Li Tian, Meng-Yuan Li

1School of Nursing, Tianjin University of Traditional Chinese Medicine, Tianjin, China; 2Department of Brain Cancer,Tianjin Medical University Cancer Institute & Hospital, Tianjin, China.

Abstract Objective: To investigate the status quo of fear of disease progression in postoperative patients’ spouse of bladder cancer and analyze its influencing factors.Methods: Postoperative patients’ spouse of bladder cancer of a cancer hospital in Tianjin were selected as the research objects by the convenience sampling method.The general data questionnaire, spouse fear of disease progression scale and self-efficacy scale were used to investigate.Multiple linear regression was used to analyze the influencing factors of the fear of the disease progression in the postoperative patients’ spouse of bladder cancer.Results: The score of fear of disease progression was (35.75 ± 9.86).The results of multiple linear regression analysis showed that the spouse’s age, medical payment method, occupational status and self-efficacy were the main influencing factors for the spouse’s fear of disease progression after bladder cancer (P ＜ 0.05), which accounted for 55% of the total variation.Conclusion: The spouse’s fear of disease progression in patients with bladder cancer is at a moderate level, and age, medical payment method, occupational status and self-efficacy are the main influencing factors.It is suggested that clinical medical staff focus on young, rural cooperative medical care, self-financed, in-service, and unemployed, low self-efficacy of postoperative bladder cancer patients' spouses.A series of psychological counseling and health education should be given to help the patient spouse correctly understand and deal with diseases, reduce the patients’ spouses of negative emotions, improve the patients’ spouses of self-efficacy, and reduce the spouse fear level of disease progression.

Key words: Bladder cancer, Spouse, Fear of disease progression, Self-efficacy

Introduction

Bladder cancer is a common malignant tumor of urinary system in our country, and two-thirds of the patients were diagnosed with non-muscular infiltration of bladder cancer for the first time [1].Transurethral resection of bladder Tumor is the best treatment plan for invasive muscle layer bladder cancer, but as much as 45% of patients recur within 1 year after transurethral resection of bladder tumor treatment, 6%～17% of the patients can appear tumor progression [2], and the higher recurrence rate and rate of progress make the patient and spouse have a series of psychological problems, anxiety, depression.The fear of disease progression and recurrence is one of the most serious problem [3,4].The fear of disease progression (FOP) refers to the whole fear psychology that is related to different kinds of biological and psychosocial consequences arising from the progression of fear disease, or the re-recurrence of fear disease [5].Studies have shown that the fear of spouses of bladder cancer patients is far greater than that of patients themselves [6], and the fear of spouses can seriously affect the quality of care, patients and their own quality of life.There are many studies about fear of disease progress, but lack studies about the fear of disease progression in spouse, so this study aims to investigate fear of disease status quo and analysis the influencing factors for the high recurrent postoperative bladder cancer patients’ spouse to provide some reference for specific interventions and basis.

Methods

Participants

The spouses of patients who underwent transurethral cystectomy in the urology department in Tianjin cancer hospital from July to November 2019 were selected as the research objects by convenient sampling method.Inclusion criteria:(1) the spouse of a patient with pathologically diagnosed non-muscle-invasive bladder cancer without distant metastasis; (2) Age ≥18 years old; (3) Normal cognitive function, a certain degree of reading ability.Exclusion criteria:(1) mental disorders or cognitive impairment; (2) Refuse to participate in this study.

Instrument

General InformationQuestionnaire was designed by myself, including gender, age, education level, monthly income of family, occupational status, medical payment method,disease awareness, recurrence, recurrence, and bladder perfusion chemotherapy.

The Fear of disease Progression Scale in spouse (FOP-Q-SF/P)It was developed by Zimmermarm [7] in 2011, and was used to assess the risk disease Progression of spouses of chronic diseases.Cronbach was 0.88.The Chinese version of the scale was translated into Chinese by Wu Qiyun [8] and introduced into China for assessing the level of spouse fear of disease progression in patients with primary liver cancer.The Cronbach’ coefficient of the scale was 0.834, and the Cronbach’ coefficient of each dimension was 0.699～0.835, showing good reliability and validity.Li Jiaqian [9] used this scale to measure the level of fear disease progression of spouses of patients with advanced cancer.The scale includes family health (8 items) and social function (4 items), with 12 items in 2 dimensions.Likert 5 rating was adopted for all the partners, and 1～5 points were assigned according to never to always, with a total score of 12～60 points.The higher the score was, the more severe the disease progression of the partner was.The Cronbach, coefficient of this scale in this study is 0.885.

