Beruflich Dokumente
Kultur Dokumente
By
TSAY-YI AU
January, 2010
CASE WESTERN RESERVE UNIVERSITY
______________________________________________________
Tsay-Yi Au
Ph.D.
candidate for the ________________________________degree *.
(signed)_______________________________________________
Jaclene A. Zauszniewski
(chair of the committee)
________________________________________________
Barbara J. Daly
________________________________________________
Faye A. Gary
________________________________________________
Gary T. Deiming
________________________________________________
________________________________________________
(date) _______________________
November 10, 2009
*We also certify that written approval has been obtained for any
proprietary material contained therein.
TABLE OF CONTENTS
Page
Abstract …………………………………………………………………………………..ix
CHAPTER I: INTRODUCTION
Purpose …………………………………………………………………………..14
Significance ……………………………………………………………………...35
Conclusion ……………………………………………………………………..104
Design ………………………………………………………………………….107
Setting ………………………………………………………………………….109
i
Sample and Sampling Issues …………………………………………………...110
APPENDIXES
ii
APPENDIX B Data Collection Instrument…………………………………...260
BIBLIOGRAPHY.....………………………………………………………….. 269
iii
LIST OF TABLES
Table 4.1 Comparison of Sample Age and Taiwan Government Study ………….153
Table 4.5 International Index of Erectile Function and Score Distribution ………169
Table 4.6 Female Sexual Function Index and Domain Score Distribution..……...170
Table 4.11 Pearson’ correlation coefficients between Age and Study Variables ….182
Variables ……………………………………………………………….192
Variables…….. ………………………………………………………...192
Table 4.17 Correlations between Time since Operation and Study Variables .……195
iv
Table 4.19 Correlations Matrix of Major Study Variables ………………………...199
Variables ……………………………………………………………….201
Variables ……………………………………………………………….202
v
LIST OF FIGURES
Variables………………………………………………………………..213
vi
ACKNOWLEDGEMENTS
committee, Dr. Jaclene Zauszniewski for her invaluable guidance, generous sharing of
research student and a project manager, I had the privilege of interacting with her and
working under her supervision, which has been a unique instructive experience for me
and extended my perspective in nursing research. She has been a great “resource” of
Babara Daly, who provided insightful expert advice during the preparation of my
dissertation. Especially, she provided her time, valuable comments, and extreme support
during almost one year of waiting for the approval of human subjects review board.
Special thanks is also due to Dr. Faye Gary, for her practical comments, encouragement,
and concerns about me and my family. I am extremely thankful to Dr. Gary Deimling for
his valuable advice and for taking the time to read my dissertation and sharing his
experience. I would also like to give special thanks to all the committee members for
their generous sharing of knowledge and time with me and providing constructive
I would like to express my gratitude to Dr. Chris Burant and Mr. Greg Graham for
providing statistical advice and guidance while performing my data analyses. This study
was financially supported by the Frances Payne Bolton Alumni Association and the
vii
I would like to express deepest gratitude to the chief of the department of
colorectal surgery at the medical center in Taiwan, Dr. Tai-Ming King and his colleagues
for their generosity in providing research opportunities and support, and for helping me
with recruitment during my data collection. Special appreciation goes to all the study
participants who were involved in cancer treatment for contributing their invaluable
Christian Church, and the Bread of Life Christian Church in Taiwan, who have been
praying for me during these years. Special thanks go to Wang, Hsu, and House’s families
and friend Sheau-Huey Chiu in Cleveland, and Chou’s families in Taiwan. Especially, I
would like to thank friends Hsueh-Chih Chou, Chi-Mei Shih, Tsui-Yen Lee, Cheng-Hui
Chou in Taiwan for their prayers, encouragement, and support during these years.
Special appreciation goes to the vice president of Fooyin University in Taiwan, Dr. Chi-
Hui Kao Lo who provided guidance and inspired me to enter nursing doctoral program.
I would like to thank the Au family (my parents, sisters, brothers, brothers-in-law,
nieces, and nephews) for all their generous love and support during these years. I would
also like to thank my son, Eric and daughter, Ann, for their understanding, independence,
and sharing in doing the housework with me. Most of all, I would like to thank my
beloved husband, Tai-Ming for his patience, tolerance, assistance, and encouragement.
