The mediating role of resilience in the relationship between social support and posttraumatic growth among colorectal cancer survivors with permanent intestinal ostomies: A structural equation model analysis

https://doi.org/10.1016/j.ejon.2017.04.007Get rights and content

Highlights

  • Moderate to high PTG in CRC survivors with permanent intestinal ostomies.

  • Resilience and perceived social support positively associated with PTG.

  • The mediating role of resilience between perceived social support and PTG.

Abstract

Purpose

Information on posttraumatic growth (PTG) among colorectal cancer (CRC) survivors with permanent intestinal ostomies is limited. The aim of this cross-sectional study was to investigate the occurrence of PTG among CRC survivors with permanent intestinal ostomies and its association with perceived social support and resilience.

Methods

This study was conducted with 164 CRC survivors with permanent intestinal ostomies at least one month after surgery. Participants completed questionnaires assessing socio-demographic and clinical characteristics, perceived social support, resilience and PTG.

Results

The mean total score on the Post Traumatic Growth Inventory was 66.74 (SD = 13.99). Perceived social support (r = 0.450) and resilience (r = 0.545) were significantly positively correlated with PTG. Structural equation modeling analysis showed that resilience mediated the relationship between perceived social support and PTG in which the indirect effect of perceived social support on PTG through resilience was 0.203 (P < 0.001).

Conclusions

Moderate to high PTG was found in CRC survivors with permanent intestinal ostomies. The most important implication of this study was that improving social support and resilience might be scientific intervention strategies for promoting PTG among CRC survivors.

Introduction

Colorectal cancer (CRC) is the third most common and leading cause of death from cancer worldwide (Siegel et al., 2013). Treatment approaches for CRC include surgery, radiation, and chemotherapy, and are usually accompanied by the placement of an intestinal ostomy, or stoma (Wendel et al., 2014), of which a permanent intestinal ostomy is the most frequently used (Krouse et al., 2009). A permanent intestinal ostomy is an intrusive surgical operation, which unavoidably results in the absence of a significant body function (Sun et al., 2013)and a devastating alteration of body image (Sharpe et al., 2011). It may lead to negative changes among CRC survivors, including low self-esteem, social withdrawal, depression and even suicidal ideations (Ahwal et al., 2016, Chongpison et al., 2015, Hong et al., 2014). Although both CRC and a permanent intestinal ostomy are traumatic events (Koopman et al., 2002, Salsman et al., 2009), studies have found that a relatively large proportion of CRC survivors report positive changes in the context of their diseases (Hawkes et al., 2014, Jansen et al., 2011, Occhipinti et al., 2015, Salsman et al., 2009), such as posttraumatic growth (PTG) (Tedeschi and Calhoun, 2004). A result of the struggling with a traumatic event, PTG is defined as psychological growth beyond previous levels of functioning and an active change in one's capacity to deal with adverse events (Sumalla et al., 2008, Tedeschi and Calhoun, 2004). Even years after the cancer diagnosis and treatment, PTG may develop in several areas of life: relating to others, new possibilities, personal strength, spiritual change, and appreciation of life (Calhoun et al., 2006).

The social-cognitive processing model (Tedeschi and Calhoun, 2004)emphasizes the significance of cognitive processing in producing PTG, and the important role of social interactions in enhancing or hindering the cognitive adaptation processes. Some studies have found that social support, as a supportive social context and a key environmental resource (Calhoun and Tedeschi, 2004, Schaefer and Moos, 1992) can facilitate the successful confrontation of difficulties and cognitive adaptation processes when facing a cancer diagnosis, and thereby promote PTG (Morris and Shakespeare-Finch, 2011, Nenova et al., 2013, Scrignaro et al., 2011, Silva et al., 2012). However, social support is a complex multifaceted construct, and different types of social support yield different effects on PTG (Lepore and Revenson, 2007, Schroevers et al., 2010), which may be one of the reasons for the mixed results of correlations between social support and PTG (Prati and Pietrantoni, 2009, Sears et al., 2003, Weiss, 2004).Furthermore, to date, research has not yet tried to understand the relationship between perceived social support and PTG in CRC survivors with permanent intestinal ostomies. Therefore, more research is needed in the next step to understand the relationship between social support and PTG.

