Relationship between Self-care Agency and Quality of Life
Among Cancer Patients Undergoing Outpatient Chemotherapy
Kumiko Yoshida and Kiyoko Kanda
1 Takasaki University Graduate School of Health and Welfare, 501 Nakaorui-machi, Takasaki, Gunma 370-0033, Japan
2 Department of Nursing, Gunma University Graduate School of Health Sciences, 3-39-22 Showa-machi, Maebashi, Gunma 371-8514, Japan
Abstract
Purpose/Objectives:The purpose of this study was to demonstrate the relationship between self-care agency and quality of life (QOL) in cancer patients undergoing outpatient chemotherapy. Design: The study used a cor-relational research design with cancer patients undergoing outpatient chemotherapy at a medical facility. M ethods: The subjects of the study were cancer patients from Facility A undergoing outpatient chemotherapy. A self-report survey form was distributed to subjects and responses were returned by mail. The main variables of interest consisted of(1)Honjo s(2001)SCAQ to test chronic patients self-care agency and (2)Cellas(1993)FACT-G for QOL. Findings:The average age of subjects was 58.4, and the leading cancer types were breast cancer (38％) and lymphoma malignum (20％). The mean score(±SD)for each scale was 124.02± 13.56 on the SCAQ and 72.91± 17.04 on the FACT-G. A significant correlation was found between the scores on these two scales (r＝.245, p .05). Conclusions: People with greater self-care agency have a higher level of QOL. The results suggest the importance of nurses support in helping to cultivate patients self-care agency.
Introduction
In recent years,arrangements for cancer treatment have involved shorter hospitalization periods along with greater reliance on outpatient treatment,meaning that patients frequently have to cope with treatment side effects at home. In addition, cancer patients undergoing chemotherapy may experience physical and mental strains that can accompany therapy as well as lifestyle changes;these can be very stressful. There-fore, it is necessary for patients to consciously adjust the physical and psychosocial aspects of their lifestyles to cope with their condition.
The self-care agency of cancer patients has been described as making decisions to maintain ones life-style by searching for and applying information related to cancer. Moreover, it is also composed of coping with the side-effects of cancer therapy and changes in condition and enacting health behaviors to suppress the progression of cancer . Because cancer patients undergoing chemotherapy may experience treatment side effects, there are multiple instances when patients engage in substantial coping behaviors during therapy, including making adjustments in their physical and mental activity.
Regarding self-care agency, Orem stated as fol-lows: A person s agency, including agency related to self-care,is developed in daily life through a voluntary learning process. This development is cultivated through intellectual curiosity, direction, and leader-ship from others, and the experiences of enacting self-care policies . Studies of cancer patients self-care agency during the treatment phase have shown that this Article Information
Key words:
Outpatient Chemotherapy, Cancer, Self-Care Agency, Quality of Life Publication history: Received: June 17, 2016 Revised: August 31, 2016 Accepted: September 1, 2016 Corresponding author: Kumiko Yoshida
Takasaki University Graduate School of Health and Wel-fare, 501 Nakaorui-machi, Takasaki, Gunma 370-0033, Japan
Tel: ＋81-27-352-1291
E-mail: yoshikumi＠takasaki-u.ac.jp
agency developed through the involvement of nurses or other health care professionals,or through the patients experiences. Self-care agency is crucial during recuper-ation to cope with the side effects of therapy and the accompanying psychological changes. The applica-tion of self-care agency is particularly important for cancer patients who receive outpatient chemotherapy because they have to continue therapy while practicing self-care at home to cope with various adverse effects.
