|Year : 2012 | Volume
| Issue : 3 | Page : 287-292
Posttraumatic growth in Iranian cancer patients
A Rahmani1, R Mohammadian2, C Ferguson3, L Golizadeh3, M Zirak1, H Chavoshi1
1 Hematology and Oncology Research Center of Tabriz University of Medical Sciences, Tabriz, East Azerbaijan Province, Iran
2 Department of Nursing, Islamic Azad University, Maraghe branch, Maraghe, Iran
3 Faculty of Nursing, Midwifery and Health, University of Technology Sydney, Sydney, Australia
|Date of Web Publication||12-Dec-2012|
Hematology and Oncology Research Center of Tabriz University of Medical Sciences, Tabriz, East Azerbaijan Province
Source of Support: Financial support of the Hematology and Oncology Research Centre affiliated to the Tabriz University of Medical Sciences, Conflict of Interest: None
Objectives: To investigate the level and determinants of posttraumatic growth in Iranian cancer patients. Materials and Methods: This descriptive-correlational design study was conducted within a university-affiliated oncology hospital in Iran. A convenience sample of 450 patients with a definitive diagnosis of cancer of any type completed a demographic questionnaire and a posttraumatic growth inventory. Some disease-related information was obtained from patients' medical records. Results: The mean of posttraumatic growth reported by participants was 76.1. There was a statistically significant association between experience of posttraumatic growth and age (r = − 0.21, P=0.001), education at university level (F = 8.9, P=0.001) and history of treatment by radiotherapy (t = 2.1, P=0.03). Conclusion: The findings of this study suggest that Iranian cancer patients experience a moderate to high level of posttraumatic growth and confirm the hypothesis that the level of posttraumatic growth in non-Western cancer patients is more than that of Western cancer patients. Although, assessing the reasons for this difference needs more investigations.
Keywords: Cancer, posttraumatic growth, positive adjustment, posttraumatic growth inventory
|How to cite this article:|
Rahmani A, Mohammadian R, Ferguson C, Golizadeh L, Zirak M, Chavoshi H. Posttraumatic growth in Iranian cancer patients. Indian J Cancer 2012;49:287-92
| » Introduction|| |
Cancer is a life-threatening disease that is considered as incurable in many cultures.  Most cancer treatments are aggressive and may be associated with pain and other side-effects. After the initial phases of treatment, cancer survivors may experience uncertainty and many other psychological problems.  Generally, cancer is perceived as a major life crisis which affects all aspects of a patient's life. , Consequently, adjustment to cancer requires the mobilization of psychological resources and occurs over time. The traumatic nature of cancer has received great attention over the last decades, while recent evidence show that cancer generates both negative and positive psychological effects. ,
For decades, trauma was understood as a completely negative experience; however, recent literature indicates that trauma can also lead to positive changes referred to as posttraumatic growth. , Posttraumatic growth can be defined as an individual's experience of significant positive transformation that occurs in face with major traumatic events. ,,, Alternatively used terms are benefit finding and stress-related growth. , Benefit finding refers to an individual's perception that major positive changes have occurred as a result of challenging life events such as major illness or trauma.  In addition, stress-related growth is a perception of experiencing positive life changes following stressful life experiences.  It should be noted that these terms are often used interchangeably, given that the central assumption underlying them is uniform: that is, they all refer to positive change in the aftermath of trauma and diversity. 
Additionally, it should be noted that posttraumatic growth dose not negate the experience of psychological trauma, but emphasizes that in spite of harming experiences, trauma survivors may find new meanings and purposes in life that inspire positive personal change.  The cognitive processing theory of posttraumatic growth proposes that the experience of a highly stressful life event may positively challenge valued personal life goals and fundamental beliefs about oneself, the future and resulting in reduced emotional distress and increased meaningful activities in trauma survivors.  The enduring of stress is essential to the experience of posttraumatic growth. ,
Some studies have been able to demonstrate that efforts to make meaning is related to better adjustment to cancer experience,  however, studies on posttraumatic growth after cancer have been mainly conducted in Western countries. These studies reported a moderate level of posttraumatic growth in Western cancer patients. ,,,,, There is paucity of data on the experience of posttraumatic growth in cancer patients from other cultures. ,,, The available evidence from non-Western populations shows that the level of posttraumatic growth in Asian cancer patients is significantly higher than that of cancer patients from Western cultures. In an extensive review of the literature, there were no studies identified which investigated the experience of posttraumatic growth in cancer patients in Middle Eastern countries. Previous studies indicate that posttraumatic growth is dependent on factors such as religion  and culture.  Therefore, the results of other studies in other parts of the world, with different religions and cultures, may not be applicable for the Middle East. This study was conducted with an aim to address this deficit of research regarding posttraumatic growth of cancer patients in the Middle East, including Iran. The purpose of this study was to investigate the experience of posttraumatic growth in Iranian cancer patients and examine the correlation of posttraumatic growth with some characteristics of patients.
| » Cancer in Iran|| |
Each year about 50,800 new cancer cases occur in Iran. Among them, more than 53% are male with an age-standardized incidence rate of 116.8 per 100,000 for males and 93.1 per 100,000 in females. It is estimated that cancer is responsible for 35,000 deaths in Iran per year.  The most common cancer among women and men was breast cancer and stomach cancer, respectively. The current low cancer incidence in Iran may be due to incomplete registration of cancer, incomplete cancer diagnosis and lack of national cancer screening programs for many cancers. 
