Print version ISSN 0103-2100
Acta paul. enferm. vol.25 no.2 São Paulo 2012
Coping strategies and the relationship with sociodemographic conditions of women with breast cancer*
Estrategias de enfrentamiento y relación con condiciones sociodemográficas de mujeres con cáncer de mama
Franciéle Marabotti Costa LeiteI; Maria Helena Costa AmorimII; Denise Silveira de CastroII; Cândida Caniçali PrimoIII
IM.Sc. in Collective Health. Faculty,
Nursing Department, Universidade Federal do Espírito Santo - UFES - Vitória
IIPh.D. in Nursing. Faculty at Centro de Ciências da Saúde, Universidade Federal do Espírito Santo - UFES - Vitória (ES), Brazil
IIIM.Sc. in Collective Health. Faculty, Centro de Ciências da Saúde, Universidade Federal do Espírito Santo - UFES - Vitória (ES), Brazil
OBJECTIVE: To examine the relationship
among the coping strategies adopted by women with breast cancer using tamoxifen
and sociodemographic conditions.
METHODS: A cross-sectional study, with a quantitative approach. Data were obtained in an interview conducted with 270 women, with a diagnosis of breast cancer using tamoxifen, users of the outpatient Ylza Bianco center, belonging to the Hospital Santa Rita de Cássia, in Vitória / ES (Brazil). The analysis was performed using SPSS - Version 13.0 - 2004.
RESULTS: Illiterate women faced the problem by prioritizing the search for religious practices (p <0.05); and women with higher education, belonging to economic class B, with family income more than three times the minimum wage and who lived in urban areas employ more coping strategies that are focused on the problem (p <0.05).
CONCLUSION: The coping strategy adopted is associated with sociodemographic characteristics.
Keywords: Breast neoplasms; Tamoxifen/therapeutic use; Adaptation, psychological; Socioeconomic factors
OBJETIVO: Examinar la relación
entre las estrategias de enfrentamiento adoptadas por mujeres con cáncer
de mama que usan tamoxifeno y las condiciones sociodemográficas.
MÉTODOS: Estudio descriptivo, transversal, con abordaje cuantitativo. Los datos fueron obtenidos en entrevista realizada a 270 mujeres, con diagnóstico de cáncer de mama que usan tamoxifeno, usuarias del Consultorio Externo Ylza Bianco, perteneciente al Hospital Santa Rita de Cássia, en el Municipio de Vitória/ES. El análisis fue realizado por medio del SPSS - Versión 13,0 - 2004.
RESULTADOS: Las mujeres no letradas enfrentan el problema priorizando la búsqueda de prácticas religiosas (p<0,05); y mujeres con mayor escolaridad, pertenecientes a la clase económica B, con ingreso familiar superior a tres salarios mínimos y que viven en área urbana emplean más la estrategia de enfrentamiento con foco en el problema (p<0,05).
CONCLUSIÓN: La estrategia de enfrentamiento adoptada está asociada a aspectos sociodemográficos.
Descriptores: Neoplasias de la mama; Tamoxifeno/uso terapéutico; Adaptación psicológica; Factores socioeconómicos
The breast cancer diagnosis entails the stigma of pain, suffering and death, mainly because it is associated with losing one's breast, which is highly valued and significant in the Brazilian culture, representing a part of female identity (1).
Treatments in the fight against this tumor range from local procedures, such as surgery and radiotherapy, to systemic action, which is the case of chemotherapy and hormone therapy (2). The latter has been frequently used in breast cancer, as about 80% of women with breast tumors present positive hormonal receptors(3).
The main hormones used include tamoxifen. This drug is an anti-estrogen agent that connects with the estrogen receptors present in part of the breast tumors, blocking cell growth and proliferation (4). Although it inhibits the growth of cancer cells and most women tolerate it well, depending on the target tissue, tamoxifen can trigger side effects like hot flashes, nausea, vomiting, menstrual alterations and nervousness (5).
Both the breast cancer diagnosis and its treatment motivate changes in the woman's body image and are also responsible for distancing from their daily activities (6). These generate insecurity, anguish and, consequently, stress, which can be mitigated through coping, defined as a mechanism individuals develop to deal with so-called "stressful" problems or situations (7).
Coping comprises cognitive and behavioral efforts to manage the internal or external demands that emerge from individual interaction with the environment (8). The coping strategies used to administer internal and external stimuli, according to individual assessment, can be joined in two foci: problem-centered coping and emotion-centered coping (9).
In problem-centered coping, individuals attempt to solve the situation by seeking information about the stressful event, assessing their alternative actions so as to select what they believe to be the most feasible alternative. In emotion-centered coping, on the other hand, the strategies used come with a high emotional burden and result from the person's self-defense processes, triggering mechanisms of distancing, flight and avoidance that serve as a shield and avoid the individual's confrontation with the stressor (9).
