Gastric and colorectal cancers are the leading causes of cancer-related death and are also the most prevalent group of cancers in China.1 According to the report of the Ministry of Health People’s Republic of China in 2002, the morbidity and mortality rates of colorectal cancer ranked third and fifth in the 1990s.2 Now, it is estimated that gastric cancer will remain a significant cancer burden in China during the next decade. With recent advancements in screening and surgical techniques, chemotherapy regimens, and supportive care, the overall mortality rates have declined, and survival time has been extended.3 However, the numbers of new cases and survivors of gastric and colorectal cancer are increasing in China. Cancer represents a stressful life event. Reactions to diagnosis, treatment, and supportive care of cancer vary widely and include a range of physical, psychological, and social effects.4 Cancer now is increasingly considered as a chronic condition.5 Currently, the best management approach to this chronic condition is self-care, which is defined as cancer patients engaged in self-observing, recognizing, and labeling symptoms and judging their severity, assessing and choosing treatment options, and evaluating the effectiveness of self-care.6 A study by Lev7 indicated that participants who used self-care strategies had lower self-ratings of stress than did participants who did not use such strategies, suggesting that the use of self-care strategies could enhance coping. One of the most widely applied theories in predicting health behaviors is the self-efficacy theory,8 which provides a comprehensive mechanism analysis of self-efficacy in changing behaviors. However, little literature evaluates the relationships among the physical, psychological, social, demographic, and disease-related variables and self-care self-efficacy among gastric and colorectal cancer patients in China.
Self-efficacy and Self-care Self-efficacy
As a psychological concept derived from Bandura’s9 self-efficacy theory, self-efficacy is defined as an individual’s confidence in his/her ability to perform a specific behavior or task. As well, self-care self-efficacy focuses on performing relevant self-care behaviors. Bandura’s theory10 suggests that people with stronger efficacy expectations are more likely to persist with different tasks, even after experiencing an initial impediment or failure. In recent years, self-efficacy is recognized for its significant effect on patients’ adaptation to diseases.11 Findings of certain studies indicated that increased self-efficacy was associated with increased participation in cancer screening and adherence to cancer treatment, increased self-care behavior,12 decreased physical and psychological symptoms,13 and better adjustment to cancer diagnosis.14 Furthermore, findings coneyed that self-efficacy was positively correlated with quality of life and negatively correlated with mood in several studies.15–17
Self-efficacy and Related Factors
According to Bandura’s9 theory, behavioral self-efficacy was developed from 4 resources of information, including mastery experiences, vicarious experiences, verbal persuasion, and physical and affective states. Mastery self-efficacy experiences and vicarious experiences such as cancer patients taking part in cancer self-management programs that contained disease management skills (mastery experiences) resulted in participants having a high degree of self-efficacy. The programs also included observing and modeling behaviors (vicarious experiences). Currently, most published articles report on correlations of self-efficacy with quality of life, psychological adjustment, and health behaviors.15–17 However, few studies examine factors that influenced self-efficacy in specific situations.
The investigation of opioid-taking self-efficacy of Liang et al18 documented that individuals with lower levels of education reported lower confidence in taking their analgesics. The result was in accordance with that of the study of Akin et al15 among Turkish breast cancer patients. In addition, Akin and colleagues15 reported that occupation, body mass index, and chemotherapy protocol were positively associated with self-care self-efficacy.
The study of 307 cancer patients at all stages of disease of Lev et al19 demonstrated that age was an influencing factor on self-care self-efficacy. Levels of self-care self-efficacy decreased over time without additional interventions. Of note, the positive relationship between age and self-care self-efficacy in this study differed from the results of the study of Akin et al,15 which did not find a relationship. However, Rogers and colleagues20 reported that lower task self-efficacy of breast cancer patients was associated with older age.
Rogers et al21 also documented that the level of self-efficacy was the lowest when cancer survivors felt nauseated and tired. Structural equation analyses yielded significant and direct associations for perceived physical activity (PA) barriers (β = −.29), fatigue (β = −.24), social support (β = .12), enjoyment (β = .12), and prediagnosis PA (β = .11) with barrier self-efficacy. In addition, task self-efficacy was associated with prediagnosis PA but not perceived barrier.