He was always been there for me all these years. This dissertation is dedicated to him.
Last but not least, I would like to thank the Lord for His grace and Words that
have guided me through this journey, which made me experience His deep love and
faithfulness.
viii
Perceived Stress, Spirituality, Resourcefulness and Sexuality
In Patients with Rectal Cancer undergoing Cancer Treatment
Abstract
By
TSAY-YI AU
and its treatment has been associated with sexual dysfunction. Experiencing sexual
dysfunction in conjunction with a cancer diagnosis can produce overwhelming stress and
compromise one’s ability to adapt to illness and change in sexual function. This study
using Neuman’s systems model, Lazarus’s stress and coping theory, and Zauszniewski’s
sample of 120 rectal cancer adults receiving treatment was recruited from a 1,500-bed
Medical Center in southern Taiwan. Data were collected during face-to-face interviews.
Participants’ ages ranged from 29 to 85 (M = 61) years; 32% had cancer classified as
and average length of time since cancer diagnosis/operation was 36 months. Results
indicated that greater stress was associated with female gender, younger age, colostomy
performed, shorter time since operation, and lower scores on sexuality measures. Higher
appraisal of stress was associated with colostomy performed and lower scores on
sexuality measures. Lower resourcefulness was found in men and associated with more
comorbid conditions, less education, greater stress, lower spirituality, and lower scores on
ix
sexuality measures. Lower spirituality was related to greater stress and lower scores on
sexuality measures. Lower sexual function was correlated with older age, less education,
colostomy performed, higher tumor stage, greater number of cancer treatments and
greater stress. The findings have important implications for theory development, clinical
practice, nursing education and health policy. Advanced practice nurses should focus on
patients before and after surgery. In addition, health promotion programs for long-term
survivors should include the use of well-developed screening measures to assess rectal
cancer patients at risk for high stress, who may also have low resourcefulness, low
spirituality, and low scores on measures of sexuality. Future research with larger, diverse
x
CHAPTER I: INTRODUCTION
Introduction
resourcefulness, and sexuality among Taiwanese patients with rectal cancer undergoing
cancer treatment. The relationships between and among demographic and cancer-related
variables and each independent and dependent variable were also examined. This chapter
describes the background, outlines the significance of the problem, the purpose of the
study, and the theoretical framework. The assumptions and the hypotheses are described
Health is the major concern of the nursing discipline, which strives to help the
individual attain, maintain, or regain wellness. Sexual health involves the integration of
the somatic, emotional, intellectual, and social aspects of sexual being (WHO, 1975),
which reflects a holistic perspective of human beings. Sexuality is unique to each couple
or individual. Cancer of the colon and rectum is reported as the second most common
cancer in Taiwan with 10,248 new cases annually (Taiwan Report, 2006), and also the
second most common cancer in the United States with 146,970 new cases per year
(National Cancer Institute [NCI], 2009). Nowadays, the survival rate for cancer patients
is better because of advanced cancer surgery and adjuvant therapy. The 1- and 5-year
relative survival rates for patients with colorectal cancer are 81% and 61%, respectively
(American Cancer Society, 2002). However, the complications derived from the cancer
treatments for patients with rectal cancer are usually unavoidable. Sexual dysfunction
1
remains a significant problem following cancer surgery for patients with rectal cancer
adjustment (Lazarus & Folkman, 1984). Lazarus and Folkman (1984) asserted that
appraisal and psychological resources are important for understanding the experiences of
individuals dealing with stressful events (Lazarus & Folkman, 1984). Cancer diagnosis
and treatment can be appraised as mostly stressful. Studies indicate that a cancer
diagnosis is usually appraised as a stressful event that poses a threat (Krause, 1991; Lev,
1992). Cancer is a threat to the individual’s whole existence and the satisfaction of the
individual’s fundamental needs (Mishel, Hostetter, King, & Graham, 1984). Elliot and
Eisdorfer (1982) indicated that having a chronic and debilitating medical illness and
unremitting sexual dysfunction are chronic stressors (Derogatis & Coons, 1993). The