The therapeutic regimen of outpatient chemother-apy presents patients with the challenge of determining and maintaining their life path while facing the impact of both cancer and therapy while overcoming anxiety. Self-care agency is necessary for cancer patients to lead a life they desire while undergoing cancer treatment; effectively applying self-care agency can lead to an improvement in quality of life(QOL).For the past 20 years, particularly in Europe and North America, the construct of QOL has been used to describe these considerations. QOL is composed of physical,psycho-logical (mental), social, and activity status (role) aspects, all of which are supported by spirituality. Based on this construct, the self-reported QOL questi-onnaire called the Functional Assessment of Cancer Therapy-General (FACT-G ) was developed to focus on the QOL of cancer patients.
A study by Jansen analyzed the relationship between side effects and QOL in patients undergoing therapy for 5 years after receiving their initial cancer diagnosis. This research showed that the symptoms of dysgeusia, anxiety, and hair loss decreased QOL. The results indicated that it was extremely important for patients receiving chemotherapy to have their own approaches for alleviating adverse effects. Therefore, supporting the development of the agency that forms the basis of self-care also supports the maintenance of a desired lifestyle and is critical for improving QOL.
Based on the above considerations,the aim of this study was to demonstrate the relationship between the self-care agency and QOL of cancer patients in chemo-therapy. Moreover,it will be important to apply these findings to nursing care to appropriately support the required self-care agency.
Purpose
The purpose of the study was to demonstrate the relationship between self-care agency and QOL in cancer patients undergoing outpatient chemotherapy.
M ethods
Operational Definition of Terms Self-Care Agency
Self-care agency is the agency to practice inten-tional behavior for the adjustment of oneself or ones environment to improve ones life status. This is an acquired agency that can be learned.
Quality of Life (QOL)
The construct of QOL includes physical,
psycho-logical,social,and activity status aspects,with a foun-dation of spirituality. QOL refers to the quality of these dimensions.
Study Design
A correlational research design was used. Subjects
The subjects of the study were cancer patients from Facility A undergoing outpatient chemotherapy. The subjects for this study were patients aged 20 years or over who were receiving chemotherapy at medical facilities. Patients who would have felt undue stress by participating in this study and those with very advanced cancer were excluded.
Survey M ethod
A self-report-style questionnaire survey was used. The participants were given the questionnaire along with a written explanation of the aims of the study and instructions for completion of the questionnaire. The questionnaires were collected by regular mail so the participants could return them at their convenience. Survey Contents
General Background
The background information included gender, hospitalization experience, performance status, family composition, and occupational status.
Tool
Self-Care Agency Questionnaire (SCAQ)
We used the Self-Care Agency Questionnaire (SCAQ) developed by Honjo, the reliability and validity of which has been confirmed, with α＝0.91. The SCAQ scale is composed of the following four subscales: acquiring and continuing health manage-ment methods, adjustment of physical condition,
interest in health management methods, and acquir-ing effective support. It contains a total of 29 items, which are each measured on a five-point Likert scale. The total scores can range from 29 to 145.
As an illustration, the acquiring and continuing health management methods factor includes items such as I incorporate things necessary for the mainte-nance of my health in my daily life. An example of the adjustment of physical condition subscale is an item stating that I pay attention to the effects of therapy, including the side effects. A sample item within the interest in health management methods factor is I pay attention to test results, while acquir-ing effective support includes items such as I have doctors with whom I can consult.
We obtained written permission from the devel-oper of the SCAQ to use this scale for the study.
FACT-G QOL Scale for Cancer Patients
We used the FACT-G developed by Cella, the reliability and validity of which has been previously verified. This scale contains a total of 28 items scored on a five-point Likert scale from 0 to 4. It has four subscales that are aligned with the four aspects of
ity status. The total possible scores range from 0 to 112.
The physical aspect subscale includes items such as I have pain, the psychological aspect subscale includes items such as I worry about my disease worsening, the social aspect subscale includes items such as I feel intimacy with my family, and the activity status aspect subscale includes items such as
work brings liveliness to my life.
Written permission for its use was obtained from the developer of the FACT-G.