The findings from a study by Perkins and colleagues22 of breast cancer survivors included that vitality, bodily pain, and mental health were associated with self-efficacy specifically for PA. In patients with prostate cancer, education, vitality, and bodily pain were influencing factors.22 However, treatment factors and comorbidities were not associated with self-efficacy.22 As to emotion, Jensen et al23 found that greater mood disturbance was associated with a lower level of self-efficacy for carrying out recovery-related behaviors. The results were in accordance with the research of Perkins et al24 on the association of mood disturbance with self-efficacy expectation and behavior performances of recovery activities in angioplasty patients.
Although the influencing factors of self-efficacy have been analyzed in opioid-taking patients, carrying out recovery-related self-care behaviors and PA, some results were inconsistent and need to be further explored. Until now, few investigations have addressed self-care self-efficacy and comprehensively explored its influencing factors in Chinese cancer survivors. Therefore, in this study, we measured levels of self-care self-efficacy in Chinese gastric and colorectal cancer survivors. We identified the demographic and disease-related characteristics, health status, social support, and psychological factors associated with self-care self-efficacy. We believed that the resulting information would assist health providers in identifying vulnerable patients and populations and helping these patients improve their self-care.
Design, Sample, and Procedure
The study used a cross-sectional survey design. A convenience sampling method was used to recruit the participants. The sampling frame was the gastric and colorectal cancer patients who were admitted to inpatient oncology wards of the 2 hospitals in Shanghai and Shandong Province of China. Patients were eligible for enrolment in the study if they met the following inclusion criteria: (1) had a cancer diagnosis (gastric or colorectal cancer), (2) age 18 years or older, (3) able to be interviewed, (4) at least 6 months after a diagnosis of gastric and colorectal cancer, and (5) knew that they had cancer. The patients with significant mental diseases or cognitive impairment were excluded. A total of 170 patients were approached; 22 declined participation. Reasons given for not participating were not interested or about to end treatment. The remaining 148 eligible participants enrolled and completed the study.
After the approval of the study by the ethics committee of the Second Military Medical University (approval file no. 2010LL008), investigators approached potential participants in the wards of hospitals. The aim of the study and research rights were explained to participants. The participants who were unable to complete the questionnaires by themselves were read the items by the investigators. Certain medical data were obtained from the patients’ medical history and recorded on the study medical data form.
DEMOGRAPHIC AND DISEASE-RELATED INFORMATION
The first study questionnaire had 2 parts composed of demographic (age, sex, religious, marital status, education, lifestyle, employment status, income, profession, personality, and type of payment) and disease-related variables (stage of disease, duration of disease, treatment regimens, complications, recurrence, and the presence of other chronic diseases).
THE STRATEGIES USED BY PEOPLE TO PROMOTE HEALTH
This scale developed by Lev and Owen16 measures self-care self-efficacy and contains 29 items in 3 subscales: (1) positive attitude, (2) stress reduction, and (3) making decisions.25 The internal consistency (α = .92) and test-retest reliability (r = 0.94) of the Strategies Used by People to Promote Health (SUPPH) are acceptably high. For this study, the SUPPH was translated and back-translated independently by 2 bilingual experts. In order to test whether the scale was suitable for the Chinese culture, we held a formal meeting with patients and oncology experts to discuss the items. We found that the items “finding ways of alleviating my stress” and “using a specific technique to manage my stress” have very similar meaning in China. Therefore, we retained only 1 of the 2 items. Reliability and validity were estimated in our preliminary study involving 194 cancer patients. The Chinese version of the SUPPH contained 28 items and 3 subscales. It had acceptable psychometric properties with Cronbach α for the 3 subscales ranging from .849 to .970. Construct validity was confirmed by factor analysis with 66.65% variance explained by the 3 factors.
THE MEDICAL OUTCOME STUDY SHORT FORM 36
The Medical Outcome Study Short Form 36 (SF-36)26 assesses a person’s functional status and well-being and includes 36 items divided into 8 subscales: physical functioning, social functioning, pain, mental health, vitality, general health, role limitation due to physical problems, role limitation due to emotional problems, and a single-item subscale on health transition. The SF-36 has high internal consistency reliability (Cronbach α =.78–.93).27 The Chinese version of the SF-36 was developed and tested by Li et al28 in 1688 Chinese subjects. Cronbach α coefficients were acceptable for most subscales, with coefficients ranging from .72 to .88; exceptions were .39 for the social functioning subscale and .66 for the vitality subscale.