The goal of coping is to trigger a response that is generally oriented towards stress reduction. This is a dynamic process, with assessments and reassessments that allow people to change their conducts and conceptions, so as to allow them to face the stressor in the most adequate and effective way possible (10).
It is highlighted, however, that sociodemographic conditions, in addition to the adversities of the clinical condition, can result in a larger number of stressors, negatively affecting patients' psychological wellbeing (11). Thus, studies have been done to verify the association between the sociodemographic condition and coping modes. These reveal that variables like age and education are related to the adopted coping strategies (12-14). Other studies reveal that older people with higher education levels use more coping based on religious practices and on emotion (12-14).
In view of the above, considering that the breast cancer diagnosis and treatment generates changes in women's daily life, that this situation demands a coping response and that knowledge on this response is extremely valuable for nursing, as it allows nurses to plan individualized care delivery to these women, consequently achieving their better adaptation to treatment (15), the following question emerged: are the coping strategies women with breast cancer undergoing tamoxifen treatment adopt related with their sociodemographic conditions?
Based on this question, the present study was elaborated to examine the relation between the coping strategies women with breast cancer using tamoxifen adopt and their sociodemographic conditions.
This descriptive and cross-sectional research with a quantitative approach was developed at the Ylza Bianco outpatient clinic, which is affiliated with Hospital Santa Rita de Cássia (HSRC), Vitória/ES. The population consisted of 1,080 women with breast cancer taking tamoxifen, 270 of whom were invited to participate in the research, when they visited the service to pick up the tamoxifen, representing a convenience sample.
The following inclusion criteria were adopted: having been diagnosed with breast cancer and using tamoxifen. Data were collected between May and September 2008. After receiving orientations and specifications about the study aims and after signing the Informed Consent Term, the women were invited to individually participate in an interview, when a form was applied to collect the sociodemographic variables: education, housing, family income and economic class. For the latter, the classification of the Brazilian Association of Market Research Companies (ABEP) was adopted (16). To identify the coping strategy, the Problem Coping Mode Scale (EMEP) was applied, validated by Seidl, Tróccoli e Zannon (2001), in a factor analysis of a Brazilian population, comprising people from the general population and people with chronic conditions (12).
The EMEP contains 45 items, divided in four coping strategies: problem-focused coping, emotion-focused coping, search for religious practice / imaginary thinking and search for social support. Answers are evaluated on a 5-point scale (1 = I never do that; 5 = I always do that). Higher scores indicate greater use of a given coping strategy. For statistical analysis of medians, standard deviations and Wilcoxon's non-parametric test, Statistical Package for the Social Sciences (SPSS) software - version 13.0 - 2004 was used. Significance was set at p<0.05.
This research complies with the ethical determinations established in National Health Council (CNS) Resolution No. 196/96 and received approval from the Research Ethics Committee at Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória (EMESCAM), under No. 037/2008.
Illiterate women predominantly use religion-focused coping (p<0.05), while the group with secondary and higher education degrees more frequently uses problem-focused coping (p=0.000). In groups with or without a primary education degree, no statistically significant association was found when relating religious and problem-focused coping strategies (p>0.05). Independently of education, women use the problem focus more than the search for social support and emotion (p=0.000) and find more help in religion than in social support. Emotion (p=0.000) and social support are more present than emotion-focused coping (p=0.000). Women with breast cancer using tamoxifen have made less use of emotion-focused strategies (Table 1).
Women from economic class B experience more problem-focused strategies (p=0.000) and, among women from classes C, D and E, no greater use of religion or problem-focused strategies was found (p>0.05) (Table 2). Independently of economic class, women adopt the problem-focused strategy more than the search for social support and emotion (p=0.000), uses religion more than social support and emotion (p=0.000), and the search for social support is used more than emotion (p=0.000).
Data in Table 3 demonstrate the relation between coping strategies and family income. In all groups, the problem focus is used more than the search for social support and emotion (p=0.000). Religion is also used more than social support and emotion (p=0.000), and the search for social support has been more adopted than emotion (p=0.000). A very relevant data is the fact that, in the group of women with a family income of three or more minimum wages, the problem-focused coping strategies are used more (p<0.05).
Women living in urban areas experience problem-focused coping more (p<0.05). For women living in rural areas, no statistically significant association was found between religion and problem-focused coping (p>0.05). It is highlighted that women living in urban and rural areas use religious coping strategies more than the search for social support and emotion (p=0.000), uses social support more frequently than emotion (p=0.000) and the problem focus is more adopted than social support and emotion (p=0.000) (Table 4).