Research has demonstrated that a large proportion of cancer patients in Iran are not informed of their diagnosis and 37-65% of Iranian cancer patients do not know their diagnosis, ,, and 93% are unaware of their prognosis.  In one study, Iranian physicians and nurses believed that less than 20% of cancer patients had been told their diagnosis.  Despite the common practice of non-disclosure, there is initial evidence that many Iranian cancer patients do, in fact, want to be informed of their diagnosis.  Interestingly, within this study many cancer patients, especially women cancer patients, were not aware of their cancer diagnosis. Particularly, they were not aware that their treatments were for cancer.
| » Materials and Methods|| |
This descriptive-correlational design study was conducted in a tertiary referral university-affiliated hospital in the northwest of Iran in the year 2010. Data was collected over a five-month period from a total of 450 patients who had a definitive diagnosis of cancer of any type and any disease stage, being informed of their diagnosis, aged 18 years or above, were Iranian citizens, and were able to communicate in Persian language. The other inclusion criteria included at least six months having passed since they were informed of their cancer diagnosis, not having recent history of other life-threatening diseases, and being physically and cognitively able to participate in the study. None of the cancer patients, since being informed about the exact diagnosis, reported other traumas that may influence their experience of posttraumatic growth.
For data gathering an instrument was used that consisted of two parts. Firstly, a demographic questionnaire: The demographic characteristics (e.g., age, gender, education) and medical information (e.g., time passed since being informed about diagnosis) of participants were collected by using a researcher-developed questionnaire. Some data were obtained from patients' medical records (e.g. exact diagnosis, treatment modality). Secondly, the Posttraumatic Growth Inventory (PTGI): The PTGI is a 21-item instrument that assesses positive outcomes reported by individuals who have experienced highly stressful events. The PTGI consists of five subscales including: relating to others (seven items), new possibilities (five items), personal strength (four items), appreciation of life (three items) and spiritual changes (two items). Items are rated on a six-point Likert scale ranging from 0 (I did not experience this change as a result of cancer) to 5 (I strongly experienced this change as a result of cancer). The total PTGI scores range between 0-105. The PTGI has been tested in wide range of stressful events and demonstrated an acceptable alpha reliability. ,,, For the purpose of this study, a Persian version of PTGI was developed from the original English version adopting translation and back-translation procedures. The validity of the translated questionnaire was determined by content validity. The questionnaire was mailed to 12 academic staff from Tabriz University of Medical Sciences and revised according to their comments. Subsequently, the questionnaire was pilot-tested in a sample of patients with cancer disease, which yielded high internal consistencies for both the whole scale (Cronbach alpha = 0.91) and subscales (Cronbach alpha ranging between 0.83-0.93 for different subscales).
The Ethics Committee of Tabriz University of Medical Sciences approved the study. The principle researcher provided information about the study to all the participants verbally and informed them about their rights and obtained an informed consent from all study participants.
A coordinating nurse from the selected hospital identified potential participants from different wards of the hospital and outpatient clinics and invited them to participate in the study. It was sometimes difficult to ascertain a patient's awareness of their precise diagnosis, as many studies in Asian countries demonstrated that many cancer patients are not informed about their exact diagnosis. ,,,, In consideration of this, patients' family members, nurses, and treating physician were asked about it, and then the exact awareness of patients was determined by a short private interview. Only patients who were informed of their exact diagnosis were included in this study. It should be noted that, during five months of data collection, a coordinating nurse invited all patients who met the study criteria using an eligible sampling method.
Literate patients (44.4%) completed the questionnaire themselves and they were guided by researchers only when it was necessary. The researcher completed the questionnaires on behalf of the patients if they had low literacy levels (55.6%). During five months 472 patients were invited to participate in the study and 450 in total accepted (acceptance rate = 95.3%). The data from all patients who agreed to participate was collected.
Statistical analyses were performed using the software Statistical Package for Social Sciences (SPSS) for Windows, Version 17.0. Descriptive statistics, including frequencies, mean and standard deviation were used to describe the characteristics of the participants and the level of posttraumatic growth. Inferential statistics included examining the relationship between posttraumatic growth and some patients' characteristics using the Pearson's correlation. Independent t test and one-way analysis of variance (ANOVA) was applied to compare the mean scores of the PTGI in several demographic variables. According to the results of the Levene and Kolmogorov-Smirnov tests the data were normally distributed and therefore, parametric statistics was used for data analysis.
| » Results|| |
The mean age of study participants was 56.5 ± 16.8 years ranging from 18 to 85 years and the mean time passed since patients were informed of cancer diagnosis was 29.4 ± 30.4 months ranging from 8 to 190 months. Other demographic characteristics of patients are reported in [Table 1]. It should be noted that our sample is not representative of all cancer patients in Iran. For example, it is obvious that many of our samples are male. The reason is that in this study we included only informed patients, not all patients, and the percentage of males who were informed of the exact diagnosis is greater than that of women.