THE SOCIAL SUPPORT QUESTIONNAIRE
The Social Support Questionnaire developed by the Mental Health Institution of the Hunan Medical University measures social support for cancer patients in China.29 The 10-item questionnaire measures objective support (3 items), subjective support (4 items), and the use of available social support (3 items). Participants are required to select 1 of 4 statements that represent their perceptions of support during cancer treatment. Xiao and Yang30 reported internal consistency of .81 and a test-retest reliability of 0.92.
THE HOSPITAL ANXIETY AND DEPRESSION SCALE
The Hospital Anxiety and Depression Scale has 2 subscales: anxiety and depression, specifically designed for general medical and surgical patients,31 and has been widely used in cancer patients in recent years. The scale consists of 14 items, each rated on a 4-point (0–3 points) range.32 The Chinese version of Hospital Anxiety and Depression Scale has test-retest reliability for the anxiety and depression subscales of 0.92 and 0.84, respectively.33 Zigmond and Snaith32 recommended 2 cutoff scores for both subscales: 7/8 for possible and 10/11 for probable anxiety or depression.
The Statistical Package for the Social Sciences version 16.0 (SPSS for Windows; SPSS Inc, Chicago, Illinois) was used to analyze the data. Descriptive statistics included frequencies, means, SD, and percentage, demonstrating a general description of the sample characteristics. Normality and homogeneity of variances were first inspected for each variable. Self-care self-efficacy and its relationships with demographic and disease-related factors were examined through 1-way analysis of variance. For skewed distributions, we used the nonparametric Kruskal-Wallis H test. Second, we examined the relationships between variables (health status, social support, and psychological indicators) and self-care self-efficacy using the Spearman rank correlation coefficient. For the unranked variables, dummy variables were also created, such as work status, profession, and characteristic. Finally, we used multiple regression analysis (stepwise method) to examine how self-care self-efficacy was related to selected independent variables. The α level of significance was set at .05.
Characteristics of Subjects
A total of 148 gastric and colorectal cancer patients completed study questionnaires (Table 1).
The Level of Self-care Self-efficacy
The mean total score of the SUPPH was 80.34. Scores of subscale stress reduction, making decision, and positive attitude were 28.69, 8.95, and 42.71, respectively (Table 2). The Spearman correlations were significant (P < .01), except that no associations were noted between the subscales positive attitude, making decision, and age (Table 3). Negative relationships were seen between psychological variables (anxiety and depression) and 3 subscales of self-care self-efficacy, indicating that the worse psychological status scores the participants reported, the lower their level of confidence that they could take on self-care activities related to diseases. The relationships between other variables (subscales of the SF-36, subscales of the Social Support Questionnaire) and subscales of the SUPPH were positive and significant (Table 3).
Predictors of Self-care Self-efficacy
Profession (F = 3.150, P = .006 < .05), personality (F = 3.787, P = .025 < .05), education (F = 3.316, P = .012 < .05), stage (F = 3.303, P = .000 < .05), complication (T = 4.307, P = .000 < .05), and recurrence (T = 4.526, P = .000 < .05) were all positive predictors of self-care self-efficacy. Cancer survivors with outgoing personality and more education years reported higher levels of self-care self-efficacy; participants with dis eases recurrence, complications, and advanced disease stages reported lower levels of self-care self-efficacy. A significant difference in self-care self-efficacy by work status was found (χ2 = 8.208; P = .042 < .05). The patients who had a full-time job had the highest score of self-care self-efficacy. We entered the above variables into the multiple regression analysis (Table 4). Five variables (depression, physical functioning, use of available social support, vitality, and profession) were separately entered in the model. Results indicated the model was significant (F = 41.396, P = .001). These variables accounted for 60.90% of the variance in self-care self-efficacy. Among these, the variable of depression accounted for 45.90% of the variance.
The purpose of the study was to identify demographic and disease-related characteristics, health status, social support, and psychological factors associated with self-care self-efficacy among gastric and colorectal cancer patients. The cancer patients in this study were moderately confident of being able to perform the self-care activities (mean, 80.34).