Based on the findings, it could be identified that, independently of sociodemographic characteristics, women preferably adopt religion and problem-focused coping strategies, followed by the search for social support and emotion. These data are similar to other studies that indicate that, in general, high scores for problem-focused coping are associated with low scores for emotion-focused coping. This fact indicated that these two strategy types are somewhat incompatible, as active coping, directed at handling the situation and at a new way of seeing the problem, i.e. problem-focused coping, is opposed to emotion-focused coping (13,14).
Thus, it is extremely important to know that, among other strategies, women with breast cancer using tamoxifen more frequently adopt the problem-focused coping mode, as this strategy represents adaptation to the disease as a form of adjustment to the new reality, characterizing a positive attitude towards the stressor (17). This finding discloses adaptive responses that entail improved self-esteem and self-concept (18).
The religion-focused coping strategy also plays a relevant role in coping with breast cancer, as belief in God, optimism and positive thinking strongly influence the development of adaptive responses to difficult situations deriving from the disease (18). It was verified in the study that women have been using this type of coping. Thus, research by Silva(19) affirms that faith in God is the main way in which women with breast cancer cope with the treatment.
Although less present than problem and religion-focused strategies, the search for support represents the search for social and emotional or instrumental support to help them to cope with the problem (20). In this study, it was verified that this mode is less frequent than the focus on the problem and religion. The lesser use of emotion-focused coping is highlighted though, which is extremely significant and positive, as this coping mode indicates the presence of emotional difficulties, associated with feelings of guilt towards oneself and the other. Negative emotions and avoidance behavior indicate that higher scores for this type of coping point towards relevant psychological difficulties, which was not observed in this study, showing lesser use of the emotion-focused coping mode (12-14).
In the relation between coping modes and education, it is verified that illiterate women adopt the religion-focused coping strategy more (p=0.000), in line with other studies (12-14). The search for religion, as a coping strategy in the act of praying, as well as the search for religious services can help to adapt to this new concept of life, in which women can start to see the diagnosis as part of a broader plan that is meaningful for their life, instead of defining it as a random event (21). Faith plays a significant role as a coping strategy, as belief in God influences the development of adaptive responses to difficult situations deriving from the disease (18). It should be highlighted, however, that the search for religious practices can also function as a justification to deny the problem and attribute its solution to a divine being (12).
The group of women with secondary and higher education degrees, in economic class B, with a family income of three or more minimum wages and living in urban areas, adopt the problem-focused coping strategy more (p<0.05). This result is in line with other findings that reveal that people with higher education levels use problem-focused strategies more (12). The greater use of this coping mode demonstrates further approximation with the stressor and a modified relation between the person and the environment, through the control or alteration of the problem causing stress, as situations are considered modifiable. The problem is addressed (9).
Independently of sociodemographic variables, in this process of coping with breast cancer and tamoxifen treatment, these women experience the four coping strategies: focus on the problem, religion, social support and emotion. Nevertheless, the religion and problem-focused strategies are used more.
It is underlined, however, that social and economic aspects are associated with the problem coping mode, that is, illiterate women turn more to religious practices as a problem coping strategy, while secondary and higher education graduates in class B, with a family income of three or more minimum wages and living in urban areas, make greater use of the problem focus.
These findings are highly relevant for the health area, especially for nurses, due to their closer contact with women diagnosed with breast cancer. These professionals should heed the sociodemographic context these women are inserted in and the stressful elements they are facing. Then, they should promote holistic and humanized care, going beyond technical care and acknowledging mastectomized women as protagonists in this unique moment for themselves and their families.
Thus, during all disease phases in which women experience stress, nurses should contribute by medicating more adaptive responses and enhancing effective problem coping.
As a study limitation, it is highlighted that the analysis was quantitative only, which did not permit the identification of other coping modes not addressed in the adopted instrument. Also, further research is due to investigate the coping strategies women with breast cancer taking tamoxifen adopt in the different phases of the disease.
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Corresponding Author: Received article 22/12/2010 and accepted 17/09/2011 * Research developed at the outpatient clinic
Ylza Bianco, Hospital Santa Rita de Cássia (HSRC), Vitória/ES.
Franciéle Marabotti Costa Leite
Endereço: Rua Lumberto Maciel de Azevedo, 405, Apt. 702, Jardim Camburi, Vitória (ES), Brasil. Cep: 29090-700. Tel: (27) 3335-7280.
Received article 22/12/2010 and accepted 17/09/2011
* Research developed at the outpatient clinic Ylza Bianco, Hospital Santa Rita de Cássia (HSRC), Vitória/ES.