The results of analysis of the PTGI scores showed that patients experienced posttraumatic growth in a moderate to high degree, with mean total scores of 76.1 ± 18.3, ranging from 12-105. [Table 2] presents the descriptive statistics for each of the subscales.
There was found a significantly negative correlation between age and total PTGI scores (r=−0.21, P=0.001), whilst time passed since patients were informed of their cancer diagnosis had no significant correlation with the PTGI scores (r=0.007, P=0.88). The total scores of the PTGI according to some demographic and disease-related variables of study participants are presented in [Table 3].
|Table 3: Total score of PTGI according to socio-demographic and disease-related variables|
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There was found a statistically significant difference in mean PTGI scores according to patients' previous history of radiotherapy (t=2.1, P=0.03), with patients with no previous history of radiography having higher scores on the PTGI (76.4 vs. 64 respectively). There was also a statistically significant difference in mean PTGI scores according to the level of education of the participants (F=8.9, P=0.001), with patients with a university degree reporting significantly higher scores on the PTGI than patients with lower education levels.
| » Discussion|| |
This study is a first to investigate the posttraumatic growth experienced by cancer patients in Iran and the Middle East. The results of the study showed that Iranian cancer patients experienced moderate to high level of posttraumatic growth. This finding supports the hypothesis that an experience of trauma, such as cancer, may lead to positive psychological effects in trauma survivors. The level of posttraumatic growth experienced by Iranian patients is comparable with that of cancer patients from Asian cultures (Mean of PTGI=70.5). ,, However, literature from Western countries indicates that cancer patients experience a moderate level of posttraumatic growth (mean of PTGI=49.6). ,,,,,,, The findings of this study suggest that compared to the data from Western populations, cancer patients in Iran experience a higher level of posttraumatic growth. These results support the idea that the level of posttraumatic growth in non-Western cancer patients is more than that of Western cancer patients. Some previous studies reported that maybe the cultural background could be an important factor that facilitates this growth.  However, in this study and other related studies the cultural differences were not assessed and therefore making any conclusion is impossible and other factors may be responsible for such differences. Furthermore, the comparison of results of different studies on posttraumatic growth of cancer patients is difficult because these studies investigated the level of posttraumatic growth in heterogeneous cancer patients. Hence, the interpretation and comparison of their results should be made with caution.
We found that the level of posttraumatic growth was significantly associated with age and education. Studies examining the relationship between posttraumatic growth and patients' demographic characters have reported mixed results. Some studies have reported a significantly negative relationship between age and posttraumatic growth, ,, while others have failed to demonstrate any association between them. ,, Similarly, there are no consistent results from studies which examined the relationship between education and posttraumatic growth. Cordova et al., (2007) reported a positive association between posttraumatic growth and education,  other studies reported either a negative relationship between the two variables, , or failed to demonstrate any association between level of education and posttraumatic growth. ,,, We found no statistically significant association between gender and level of posttraumatic growth which is consistent with results reported from some previous studies. ,, However, some studies reported significantly higher level of posttraumatic growth in females. ,, In this study there was a positive association between history of treatment with radiotherapy and experience of posttraumatic growth, however, the association between history of treatment with chemotherapy and posttraumatic growth was not statistically significant. These findings are not inconsistent with results of previous studies which reported a positive relationship between history of treatment with chemotherapy and posttraumatic growth. ,,
The results of this study have important clinical implications. Some previous studies in Iran showed that many healthcare providers are afraid of cancer disclosure to their patients because they believed that this may have a negative impact on patients. , In contrast, the results of this study showed that experience of cancer may result in a high level of positive effects in cancer patients. Reporting this level of posttraumatic growth to healthcare providers may decrease their fear about cancer disclosure and change the practice of cancer disclosure in Iran.
The results of this study should be interpreted in the context of its limitations. Firstly, in this study cancer patients with any type and any stage of cancer were included and these samples greatly vary from each other, especially with regard to time since diagnosis. Therefore, this study provides an overall view about the posttraumatic growth in Iranian cancer patients and provides a basis for further investigations. Further, there is no comparison group from Western countries and therefore, making any conclusion is difficult. In addition, the study was conducted in a single medical centre. Although the centre is a tertiary referral hospital for cancer care in northwest of Iran, patients of this centre may not be representative of cancer patients in Iran. Further, the results of this study cannot be generalized to the broader cancer population because of sampling issues. Further studies need to be carried out in Iran and the Middle East to confirm the results of this study. Cross-sectional studies are recommended to more accurately examine the effects of culture in the experience of posttraumatic growth. In this study the PTGI was appropriately translated into Persian and its validity and reliability were determined, however, further testing of the validly and standardization of the instrument and publication of this data would promote further research.
| » Acknowledgment|| |
This study was funded by financial support of the Hematology and Oncology Research Centre affiliated to the Tabriz University of Medical Sciences. Thanks to all the cancer patients who participated in this study.
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[Table 1], [Table 2], [Table 3]
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