Study Period
The study lasted from July to September of 2012. Ethical Considerations
Written approval for the study was obtained from the research facilitys ethics committee prior to the initiation of the study. (Authorization number 13-3)
Furthermore, the participant candidates were given an explanation,both oral and written,regarding their freedom to withdraw at any time and an assur-ance of privacy,and those who filled out the question-naires were considered to have given consent. In addition,sufficient measures were taken with regard to all data collection so that individuals could not be identified.
The data participants who provided valid responses,and the SCAQ and FACT-G scores,as well as the mean score on all items for each factor, were analyzed. Next,correlations between each factor of the SCAQ and the FACT-G were analyzed using Pearson s correlation coefficient. A significance level of less than 5％ was applied to each correlation.
We utilized data analysis software(IBM SPSS for Windows, version 19.0J, Chicago, IL, USA).
Results
Participants General Background
A total of 137 questionnaires were distributed and 100 were returned. The response rate was 73.0％; however, there were 98 valid responses.
The mean age± SD of the participants was 58.4± 12.6. As shown in Table 1,there were 35 male partici-pants (36％) and 63 female participartici-pants (64％). More-over, 37 participants had breast cancer (38％), 20 had lymphoma malignum (20％),and 19 had colon cancer (19％). Ninety participants (92％) had experienced hospitalization.
Concerning the performance status (PS), the majority of participants (56％) were at Stage 1 with light symptoms; they were restricted with regard to physical labor but could walk or perform light labor. The second-largest category of PS consisted of 25 participants (26％) at Stage 0.
As for employment activity,40 participants(41％) were employed full-time,self-employed,or working in agriculture, and 15 (15％) worked part-time. With
Table 1 General patient characteristics n＝98
Item No. (％)
Sex Male 35 ( 35.7)
Female 63 ( 64.3)
Cancer type Breast cancer 37 ( 37.8)
Lymphoma malignum 20 ( 20.4)
Colon cancer 19 ( 19.4)
Lung cancer 10 ( 10.2)
Stomach cancer 8 ( 8.2)
Other 4 ( 4.0)
Hospitalization experience Yes 90 ( 91.8)
No 8 ( 8.2)
Current treatment method Chemotherapy 98 (100.0)
Radiation therapy 2 ( 2.0) Hormone therapy 5 ( 5.1) Performance PS0 25 ( 25.5) Status PS1 55 ( 56.1) PS2 11 ( 11.2) PS3 7 ( 7.1)
Work (multiple responses possible) Full-time/self-employed/agriculture 40 ( 40.8)
Part-Time 15 ( 15.3)
On leave 11 ( 11.2)
Homemaker 32 ( 32.7)
Family composition Single 6 ( 6.1)
Couple 38 ( 38.8)
Cohabiting parents or children 35 ( 35.7)
regard to family composition, 38 participants (39％) lived only with their spouse and 35 (36％) were co-habiting with parents and/or children.
SCAQ Scores of Cancer Patients Undergoing Out-patient Treatment
The means± SD for the SCAQ total scores and for all individual items are shown in Table 2. The mean± SD for the total score was 124.02± 13.56,and the mean for all 29 items was 4.28± 0.47.
The factor with the highest mean score was inter-est in health management methods, which includes items such as I pay attention to test results and I want to be careful about my health so that I can be useful to people in my own way. The mean± SD was 4.63± 0.47. On the other hand, the factor with the lowest mean was acquiring and continuing health management methods, which includes items such as I incorporate things necessary for maintenance of my health in my daily life and I have learned the ropes for doing things necessary to maintain my health. The mean± SD was 3.94± 0.64.
FACT-G Scores of Cancer Patients Undergoing Outpatient Chemotherapy
The means± SD for the FACT-G total scores and for all individual items are shown in Table 3. The mean± SD for the total score was 72.91± 17.04, and the mean for all 28 items was 2.62± 0.61.