The relationship between age and self-care self-efficacy was significant and negative. Fatalism, a core construct in Chinese culture, may impact the elderly patients who report lower levels of self-efficacy for self-care activities. Many Chinese people explain most life events, including health and illness, as acts of God, or in terms of luck, fortune, or fate because these are part of a cosmology of life that forms the basic interpretative system of people living according to Chinese traditions.34 Kwok and Sullivan35 also reported that Chinese-Australian women are heavily influenced by cultural traditions related to the life cycle and disease prevention. Fatalism could be a significant barrier to their participation in cancer screening services. The physiological changes that occur with aging and biopsychosocial problem were also associated with lower self-efficacy status and age.36 Meanwhile, Beckham et al37 found that age was significantly related to cancer adjustment, and negative affect was mediated by self-efficacy, with younger age associated with better cancer adjustment and greater negative affect. In the study of Akin et al,15 the relationship between age and self-efficacy was not found.
Educational level and profession were both associated with self-care self-efficacy. In this study, patients with higher education were more confident about performing self-care activities; these results are similar to those of Lam and Fielding38 and Porter et al.13 In fact, educational level was strongly associated with seeking knowledge, which was related to the individual’s health literacy. Health literacy had been identified as a predictor of self-efficacy in colorectal cancer screening.39 The relationship could indicate that health professionals need to offer more medical information and skills support to lower-educated gastric and colorectal cancer patients to boost their self-efficacy. As for profession, the patients who were farmers had the lowest scores of self-care self-efficacy. The farmers’ low level of education may have limited their seeking information. A survey also found that participants who did not have at least a college education were significantly less likely to classify themselves as information seeker.40
In our study sample, 27.03% of participants did not have jobs. Unemployed cancer patients had lower scores of self-care self-efficacy than did retired or full-time-employment participants. Chinese people have highly valued characteristics of diligence and hardworking spirits. If a person cannot work and contribute to the family, he/she views himself/herself as a burden to family and society. The differences on self-care self-efficacy by work status were significant and consistent with findings from the studies of Lam and Fielding38 and Lev et al.41
In term of personality, 3 subgroups of self-care self-efficacy were significantly different. The scores of the outgoing-personality subgroup were higher than that of the other 2 subgroups. Perhaps, outgoing persons are more easily able to accommodate life events and are more optimistic and hopeful. Brockopp et al42 reported a significant correlation between self-efficacy and hope.
Differences in self-care self-efficacy by sex were not found in this study. If males have cancer, it would directly result in financial difficulty for their family and their immediate family (parents and siblings); traditionally, the Chinese male bears the responsibility for supporting the aged parents until death.43 It is unclear why we did not find sex differences. We also did not find an association between religion and self-care self-efficacy, unlike another study44 In China, most people were more likely to adopt the traditional Chinese belief such as Confucianism, ancestor worship, or fatalism. Nurses should pay more attention to the Chinese culture’s influence on the belief when developing the self-care interventions.
We also did not see differences on self-care self-efficacy by insurance and family income. The Chinese government has recently begun to pay more attention to rural living conditions and has implemented the new rural cooperative medical insurance. The coverage of the medical insurance is expanding. Hu and Ken45 reported that perceived financial difficulty was the most significant predictor of quality of life. Yet we did not find income level as influencing self-care self-efficacy. Similar results appeared in the study of Akin et al.15 The differences of self-care self-efficacy by lifestyle and marital status were not significant. The relationships of the above variables with self-care self-efficacy need to be verified in future studies.
Disease-Related Characteristics and Self-care Self-efficacy
Differences in self-care self-efficacy subgroups divided by the stage of disease and whether the patients had complication or recurrence were significant. With disease progression, the scores of self-care self-efficacy decrease. Our results were also consistent with those in the study of Porter et al,13 but not with those of Akin et al,15 who did not find such an association. We did not find differences in subgroups by treatment regimens. This difference in several studies may be secondary to differences in how treatment regimens were measured or secondary to longitudinal versus cross-sectional designs. The study of Lev et al19 as well revealed that the decreases in self-care self-efficacy among cancer patients at all stages at baseline, 4 months, and 8 months were significant.
