Uncertainty in Illness in Iranian Patients with Cancer and its Related Factors: A Cross-Sectional Study

Research Article

Austin Palliat Care. 2016; 1(1): 1002.

Uncertainty in Illness in Iranian Patients with Cancer and its Related Factors: A Cross-Sectional Study

Sajjadi M¹, Brant JM², Bahri N³, Abbaszadeh A4 and Rassouli M4*

¹Department of Medical-Surgical Nursing, Faculty of Nursing & Midwifery, Social Development and Health Promotion Research Centre, Gonabad University of Medical Sciences, Iran

²Billings Clinic, USA

³Department of Nursing & Midwifery School, Gonabad University of Medical Sciences, Iran

4Department of Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Iran

*Corresponding author: Maryam Rassouli, Department of Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Iran

Received: April 21, 2016; Accepted: May 17, 2016; Published: May 19, 2016

Abstract

Background: One of the most pervasive and major experiences of patients with cancer is uncertainty in illness, which can have significant effects on their psychological adjustment, quality of life and disease outcomes. Recognizing factors that impact illness uncertainty is important for nurses in that they can provide better services for patients.

Purpose: The present study was conducted to examine uncertainty in illness in patients with cancer and its relationship with certain demographic and clinical variables in them to determine its predictors.

Methods: A cross-sectional study was conducted on 420 patients with cancer admitted to two cancer referral centers in Tehran (Iran) in 2013 to investigate illness uncertainty and its related factors. Data were collected through a questionnaire on the demographic information and clinical details of the patients and also using the Persian version of the uncertainty in illness scale. Data were analyzed in SPSS-20 using descriptive statistics and statistical tests, including the Pearson r, chi-squared, independent t-tests and multiple linear regression.

Results: Participant’s mean score of uncertainty in illness was 90.1 (SD = 16.8). Uncertainty of illness had a significant positive relationship with age (r = .19, p < .001) and metastasis (r = .12, p = .026). Uncertainty with illness had a significant negative relationship with the level of education (r = -.47, p < .001) and time since diagnosis (r = -.15, p = .002).The result showed that these variables can express 27% variance of uncertainty in illness in cancer patients.

Conclusion/Implications for Practice: Patients with cancer experience a significant level of uncertainty in illness. The assessment of uncertainty in illness and understanding factors affecting it can help perform appropriate nursing interventions for more effective coping or for reducing uncertainty in illness, which contributes to improving patient’s quality of life and health.

Keywords: Cancer; Uncertainty in illness; Nursing; Iran

Introduction

Uncertainty is a normal part of the cancer experience that persists throughout the stages of the illness, from diagnosis to treatment and throughout follow-up. Uncertainty in illness is defined as the “inability to determine the meaning of events related to the disease and inability to assess events or predict the outcomes of the disease due to the lack of sufficient cues” [1]. Uncertainty is also considered a main psychological stressor [2,3], and most people seek to reduce it or find ways to cope with it [4].

Uncertainty is experienced in all acute or chronic diseases. Chronic diseases such as cancer in particular can lead to persistent uncertainty due to the long duration of the disease, the likelihood of disease recurrence or deterioration, and the patient’s unknown prognosis. Contrary to the uncertainty in acute diseases, which involves only diagnosis, treatment and recovery difficulties, in chronic diseases, uncertainty affects a wider scope of the patient’s life and daily activities and can compromise quality of life [3,5,6]. Several studies conducted in chronically ill patients with conditions such as heart disease, dialysis, hepatitis, liver transplantation, Alzheimer’s disease and specially in cancer have shown that uncertainty in illness is a challenging experience that can compromise quality of life and ability to cope with the disease [2,5,7-13]. Cancer is the second most common cause of death in Western societies [14] and the third in Iran after heart disease and motor vehicle accidents. The annual incidence rate of cancer in Iran is about 80,000 and is expected to rise in the coming decades and become a major health problem of the country [15]. The present-day technological advances for the diagnosis and treatment of cancer have increased patient’s survival, thereby quality of life throughout the survivorship trajectory has become more pressing [16]. Due to the nature of their disease and the complexities of its symptoms and treatment, patients with cancer experience levels of uncertainty in illness that are caused by the problems associated with the inability to perform daily activities, inadequacy of treatments, and concerns about the recurrence of the disease [17,18]. Several studies have been conducted in Western countries on uncertainty in illness pertaining to different types of cancer [4,9,10]. The ultimate goal of these studies is to increase psychological adjustment to the disease and to improve the patients’ quality of life through the effective handling of uncertainty [16].