There were no significant differences between the means for the subscales of each factor. The physiologi-cal aspect subsphysiologi-cale includes reverse-scored items such as I feel like I cannot build up any strength and I feel pain, and the social aspect subscale includes items such as I feel close to my friends and I have mental help from my family ;both subscales had means of 2. 7 points and 2.4 points. The activity status aspect
subscale containing items such as I can work and I can enjoy my life had a mean± SD of 2.38± 0.92. Relationship between SCAQ and FACT-G Scores of Cancer Patients Undergoing Outpatient Chemother-apy
The relationship between each factor on the SCAQ and the FACT-G is shown in Table 4 and Figure 1. A significant correlation (r＝0.245,p＜0.05) was found between the SCAQ and FACT-G scores. Moreover, when the SCAQ score was compared with each factor on the FACT-G, significant correlations were found with the social aspect subscale (r＝0.344, p＜0.01) and the activity status aspect subscale (r＝ 0.236, p＜0.05).
Regarding the correlation between each factor on the SCAQ and the FACT-G,a significant correlation (r＝0.339, p＜0.01) was found between acquiring and continuing health management methods on the SCAQ and the social aspect subscale on the FACT-G. Furthermore, a significant correlation (r＝0.287, p＜0.01)was found between interest in health manage-ment methods on the SCAQ and the FACT-G social aspect subscale as well as between this SCAQ factor and the activity status aspect subscale (r＝0.258, p＜ 0.05).
Discussion
Self-Care agency of Cancer Patients Undergoing Outpatient Chemotherapy
The mean score on the SCAQ for this study was 124.0± 13.56. Using the same SCAQ scale, other studies have found mean scores of 117.1± 17.39 for adult-onset diabetic patients with a mean age of 57.0 and 134.9 ± 10.2 for senile diabetic patients with a mean age of 73.6. When these three study results were
Table 2 Comparisons between SCAQ score and Subscale scores n＝98 No. of
items
Score Calculation Range M ean Standarddeviation M ean Standarddeviation
SCAQ 29 81-145 124.02 13.56 4.28 0.47
Subscales
Acquiring and continuing health management methods 10 24-50 39.44 6.40 3.94 0.64 Adjustment of physical condition 7 19-35 31.06 3.58 4.44 0.51 Interest in health management methods 7 17-35 32.35 3.25 4.63 0.47 Acquiring effective support 5 11-25 21.21 2.95 4.24 0.59 Table 3 Comparisons between FACT-G Score and Subscale Scores n＝98
No. of items
Score Calculation Range M ean Standarddeviation M ean Standarddeviation
FACT-G 28 18-112 72.91 17.04 2.62 0.61 Subscales Physical symptoms 7 4-28 19.13 6.17 2.73 0.88 Social/familial relationships 8 2-32 21.65 6.21 2.71 0.78 Mental condition 6 0-24 15.81 5.34 2.63 0.89 Activity status 7 0-28 16.68 6.41 2.38 0.92
compared, the senile diabetic patients had the highest mean score, followed by the cancer patients undergo-ing outpatient chemotherapy, and the adult-onset dia-betic patients had the lowest score. This may mean that cancer patients were better equipped with self-management agency than coeval patients with lifestyle-related diseases.
Furthermore, the mean score on the SCAQ subs-cale acquiring and continuing health management methods for the participants of this study was the lowest among the three aforementioned groups. This result implied that cancer patients undergoing out-patient chemotherapy required specific support in this area. Even in cases where cancer patients reassessed their life habits, adhering to health management methods may be difficult because of physical symptoms or side effects, which can lead to a decline in health management effectiveness and self-confidence; they also may experience psychological distress along with their changing condition. For these reasons, nurses should place special emphasis on helping cancer patients through acquiring and continuing health management methods ;nurses should also demonstrate to patients why these methods are important to their health and offer support so that they can experience
these positive effects. Finally, the patients own posi-tive perception of health management methods can lead to improvements in QOL.