Health Status and Self-care Self-efficacy
In our sample, the components of health status had a significant and positive correlation with self-care self-efficacy; that is, high levels of health-related quality of life had a greater impact on self-care self-efficacy. Hirai et al46 also reported that cancer patients with good physical condition had a high level of self-efficacy, accounting for 8% of the variance in self-efficacy. In the final model of this study, variables of physical functioning and vitality retained in the model explained 8.2% and 2.4% of the total variance. The subscale of physical functioning measured the extent that physical status influenced everyday activities. Hu and Ken’s45 investigation on symptom prevalence among patients newly diagnosed with gastrointestinal cancer reported that the most common were fatigue, pain, and weight loss. To some degree, these signs and symptoms could limit patients’ physical functioning. The vitality subscale measures the extent of patients’ energy and fatigue. Hoffman et al47 had tested perceived self-efficacy serving as a mediator between cancer-related fatigue and physical functional status through a path model. The study of Perkins et al22 reported that vitality was associated with self-efficacy. In the traditional Chinese medicine, Chi has been translated as “energy,” “vital energy,” or “life of force.” A healthy and strong Chi that manifests itself as yin and yang is said to be vital for holding the various organs, vessels, and tissues of the body in their correct places, hence facilitating their correct functioning.48 As to the other variables that did not enter the final model, these variables may explain the residue percentages (39.1%) of variance. However, pain is not shown as influencing self-care self-efficacy, a result contrary to the study of Perkins et al.22 Perhaps 1 symptom item alone did not provide a true indication of the symptom experience. Also, different scales were used to measure self-efficacy and could have yielded different results. Which signs and symptoms of the gastric and colorectal cancer patient impact self-care self-efficacy need to be further studied.
Social Support and Self-care Self-efficacy
In this investigation, the average social support was moderate, with a higher rating for objective social support followed by subjective social support and the use of available social support. The subscales and total of social support were significantly correlated with self-care self-efficacy. Family is a major source of practical and emotional support in China. After being diagnosed as cancer, some Chinese become socially isolated and are reluctant to talk about the disease with others or participate in social activities. This situation could block the patients’ information seeking.
Psychological Status and Self-care Self-efficacy
Anxiety and depression had a negative relationship with self-care self-efficacy. The Spearman rank correlation coefficients were separately −0.624 and −0.639. In this study, the occurrence rates of depression and anxiety were 54.8% and 53.4%. Depression was the largest psychological variable, accounting for 45.9% of the variance in self-care self-efficacy. Kohno et al49 reported that anxiety and posttraumatic stress symptoms in gastrointestinal cancer survivors were the largest sources of influence on efficacy. In China, a cancer diagnosis is viewed as taboo, and Chinese cancer patients often feel stigmatized and ashamed by illness.50 They are reluctant to mention their mood and less likely to complain to their friends or relatives. Consequently, cancer patients may be subject to anxiety and depression. Depression may be related to the person’s isolation and loneliness.51 Health professionals need to especially be aware of the patients’ psychological status.
Implications for Practice
This study clearly demonstrated a comprehensive analysis of factors related to self-care self-efficacy. Our findings help to identify the most efficacious pathways to boost patients’ self-care self-efficacy. More could be done to improve self-care self-efficacy, in particular for those who have more depression, worse physical function, less social support, and low vitality. Moreover, the results could assist in designing self-care interventions that might include more individualized, culturally sensitive measures for improving the level of self-care self-efficacy of Chinese cancer patients.
A convenient sampling method was used to recruit the participants, which may introduce bias and could limit the generalizability of the findings. This study is a cross-sectional investigation, and as such, we are not able to determine the direction or causality of any relationship between self-care self-efficacy and physical, psychological, social, demographic, and disease-related factors. We suggest using structural equation modeling to examine the exact relationships in future studies. Second, because of the small sample size, some unanticipated results need to be further tested. Third, we did not use a pain- or fatigue-specific measure; our results may be influenced by our use of a single item.
Chinese patients with gastric and colorectal cancer had a moderate level of self-care self-efficacy. Age, profession, educational level, work status, personality, stage of disease, disease complication, and recurrence were associated with their self-care self-efficacy. Depression is the largest variable influencing self-care self-efficacy.
Good physical health status and social support had a positive tie with self-care self-efficacy. Further research will examine the disputed variables such as religion associated with self-efficacy.
The authors thank Yaoqin Qiu, major in biostatistics, for her statistical consultation, and Shizheng Du and Wenjun Gao for their help during the process of investigation.
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Chinese patient; Colorectal cancer; Gastric cancer; Self-care; Self-efficacy
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