Uncertainty in illness is a multidimensional and dynamic phenomenon that is perceived differently by patients based on ethnicracial differences and varying social environments. For example, several personal-related factors can affect perception of illness uncertainty, including age and education level; illness-related factors such as history of the disease, stage of cancer, and disease-related symptoms can influence uncertainty. The effects of these factors and their importance have been reported differently in different studies Therefore, examination of uncertainty in diverse cultures and communities is essential in understanding its variability [19, 20]. Additionally, given that the response to uncertainty is shaped by social and cultural context and the background and experiences of the individual (despite a number of invariant responses), studies should be conducted in the context of different societies and cultures [3,21]. Understanding cultural, disease-related, and personal characteristics that predict uncertainty is essential so that nurses can recognize these differences as an essential nursing responsibility in order to provide optimal and holistic care to patients [11].

Despite the importance of the concept of uncertainty in illness for patients with cancer and its profound effects on patient quality of life, limited studies have been published on this subject in Iran. It is unknown which cultural, disease-related, and personal characteristics are associated with uncertainty in Iranian cancer patients and how these differ between Iranian and Western societies. Therefore, the purpose of this study was to determine predictors of uncertainty in illness in patients with cancer in Iran.

Methods

Study design and sample

The present descriptive correlational and cross-sectional study is part of a larger study conducted on uncertainty in illness through mixed methods. This study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences, Tehran (code: 86- 10837) [22].

The study population consists of patients with cancer admitted to the oncology clinics and wards of Imam Khomeini Hospital (the largest cancer referral center in Iran) and Taleghani Hospital in Tehran. Given that these centers admit patients from all over the country, the results of the study can be generalized to the entire population of Iran. A convenience sample of 420 patients with cancer were selected according to the inclusion criteria: 1) willingness to participate in the study, 2) being diagnosed with cancer by an oncologist, 3) being aware of one’s own disease, 4) being of Iranian nationality, 5) having the ability to speak and understand Persian, 6) being at least 21 in age, 7) having no other serious diseases or known mental disorders (such as schizophrenia), and 8) undergoing cancer treatment. Patients with all types and stages of cancer and types of treatment were included in the study.

Instruments

Data collection instruments used in this study include a demographic and disease information questionnaire (with 10 items on age, gender, level of education, marital status, occupation, area of residence, type of cancer, time since diagnosis, presence or absence of metastasis and the type of treatment) and the Mishel Uncertainty in Illness Scale Adult form (MUIS-A). MUIS-A has 32 items based on the Likert scale rated from 1 (completely disagree) to 5 (strongly agree). Higher scores signify a higher level of uncertainty. The instrument has four dimensions, including ambiguity, complexity, inconsistency and unpredictability [23]. Ambiguity has 13 items (unexplained disease symptoms or an overlap between the disease symptoms and other symptoms), complexity 7 items (pertaining to a diverse range of complex treatment and care systems), inconsistency 7 items (the inconsistency of the information the patient receives about his disease) and unpredictability 5 items (the inability to predict disease outcomes through its symptoms). Reliability was evaluated in several studies; Cronbach’s alpha was calculated as α = .87 for the complete scale. Dimension subscales ranged from α = .65 to α = .86, indicating the instrument’s good internal consistency [23]. Results of a study conducted by Sajjadi et al. showed a good reliability and validity for the Persian version of this scale among a population of Iranian patients with cancer. Consistency of the instrument in that study with a three-week interval was r = .91. Cronbach’s alpha was .89 for the whole scale of 32 MUIS-A items and α = .58 to .86 for its four factors [24].

Data collection and analysis

Participants were informed of the study objectives and provided informed consent if they agreed to participate in the study. Questionnaires were then distributed to participants at the time of consent, completed on site, and collected after completion. The Principal Investigator (PI) was responsible for patient selection at the cancer clinics and wards, informed consent, distribution of questionnaires, and data collection. For illiterate patients or for those with vision or writing difficulties, the PI read the questionnaires aloud and marked patient responses. Completing the questionnaires took at most 20 minutes. Data were explored in SPSS-20 using descriptive statistics were used to examine and analyze the relationship between the patient’s demographic and clinical factors and uncertainty in illness. Relationships between variables were tested using the Pearson r, chi-squared and independent t-tests as appropriate. Variables that had a significant relationship with illness uncertainty (p<.05) were entered into the model. Multiple linear regression was used to determine predictors on illness uncertainty. A total of four variables was entered into the regression model. They included age, level of education, time since diagnosis, and metastasis of cancer.

Results

The return rate for the questionnaires was 100% since all were returned at the time of enrollment and in the presence of the researcher. The participants’ demographic information and clinical details are shown in Table 1. The majority of participants were female (51.7%), married (78.8%), nonmetastasic disease (63.7%), and most of them working in the home as a housewife (41.4%), were diagnosed less than 6 months (39.5%) and had a primary and guidance school education (36.0%). The most common type of cancer among participants was breast cancer (24.5%).