The existence of PTG in cancer survivors is well known, although less is known about why some cancer survivors experience more positive changes than others do. It believes that resilience is the main factor that accounts for the different perceptions found in patients about their PTG (Mancini and Bonanno, 2006). Resilience refers to the process of adapting well in the face of adversity, trauma, and even significant sources of threat (Norris et al., 2008, Southwick and Charney, 2012b) . Resilient individuals are more likely to focus on positive emotions (Cohn et al., 2009), and exhibit cognitive flexibility (Southwick and Charney, 2012a)under stressful circumstances, which thereby help them maintain psychological adjustment to other challenging situations (Cohn et al., 2009, Manne et al., 2014). Recently, the comprehensive concept of resilience has been introduced to refer to protective attributes in an individual's adaptation to cancer (Gouzman et al., 2015) . Studies have found that individuals with greater resilience manifest a better psychological state and quality of life (Molina et al., 2014, Rosenberg et al., 2015a, Wu et al., 2015), and previous research suggests resilience can have an effect on an individual's PTG (Gouzman et al., 2015, Tedeschi and Mcnally, 2011, Wilson et al., 2014). Additionally, social support, as an external resource has been found to have enhancing effects on resilience (Mo et al., 2014, Southwick and Charney, 2012b, Stewart and Yuen, 2011). Hence, based on previous studies, it can be deduced that resilience might mediate the relationship between social support and PTG.

Above all, the primary aim of this study was to test the direct and indirect effects of variables on PTG among CRC survivors with permanent intestinal ostomies. Based on previous research, it was hypothesized that a positive association would be found between perceived social support, resilience, and PTG. In addition, the mediation effect of resilience might exist between perceived social support and PTG. To the authors’ knowledge, this is the first study that aimed to investigate the correlations between perceived social support, resilience, and PTG among CRC survivors with permanent intestinal ostomies. Furthermore, this study was designed to explore an important target of treatment to develop intervention that contributes to improving PTG.

Section snippets

Participants and procedures

This cross-sectional, observational study was conducted over a period of 2 years from 2014 to 2015 in Shandong Cancer Hospital & Institute, and was approved by the Ethics Committee at Shandong University. All CRC survivors with permanent ostomies who provided informed consent were enrolled from the colostomy outpatient clinic. The inclusion criteria were as follows: (1) age 18 or older; (2) diagnosed with CRC and treated with curative intent; (3) received surgery at least one month before the

Patient characteristics

The socio-demographic characteristics and clinical data of the patients are summarized in Table 1. The mean age was 57.49 years (SD = 9.88, range = 26–78). Fifty-nine percent of the participants were male, most (98.8%) were married, 62.8% had less than a high school education, 33.1% had a low average monthly income (¥1000 and below), and 26.8% was were employed. As for the patients'clinical information, 34.1% received surgery more than 12 month before the study, and 32.3% had complications

Discussion

This study was intended to explore the occurrence of PTG and factors associated with PTG among CRC survivors with permanent intestinal ostomies. The results indicated that positive changes do occur among CRC survivors with permanent intestinal ostomies. In line with the hypotheses, both perceived social support and resilience had significant positive relationships with PTG, and resilience mediated the relationship between perceived social support and PTG. In this study, participants reported a

Conclusion

Moderate to high PTG was found in CRC survivors with permanent intestinal ostomies. Our results show that CRC survivors with permanent intestinal ostomies who perceived higher levels of social support would experience greater PTG. The mediating role of resilience should provide new insights for the enhancement of PTG, such as resilience training, and the most important implication of this study was that improving social support and resilience might be scientific intervention strategies for

Conflict of interest

The authors have declared no conflicts of interest.

Authors' contributions

X Dong and G Li were involved in design of the study, analysis and interpretation of data, drafting and revising the manuscript. C Liu and L Kong participated in data acquisition, design of the study, and interpretation of the results. Y Fang and X Kang provided help with the data analysis and interpretation, and revised several drafts of the manuscript. P. Li made substantive intellectual contributions to the interpretation of data and draft of the manuscript. All authors have read and

Acknowledgements

The study was supported by grants from Shandong Province Natural Science Foundation (ZR2015HM064). We are thankful for the generous contributions of the research participants and the staffs who assisted with data collection during the study.

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