cancer patient’s perception of the degree of current stress may influence how he or she is
adapting to the illness process. Stress exists when the individual perceives that he/she has
difficulty in coping with the demands related to cancer and its treatment and the
Coping can be viewed as adaptation (i.e., routine modes of getting along under
relatively difficult situations) (White, 1985). Cancer involves a wide range of situations
that require coping, such as painful or frightening symptoms, feelings of ambiguity about
the prognosis, and changes in social relationships (Dunkel-Schetter, Feinstein, Taylor, &
Falke, 1992). Miller (1980) indicated that coping consists of the learned behavioral
2
responses that are successful in lowering arousal by neutralizing a dangerous or noxious
condition (Miller, 1980). Coping involves behavioral, psychological, and social efforts
derived from illness and disability often causes a disequilibrium of mind, body, and spirit
that requires coping resources (Soeken & Carson, 1987). Ahmad’s (2005) study
demonstrated that coping strategies are stimulated when an event is appraised as stressful
(threat, harm/loss, and or challenge) but not as benign/irrelevant, which is consistent with
Spirituality may be an important coping strategy for patients facing the multitude
of stressors associated with cancer and its potential life threat. There is evidence that
within Lazarus and Folkman’s (1984) transactional model of stress, spirituality among
reducing the emotional distress associated with the disease becomes major focus
flexible coping mechanism, which is consistent with the operational definition found in
empirical literature on spirituality and religiosity (Feher & Maly, 1999; Lamdan, Taylor,
Seigel, O’Connor, & Moran, 1997). Specifically, religious and /or spiritual coping
strategies have been found to be helpful in dealing with the emotional impact of cancer
(Feher & Maly, 1999; Jenkins & Pargament, 1995; Lamdan et al. 1997). Research
suggests that spiritual coping strategies involving relationship with self, others and
Ultimate other / higher power / God or nature were found to help individuals to find
meaning and purpose in illness, resulting in self-empowerment to cope with the current
3
stress until adaptation takes place (Reed, 1986, 1987; Sodestrom & Martinson, 1987;
coping with life threatening and chronic illness (Gotay, 1984; Mickely, Soeken, &
Belcher, 1992; O’Connor, Wicker, & Germino, 1990; McCormick, Holder, Wetsel, &
considered as important personal resources that may foster the process of adaptation
(Brennan, 2004). Chiu’s (2001) study revealed that spiritual resources for Chinese
immigrant women with breast cancer in the US include family closeness, traditional
Chinese values, religion, alternative therapy, art, prose and literature and Chinese support
groups. The Chinese women gained spiritual strength and support in their connectedness
with their family (Chiu, 2001). Spirituality is an intrinsic energy source that has a basis in
both religion and existentialism (Fryback & Reinert, 1999; Kendall, 1994; Landis, 1996;
Relf, 1997).
optimism were demonstrated by patients with ovarian cancer through sharing coping
mechanisms and survival strategies for dealing with symptoms (Ferrell, Smith, Cullinane,
& Melancon, 2003). Social resourcefulness is one of many coping resources used by
some persons when acute and chronic demands threaten to disrupt their psychological or
social equilibrium (Rapp, Shumaker, Schmidt, Naughton, & Anderson, 1998). Appraisal
and resourcefulness may help caregivers modulate their thoughts, feelings, and sensations
that influence their interactions with care recipients, therefore, improve their
4
resourcefulness and spirituality have not been examined as strategies for coping and
undesirable reactions to negative and stressful events that may have an impact on their
(2001) revealed that when faced with a stressful situation, having resourcefulness skills
was the most significant predictor of health (Zauszniewski, Chung, & Krafcik, 2001).
Research indicates that highly resourceful people use adaptive coping methods more
often and more effectively when faced with stressful events, and have more trust in their
ability to control their emotions when faced with difficult and problematic situations
(Rosenbaum & Jaffe, 1983; Rosenbaum & Rolnick, 1983). Specifically, an individual
who possesses internal resourcefulness can overcome stressful situations more effectively
(Rosenbaum & Rolnick, 1983; Rosenbaum & Palmon, 1984; Rosenbaum & Ben-Ari,
internal state or to control oneself, it may positively influence one’s ability to overcome
Lovett, & Rose, 1996). Thus, internal resourcefulness can be viewed as personal
resourcefulness.
