Southern Online Journal of Nursing Research

 

www.snrs.org

 

Issue 3, Vol. 4
May 2003

 

Coping Strategies Among African American Women with Breast Cancer

 

Phyllis D. Henderson, Ph.D., APRN, BC¹; Joshua Fogel, Ph.D.^2-6; Quannetta T. Edwards, DNSc, APRN, BC⁷

 

¹Johns Hopkins University, School of Nursing; ²Johns Hopkins University, Bloomberg School of Public Health, ³Department of Mental Health; ⁴Department of Biostatistics, ⁵School of Medicine, ⁶Department of Psychiatry and Behavioral Sciences;  ⁷George Mason University College of Nursing and Health Science, Nurse Practitioner Program Coordinator at Fairfax, VA.

Interactive comments section 

ABSTRACT

Although coping strategies have proven vital in assisting women to adapt to a diagnosis of breast cancer, few researchers have focused on coping strategies used by African American women with breast cancer. The objectives of this study were to determine the coping strategies used by African American women with breast cancer and to explore sociodemographic variables such as age, income, education, marital status, and length of time since diagnosis on coping strategies among African American women with breast cancer. A cross-sectional design was used to study relationships among these variables. The sample consisted of 86 African American women with a diagnosis of breast cancer living in the southeastern United States. Participants were surveyed with a demographic data sheet and the Ways of Coping Questionnaire (WCQ). Data were analyzed with descriptive statistics and multiple linear regression analyses. Results indicated that positive reappraisal and seeking social support are the most commonly used coping strategies among African American women with breast cancer. No significant relationships were found among sociodemographic variables and coping strategies among African American women. Also, a comparison of our mean coping strategy scores among African American women with breast cancer are higher than the mean coping strategy scores from a previous study of mostly Caucasian women with breast cancer. Further research is needed to explore coping strategies of positive reappraisal and seeking social support as these may be important factors in how African American women survive breast cancer.

 

Key words: African American, women, breast cancer, coping, psychological

 

Introduction

Breast cancer is the leading cause of cancer deaths among African American women.^1,2 In 2003, approximately 20,000 new cases of breast cancer will occur in African American women in the United States, and nearly 5,700 African American women will die from breast cancer.¹  In addition, African American women have a lower survival rate from breast cancer than Caucasian women.^1,3 The 5-year survival rate for breast cancer among African American women is 73% when compared to a survival rate of 88% among Caucasian women.¹   Lack of education, lower socioeconomic status, inadequate medical insurance, underutilization of mammography, higher stage at cancer diagnosis, and limited access to care are some reported reasons for the racial differences in breast cancer survival.^1,3 African American women and Caucasian women cope differently with breast cancer which may also help to explain their differences in breast cancer survival.⁴

Recently, researchers have determined that coping strategies used by women with breast cancer are a vital component for adjustment to their disease.^4-7 Although studied among Caucasian women, coping strategies for African American women have not been well defined in the majority of illnesses, including breast cancer.^8-10 Exploration of coping strategies used by African American women, and the possibility of how certain sociodemographic variables might relate to coping strategies among African American women with breast cancer, is the focus of this study. 

 

Literature Review

Theoretical Framework. This study is guided by the Roy Adaptation Model.¹¹ In this model, individuals are viewed as adaptive systems that are capable of responding to their changing environment. The environment is categorized into focal, contextual, and residual stimuli. The focal stimulus is what immediately confronts the individual, which in this study was the diagnosis of breast cancer. Contextual stimuli are factors that contribute to the focal stimulus. In this study, we conceptualized these factors to be intervening variables that included relevant demographic data of age, marital status, educational level, income, and length of time since diagnosis. These intervening variables are discussed in other studies of individuals with breast cancer.^12-15 Residual stimuli are unknown environmental factors that affect the individual’s adaptive system. In this study, we allowed for the possibility of unknown residual stimuli, although we could not quantify or measure them.

According to Fawcett,¹⁶ the Roy Adaptation Model¹¹ is related to the theory of Lazarus, Averill, and Opton,¹⁷ which describes coping mechanisms as innate or acquired methods that individuals use to respond to internal and/or external changes. Roy and Andrews¹¹ state that individuals respond to changes in environmental stimuli through regulator and cognator coping subsystems. The regulator subsystem is a coping process in which an individual automatically responds to environmental stimuli through neural, chemical, and endocrine systems. The cognator coping subsystem allows an individual to respond and adapt to the environmental stimuli through four cognitive-emotive channels: 1) perceptual and information processing, 2) learning, 3) judgment, and 4) emotion. Perceptual information processing involves activities of selective attention, coding, and memory. Learning involves imitation, reinforcement, and insight. Judgment involves decision-making and problem solving. Emotions refer to psychological defenses used to make affective appraisals and attachments. Also, the regulator and cognator coping subsystems occur in four adaptive modes: 1) physiological, 2) self-concept, 3) role function, and 4) interdependence.¹¹

Roy and Andrews¹¹ state that the goal of nursing care is to promote health among individuals by enhancing their coping mechanisms. As few researchers focus on coping strategies used by African American women, this study fills a gap in nursing knowledge by focusing on the cognator coping mechanisms of African American women with breast cancer. African American women as well as other racial groups may be viewed as adaptive systems that are capable of responding to their changing environmental stimuli through cognitive coping mechanisms that promote their adaptation to a diagnosis of breast cancer. In this study we focused on African American women.