Self-efficacy scale (General self-efficacy scale, GSES)Self-efficacy scale is compiled by a German psychologist mark schwarzer and his colleagues in 1981 [10], Wang Kang [11] put it in Chinese in 2001 to evaluate a level of confidence when individuals encounter difficulties or frustrations, scale Cronbach alpha coefficient is 0.87, Duan [12] apply the scale to the digestive tract malignant tumor patients’ spouses.The scale consists of 10 items, ranging from “completely incorrect” to “completely correct”, with a score of 1 to 4.The total score is 0～40 points.The higher the score, the higher the individual self-efficacy.The Cronbach coefficient of this scale in this study was 0.89.

Data collection

In this study, data were collected by questionnaire.Two researchers who had received unified training issued questionnaires.The purpose, significance of the survey and the filling method of the questionnaire were explained to the research subjects by unified guidance language.For those who have difficulty in reading or cannot fill in the questionnaire by themselves, members of the research group will carefully ask the subjects one by one and repeatedly confirm their answers.Then, they will fill in the questionnaire in an anonymous form.The questionnaire will be handed out and recalled on the spot to check whether the questionnaire is complete.A total of 125 questionnaires were issued and 120 valid questionnaires were collected, with a recovery efficiency of 96%.

Date analysis

Excel 2010 was used to input data for two persons, and SPSS 17.0 was used to analyze data.The measurement data of normal distribution were described by mean ± standard deviation, and the comparison between groups was performed by t-test or one-way analysis of variance.The measurement data of skewness distribution were described by median and interquartile spacing, and the comparison between groups was performed by rank sum test.Counting data are described by frequency and composition ratio.The correlation between the scores of fear of disease progression and the scores of self-efficacy was analyzed by Pearson correlation analysis, and the influencing factors of fear of disease progression were analyzed by multiple linear regression analysis, withP＜ 0.05 as the difference was statistically significant.

Results

The spouses of 120 patients after bladder cancer surgery were (62.31 ± 10.96) years old.The majority were women, 91 cases (75.8%).Education level:18 cases (15.0%) in primary school or below, 32 cases (26.0%) in junior middle school, 34 cases (28.3%) in senior high school or technical secondary school, 38 cases (31.7%) in junior college or above.Monthly family income per capita:17 cases (14.2%), 22 cases (18.3%), 57 cases (47.5%), and 24 cases (20.0%) of ＞ 5000.Occupational status:active in 33 cases (27.5%), retired in 56 cases (46.7%), unemployed in 31 cases (25.8%).Methods of medical payment:13 cases (10.8%) of public expenses, 34 cases (28.4%) of urban workers’ medical insurance, 48 cases (40.0%) of rural cooperative medical care, 25 cases (20.8%) of self-pay.No recurrence was found in 87 cases (72.5%).The number of bladder perfusion chemotherapy:24 cases (20.0%), 46 cases (38.3%), 50 cases (41.7%), 1 ～ 8 times, ≥9 times.Understanding of diseases:23 cases (19.2%) were fully understood, and 65 cases (54.1%) were partially understood.Complete ignorance was found in 32 cases (26.7%).

In this group, the total score of fear of disease progression was (35.75 ± 9.86) points, (26.78 ± 7.07) points of family health function and (8.97 ± 3.95) points of social function.According to the total score of [8] spouse ≥ 34, there were 69 cases (57.5%) with mental dysfunction, which were classified into the threshold score of mental dysfunction of fear disease progression.

The spouses of patients after bladder cancer surgery were divided into groups according to age, gender, education level, family per capita monthly income, occupational status, medical payment method, recurrence rate, recurrence rate, frequency of bladder perfusion chemotherapy, and disease understanding degree, and the scores of fear disease progression were compared.The results showed that there was no significant difference in the total score of fear disease progression among the spouses of patients with bladder cancer after bladder cancer surgery with different gender, education level, whether the patient had recurrence, the number of recurrence, and the number of times of bladder perfusion chemotherapy (P＞ 0.05).There were statistically significant differences in the total score of fear of disease progression (P＜ 0.05) among spouses of bladder cancer patients with different ages, family per capita monthly income, occupational status, medical payment method, and degree of disease understanding (P＜ 0.05).See table 1.

Table 1 Comparison of scores of fear disease progression among spouses of patients with different characteristics after bladder cancer surgery (n = 120)

In this group, the spouse’s self-efficacy score was (25.71 ± 5.30).Pearson correlation analysis showed that the spouse self-efficacy was negatively correlated with the total score of fear of disease progression (r= -0.662,P＜ 0.001), and negatively correlated with the family health dimension (r= -0.614,P＜ 0.001) and the social function dimension (r= -0.554,P＜ 0.001) of the patients after bladder cancer surgery.