On the other hand,in this study,the SCAQ factor with the highest mean score per item was an interest in health management, which includes items such as I pay attention to test results and I want to be careful about my health so that I can be useful to people in my own way. Because the cancer patients displayed a high level of interest in health manage-ment, nurses could capitalize on this interest and sup-port patients by connecting their interest to appropri-ate behaviors.
Based on these results, we believe that it is neces-sary for nurses to prioritize adaptation to the patients physical and mental changes while maintaining their interest in health management; however, nurses must understand that patients are in a difficult position with regard to the use of necessary health management methods. Therefore, assistance with cultivating self-care agency should include reflecting on these efforts and consciously connecting patients with ways to fur-ther improve self-care and recognize patient efforts at health management.
Table 4 Correlation of SCAQ and FACT-G Scores (Pearson Correlation Coefficient) n＝98 FACT-G
Total Score Physical Symptoms Social/Familial Relationships M ental Condition Activity Status Correlation
Coefficient Significance(p) CorrelationCoefficient Significance(p) CorrelationCoefficient Significance(p) CorrelationCoefficient Significance(p) CorrelationCoefficient Significance(p) SCAQ Total Score 0.245 0.015 0.083 0.416 0.344 0.001 0.086 0.398 0.236 0.018
Acquiring and Continuing Health
Management Methods 0.315 0.002 0.185 0.068 0.339 0.001 0.175 0.084 0.255 0.011 Adjustment of Physical Condition 0.012 0.903 −0.057 0.579 0.111 0.276 −0.059 0.566 0.088 0.389 Interest in Health Management
Methods 0.227 0.025 0.04 0.697 0.287 0.004 0.087 0.397 0.258 0.010 Acquiring Effective Support 0.170 0.950 0.021 0.837 0.345 0.001 0.004 0.969 0.157 0.123 ＊ p＜0.05 ＊＊ p＜0.01 Figure 1 Correlation Between SCAQ and FACT-G Scores
QOL of Cancer Patients Undergoing Outpatient Chemotherapy
The mean score on the FACT-G was 70.53± 16.75 in this study;in another study, the score on the FACT-G was 70.0± 15.5 for cancer patients who were also undergoing outpatient chemotherapy. Further-more, the mean score on the FACT-G in a study of patients undergoing outpatient radiotherapy was 74.8± 17.1. These findings indicated that the QOL of cancer patients undergoing outpatient chemotherapy was lower than that of patients undergoing outpatient radiotherapy.
In addition,after separately considering each subs-cale,cancer patients lowest mean scores were based on the psychological aspect, which contributed signifi-cantly to the lower overall scores. It is possible that patients undergoing outpatient chemotherapy feel anx-iety and uncertainty,which suggests the importance of mental support. A part of the cancer patients self-care agency was the agency to temper ones thinking to avoid being fettered by the existence of cancer, and this ability included the ability to shift ones mental attitude and the agency to express ones feelings. Having these aspects of self-care agency reinforced by nurses was another important aspect of support and can incorporate the patients psychological stability. Furthermore,the patients mental stability presumably affected the physical,psychological,and social aspects of QOL and can also influence and deepen the spiritu-ality involved in these aspects.
After the psychological aspect, the subscale with the second-lowest mean score among cancer patients in this study was activity status. A study that focused on the correlation between cancer patients malaise and QOL found that malaise had a negative correlation with activity status on the QOL. Assessing and supporting the alleviation of physical symptoms all-owed the patient to perform activities that they felt were necessary for the improvement of QOL.
It has also been demonstrated that a cancer patients view regarding health greatly influence their QOL. Based on these results, it can be inferred that cancer patients can have difficulty maintaining their own health perspectives during their convalescence while being active,performing their duties,and enjoy-ing life at the same time.