Breast Cancer, Coping Strategies, and Adaptation. Due to the physical and psychological impact of breast cancer, coping strategies are essential for adaptation.^4-7 Various strategies exist to assist women in coping with breast cancer.^13,18 Little is known about the psychological continuum within which African American women live with an illness such as breast cancer, and what enhances possible long-term survival.^19-20 It is important to recognize that African American women filter information through a cultural context. These factors may influence their perception of breast cancer and possibly influence their survival rates.^19-22

Prayer and spirituality are common coping approaches for African American women experiencing illness.^19-23 Studies show that both African American women and Caucasian women frequently use positive reappraisal, social support, and “planful problem solving” to cope with breast cancer.^8,10,24 Folkman and Lazarus²⁵ coined the term "planful problem solving" to mean that an individual utilizes an analytic approach to solve a problem or stressful situation. Northouse et al.²⁶ found that optimism was related to a high quality of life among African American women with breast cancer; however, no statistically significant relationships were found between demographic variables and quality of life among these women. A possible limitation of their study is that coping was not measured as a mediator between the antecedent demographic variables and the outcome variable, quality of life.

Support and information play significant roles in women’s adjustment to breast cancer.^27-29 Studies of Caucasian women who do not receive adequate information or social support show that they tend to experience more difficulty adjusting to breast cancer.^28-29 African American women report receiving insufficient information from their health care providers regarding how to cope with their breast cancer.^9,30 Furthermore, African American women state that some breast cancer support groups lack cultural sensitivity and do not provide them with the information and emotional support they need to cope with breast cancer.^9,31 These experiences of African American women with traditional health care services may place them at risk for inadequate adjustment to their breast cancer.

Contextual variables and coping with breast cancer. A few studies examine the relationship of sociodemographic variables among women coping with breast cancer; however, most of these studies include only a small percentage of African American women.^7,14,32 Schnoll, Knowles, and Harlow¹⁴ studied a sample of mixed gender Caucasian cancer survivors and found that demographic variables were associated with positive adaptation. Those who were married, had high income and education levels, and used lower levels of avoidant coping had better adjustment, while length of diagnosis was not related to adjustment. Most of the participants were breast cancer survivors (60%).

In another study of predominantly Caucasian breast cancer survivors (91.6%), those with lower education were more likely to use confrontive coping.¹⁵ Age, education, uncertainty, stress appraisal, or hope did not explain a significant amount of variance in any of their coping strategies. The relative mean scores (RMS) on the Ways of Coping Questionnaire indicated that their most commonly used coping strategies were planful problem solving (RMS = 0.18) and positive reappraisal (RMS = 0.17). Women with a lower educational background were more likely to use the confrontive coping strategy.

Many research studies utilize qualitative methodologies to explore the breast cancer experience of African American women.^30-31,33 However, to our knowledge only a few published studies use quantitative methodology to explore relationships between demographic variables and coping strategies used by African American women; these studies consist of combined samples of women from different ethnic/racial groups.^4,8,10,34 Additionally, there are inconsistencies in the literature regarding demographic variables that may predict coping strategies used by women with breast cancer.^8,14,34 Therefore, the aims of this study were to specifically focus on coping strategies used by African American women with breast cancer and to identify relationships among sociodemographic variables and coping strategies used by African American women with breast cancer. Based on our literature review, we hypothesized that the coping strategies of positive reappraisal, seeking social support, and planful problem solving would be related to sociodemographic variables.

 

Methods

Sample/Setting. A cross-sectional design and a convenience sampling technique were used to recruit participants for this study. Eligibility criteria were as follows: 1) African American women who self-reported a confirmed diagnosis of breast cancer, 2) no metastatic disease, 3) resident of the southeastern United States, and 4) able to provide verbal and written consent to participate in the study.

Procedures. Flyers were given to breast cancer support group facilitators, African American church leaders, and nurses and physicians at oncology clinics to distribute to potential participants. Breast cancer support group facilitators and ministers at churches allowed the first author to make verbal announcements about the study. African American women who were interested in participating in the study contacted the researcher via telephone. Written consent was obtained from each participant. Breast cancer support group facilitators allotted time for African American women to complete questionnaires if they wanted to participate in the study. Some women asked to have their surveys mailed and agreed to return them to the researcher (n = 20) while the others completed their surveys on site (n=66). Most participants (62%) were recruited from African American breast cancer support groups while the rest were not (38%). Approval to conduct this study was obtained from the Hampton University Institutional Review Board.

Instrumentation. Data were collected utilizing a background data sheet (BDS) and the Ways of Coping Questionnaire (WCQ) developed by Folkman and Lazarus.²⁵ The BDS, developed by the lead author, was used to obtain demographic data that pertained to the contextual stimuli such as age, marital status, income, educational level, and length of time since diagnosis. The WCQ served as a measure for cognator coping mechanisms utilized by African American women who had been diagnosed with breast cancer. Based on a review of the Cumulative Index to Nursing and Allied Health Literature (CINAHL) from 1996 to 2002,³⁵ the WCQ has been widely used in nursing studies guided by the Roy Adaptation Model.¹¹

The WCQ is a 66-item, 4-point Likert-type instrument that assesses cognitive and behavioral coping strategies with eight subscales.²⁵ Participants are asked to respond to each item by indicating the frequency with which each strategy was used with 0 indicating “not used,” 1 indicating “used somewhat,” 2 indicating “used quite a bit,” and 3 indicating “used a great deal.” Table 1 depicts the eight subscales and what they represent. According to Folkman and Lazarus²⁵ Cronbach alpha scores in the original study ranged from .61 to .79; in this study they ranged from .51 to .70 (see Table 1).

Table 1.   Description of Folkman and Lazarus²⁵ Ways of Coping Questionnaire Subscales and Cronbach α scores for the Original Sample and Current Sample