The fear of disease progression total score serve as the dependent variable, the single factor analysis and correlation analysis was statistically significant in six variables (age, family per capita income, occupational status, medical payment, understand the degree of disease, self-efficacy) as independent variables,multiple linear regression analysis.Independent variables are assigned as shown in table 2.The results showed that age, medical payment method, occupational status and self-efficacy were the main influencing factors for spouse fear of disease progression after bladder cancer (P＜ 0.05).Are shown in table 3.

Table 2:Independent variable assignment table

Discussions

Fear of disease progression in spouses of patients after bladder cancer surgery was moderate

This study shows the score of the fear of disease is (35.75 ± 9.86) in the medium level compared with scale intermediate value of the total score 30 points.And it is similar to the Wu Qiyun [8] with the score of (35.77 ± 7.91), higher than foreign survey of chronic disease, diabetes [7] spouse scores.The reasons may be as follows:(1) in this study, the majority of patients with multiple bladder perfusion chemotherapy accounted for 80%.The spouse saw a series of adverse reactions caused by multiple bladder perfusion chemotherapy, such as dysuria, pain, nausea and vomiting, and feared that the patient's body would be seriously threatened.(2) The majority of females in this study, accounting for 75.8%, have relatively poor psychological endurance and coping ability and are more prone to fear.(3) bladder cancer is the leading cause of cancer risk of recurrence of all the solid tumors, and recurrence rate after primary treatment for 50-80%, progress at a rate of 10-25% [10], there are even four recurrence within two years, patients need cutting, bladder perfusion and review for many times.Facing the high cost of surgery and bladder perfusion and a series of follow-up examination and treatment, the spouse fears he bad prognosis after treatment for many times, and fears family economy severely affected.Therefore, the score of fear disease progression in the spouses of patients after bladder cancer surgery was in the middle level.

Influential factors of fear of disease progression in spouses of patients with bladder cancer after operation

Agethe results of this study show that age is the main factor influencing the progression of fear disease in spouses of patients after bladder cancer surgery (B = -2.961,P＜ 0.001), that is, the younger the spouse of patients after bladder cancer surgery, the higher the level of fear disease progression, which is consistent with the findings of Myers et al.[13].The reason is:younger mates are in a critical period of career struggle, the care of patients may affect their own work, they may have great mental and physical and economic pressure and makes the young spouse fear the progress of the disease more.Most older spouses are retired and have relatively little work pressure, thus they can fully take care of patients with little fear; Older spouses tend to have strong psychological tolerance and coping ability.They can face emergencies calmly and have less fear.In addition, the younger spouse may not have conceived the next generation yet, and they worry that the patient’s multiple surgeries and chemotherapy will affect the normal fertility function, so they are more fearful than the older spouse.It is suggested that medical staff should pay more attention to spouses of young spouse, encourage spouses of patients to talk about their situation to other families, implement family members to take turns to take care of patients, deal with the relationship between work and taking care of patients, and encourage other family members to fully support spouses, so as to reduce the physical and mental pressure of spouses of patients; Health education on bladder perfusion chemotherapy focuses on the benefits of bladder perfusion chemotherapy and its impact on fertility, so that the spouse can correctly understand chemotherapy and actively accept the treatment of patients with bladder perfusion chemotherapy to reduce their fear.Some psychological counseling intervention should be given to young spouses to reduce their fear through cognitive behavioral therapy and mindful stress reduction therapy, and related successful cases should be told to improve their psychological tolerance and courage to cope with difficulties.

Medical payment methodThe results of this studyshowed that the method of medical payment was the main factor influencing the fear of disease progression among spouses of patients after bladder cancer surgery.Taking the public expense as a reference, the spouse of the rural cooperative medical care and self-financed bladder cancer patients had a higher level of fear of disease progression (B = 4.588, P = 0.040; B = 4.391,P= 0.027).The reason is:the majority of rural cooperative medical care are from the countryside, they charge for the treatment of cancer is their family income of more than 6.9 times [14] family living from the soil, have no fixed income, early treatment nearly ruin the family [15], reimbursement ratio of the late continuous perfusion chemotherapy is not high, repeated surgery and perfusion treatment make the family in debt, spouses of fear the progress of the disease.People who are self-pay come from the other hospitals in other places (northeast, Inner Mongolia), Families not only pay for the fees of surgery and perfusion but also solve the problem of food and accommodation and transportation because of bad long distance medical care [16], all the pressure are borne by the partners.The little money may lead to family missing good treatment opportunity, further increasing the feel of fear [17].It is suggested that clinical medical staff should pay more attention to patients and spouses from rural areas who seek medical treatment in other places, and choose appropriate treatment methods for them, so as to reduce their burden as much as possible and reduce their spouse’s fear.The state should establish and improve the medical security system and increase the proportion of medical insurance reimbursement between the rural population and non-local people.