People gain a sense of accomplishment and mean-ing in life through the process of actively performmean-ing work activities, enjoying their lives, and expending energy toward productive results. Therefore,a part of the nurses role should be to support the patient when conducting activities that enhance physical and psy-chological stability so that the patient can develop the motivation to fulfill work roles and enjoy life. Relationship between Self-Care Agency and QOL in Cancer Patients Undergoing Outpatient Chemother-apy
A study on the relationship between self-care agency and the aspects of QOL in patients with renal
failure who required hemodialysis found that the strongest relationship was between self-care agency and the physical domain of QOL. Therapy with patients who had lifestyle-related diseases required improve-ment in and ongoing maintenance of good living habits, including daily nutrition. For this reason, patients require self-care agency to maintain healthy living habits.
To receive treatment that halts the progress of the disease, cancer patients must choose the method of therapy and decide on their lifestyle through their recuperation period. Therefore, the application of self-care agency by patients can lead to a recuperative lifestyle that is appropriate for their treatment regimen and the life that the patient desires; this leads to an improved QOL.
A significant correlation was found between SCAQ and FACT-G scores. These results demon-strate that self-care agency and QOL were related, giving meaning to the value of supporting patients self-care abilities.
In terms of relationships between the SCAQ and FACT-G factors, there were correlations between scores on both acquiring and continuing health management methods and interest in health manage-ment on the SCAQ and social and activity status subscales of the FACT-G. Cancer patients undergo-ing outpatient chemotherapy may need to adjust their lifestyles to cope with symptoms due to side effects,but their agency to take these steps can be influenced by the social and activity status aspects of their QOL.
These results can be discussed from two perspec-tives. The first was the support of self-care agency related to the patients health management. The cancer patients self-care agency does include the agency to subjectively perceive changes in condition and the agency to notice changes in the bodily conditions. It also included the agency to make appropriate decisions in accordance with bodily conditions such as choosing proper diet and rest appropriate for his or her condition. When assisting outpatients, nurses must consider patients self-care agency and provide them with support in coping with their condition so that they can perform their own health management and improve their QOL.
The second perspective has to do with self-care agency and its relationship with the social aspect of QOL. A study measuring the QOL of cancer patients in long-term recovery demonstrated that having good relationships with a partner leads to pain reduction and is reflected in QOL. Moreover,these results indi-cate that one characteristic of high-QOL patients was the presence of sufficient social support,which assisted the patient in coping with emotional demands. Because social stability affected patients pain levels and emotional status, nurses should consider the importance of maintaining the patients harmony with family members and with society in general. One method of doing so would be to focus on cancer patients ability to maintain connections with people
and adjust their social lives, which is part of the cancer patients care agency. This aspect of self-care can include the agency to partially entrust deci-sions to others regarding household matters, which can allow patients to live their social life smoothly while undergoing therapy. Taking steps to help patients adjust their social lives and strengthen their support systems while coordinating with other profes-sionals becomes all the more necessary. A study by Morgan et al indicated that adherence to health management methods, particularly their psychological components, was difficult for patients to achieve on their own. Nurses need to consider the patients self-care agency, assess their level of social support based on their relationships with people around them, and accordingly deliver nursing care to improve their QOL. For example, even when working with the client on measures to reduce nausea and the loss of appetite following chemotherapy, obtaining family members cooperation while considering familial relationships would cultivate their self-care agency and, in the long run, lead to improvement of the patients QOL.
Conclusion
This study obtained the following conclusions on the relationship between self-care agency and QOL of cancer patients undergoing outpatient chemotherapy: 1. A correlation was found between the self-care agency and the QOL of cancer patients undergo-ing outpatient chemotherapy;this suggested the importance of supporting self-care agency. 2. Supporting aspects of cancer patients
self-care agency related to the social and activity status aspects of their lives should be particular-ly valuable in improving their QOL.
Acknowledgments
I would like to express my gratitude to all the patients who graciously cooperated in this survey and to all persons who provided great support and guid-ance in the completion of this study. This work was supported by JSPS KAKENHI Grant Number 22592462 and 25463440.
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