on 05.04.2016

Asian J. Nur. Edu. and Research.2017; 7(1): 1-6.

DOI: 10.5958/2349-2996.2017.00001.5

Sl No	Stress Areas	Mean	Standardised mean score	Rank
1	Psychological Stressors	19.36	1.38	5
2	Physical Appearence Stressors	6.15	1.54	4
3	Family Stressors	4.87	1.62	3
4	Sexual Stressors	1.68	0.84	6
5	Financial Stressor	1.75	1.75	2
6	Social Stressor	11.41	1.90	1