Table 3.Multiple linear regression analysis of the influential factors of fear of spouse disease progression in patients after bladder cancer surgery

Professional statusThe results of this study showed that occupational status was a major factor influencing the progression of fear among spouses of patients after bladder cancer surgery.Taking retirement as a reference, the spouse of in-service and unemployed bladder cancer patients had a higher level of fear of disease progression (B = 4.331,P= 0.024; B = 4.835,P= 0.012).The reasons are as follows:the retired spouse has more time and energy to take care of the patient with all his/her heart without worrying about the negative impact on the work.They have a fixed income to bear the medical expenses and can face the volatility of the disease calmly, which causes the least fear.Working spouses have a certain fear.They have to take care of patients while working, fearing that the progress of the disease will affect their career.However, work can make spouses switch between the roles of caregiver and worker, which can buffer the fear of disease progression [18].The unemployed spouse has to take care of the patient all the time and they sees many adverse reactions (dysuria, dysuria, nausea and headache) caused by the infusion chemotherapy which causes a certain negative emotion.They also face huge medical expenses with no income, thus they have the highest level of fear of disease progression.Suggestion:Clinical medical staff should focus on the spouses of patients with non-occupational.At the beginning of treatment, nurses should introduce different treatment options and related costs to the spouses, so that the spouses can choose the most feasible and affordable treatment options to reduce their economic pressure.More guidance about adverse reactions caused by bladder perfusion chemotherapy should be given to the spouses so as to guide the spouse right deal with the adverse reaction.Nurses should hold lectures and to hand out the corresponding brochures to teach spouses to cope with adverse reaction caused by chemotherapy of processing to reduce the negative emotions.

Self-efficacyThe results of this study showed that self-efficacy was the main influencing factor (B = -0.967,P= 0.000), that is, the higher the self-efficacy of spouses of patients after bladder cancer surgery, the lower the level of fear of disease progression，which is similar to the [19] study.Self-efficacy is a good guarantee for individuals to have a healthy mind [20].The higher the self-efficacy of the spouse, the more positive the mentality [21].They have the ability to

exert subjective initiative, adjust a series of negative emotions such as fear and anxiety [22] and reduce the impact of negative emotions.The higher the self-efficacy, the stronger the spouse’s ability to resist pressure and determination to overcome difficulties, they have the power to change the dilemma and adopt a positive coping style to deal with all unexpected things.Therefore, the spouse with higher self-efficacy has less fear.Bandura's theory shows that factors affecting self-efficacy include the success or failure experience of others, encouragement and persuasion of others, and emotions.Suggestion:clinical medical staff can organize some peer interaction for patient and spouse to let the successful patients and spouses tell the relevant experience and coping strategies to increase the confidence to overcome difficulties, improve the spouse's self-efficacy, reduce the spouse's fear of disease progression; Nurses can carry out certain psychological education intervention for patients and spouses.Clinical medical staff should increase exchanges with spouses at ordinary times, discover the patients’ spouses of bad feelings, encourage patients spouses to participate in some activities unleashing bad mood, and guide the patients’ spouses optimistic point of view, to improve their self-efficacy, reduce their fears.

Conclusion

To sum up, the spouse’s fear of disease progression was at a moderate level after bladder cancer surgery.Age, medical payment method, occupational status and self-efficacy were the main influencing factors.It is suggested that clinical medical staff should focus on the spouses of young, rural cooperative medical care, self-financed,in-service,unemployed,and low-self-efficacy spouses after bladder cancer surgery, and focus on providing the spouse with the best treatment plan to reduce the spouse's economic pressure.Medical staff should also help patients and spouses to correctly understand and deal with the disease, reduce the negative emotions of patients’ spouses, improve the self-efficacy of patients' spouses through a series of psychological counseling and health education, which finally reduce the spouse's fear of disease progression.The shortcoming of this study is that only spouses of patients with bladder cancer after surgery were investigated in a grade III a tumor hospital, and the sample size and representativeness were insufficient, so the multi-center and large-sample study should be carried out in the future.