(Zauszniewski, 2006). Bailey and her colleagues’ (2003) study revealed that differences
in age and social resources exist between patients with colorectal cancer who did and did
5
not receive adjuvant chemotherapy (Bailey, Corner, Addington-Hall, Kumar, Nelson, &
Haviland, 2003). Social support consists of various social resources that can influence
adjustment (Northouse, 1988). Social support may reduce the negative impact of a
disease because of its anti-stressor effect (Cohen & Wills, 1985). Several researches
found that social support is one of the most important determinants of psychological well
being, health and coping behavior of patients faced by illness process (Schwarzer &
Leppin, 1992; Baider et al. 1996; Baider et al. 2004). Family members and relatives are a
source of social support for patients and have a potential influence on coping, morbidity
(2003) study indicated there is a substantial need for support from family, friends, and
other women, in women diagnosed with ovarian cancer (Ferrell, Smith, Ervin, et al.
2003).
of cancer as well as during the period of remission (Mickley & Soeken, 1993).
loneliness, increased emotional adjustment among seriously ill patients (Gibbs &
dimension or to something greater than the self that empowers, values, and integrates the
self (Kaye, 2000; Reed, 1987). Hiatt (1986) referred to the spirit as a non-corporeal and
non-mental dimension of the person that is the source of unity and meaning. Thus,
spirituality refers to the concepts, and behaviors that are derived from one’s experience of
6
that dimension. Spirituality represents a holistic human characteristic that is important in
human health and well-being (Brallier, 1982; Catterall, Cox, Greet, Sankey, & Griffiths,
Researchers have identified sexuality as the major component of one’s life that is
affected by gynecological cancer and related treatments (Anderson, 1993; Lamb, 1990;
McCartney & Larson, 1987). Molassiotis and his colleagues (2000) stated that the areas
of life most affected by cancer and its treatments in Chinese women with gynecological
cancers were psychological health and social relationships. Three of the most distressed
facets of life were sexuality, psychological health, and spirituality (Molassiotis, Chan,
Cancer and cancer treatments have the potential to negatively affect body image
and sexuality, and diminish sexual functioning and feelings of sexual attractiveness
(Burbie & Polinsky, 1992). Anderson and ven der Does (1994) indicated that compared
with their healthy counterparts, cancer patients are more likely to abandon sexual activity
before they are emotionally ready to do so. As a result of these difficulties, personal
relationships have heightened importance for people with cancer. While the meaning of
sexuality varies as much for the cancer patient as it does for the healthy individual, sexual
contact may have special meaning for the cancer patient: sexuality and sexual expression
convey being human and being alive, and may hold special significance for those whose
experience with disease and treatment cause them to doubt their “human-ness” and the
7
The prevalence of sexual problems following standard abdominoperineal
resection (APR) has been reported to be from 15- 100% (Balslev & Harling, 1983; La
Monica, Audisio, Tamburini, Filiberti, & Ventafridda, 1985; Santangelo, Romano, &
Sassaroli, 1987; Koukouras et al. 1991). Sometimes the injury of the pelvic autonomic
nerve during surgery for the cancer treatment of colon and rectum is unavoidable,
especially when there is evidence of tumor growth into the plexus (Maas, Moriya, Kenter,
Trimbos, & Veld, 1999). Partial or complete excision of the rectum leads to neuropraxia
or permanent damage to the autonomic nerve, which will alter bladder and sexual
function (Maas et al. 1999). The incidence of sexual dysfunction varies from 18-59%
assaults that further affect body image, sexuality, and family functioning (Spagnola et al.
2003).
Spirituality and sexuality have commonly been viewed as antagonistic from the
Western cultural perspective. However, some authors (e.g., Ammerman, 1990; Anderson
& Morgan, 1994; Chavez-Garcia & Helminiak, 1985; Coll, 1989; Gallagher, 1985;
human sexuality. The integration of sexuality and spirituality is nothing other than the
(Helminiak, 1998). The sexual experience of the integrated person includes a world of
meaning and value, a life of shared commitments. At some level it involves interpersonal
engagement, not merely physical and psychological connection (Helminiak, 1998). Spirit
is the dimension of human mind that makes people self-aware, self-transcending, open-
8
ended (Helminiak, 1998). Spirituality is also perceived as an important dimension in
MacKnee (1997) indicated that sexuality and spirituality are related aspects of the
each other. They are similar in origin and expression, and they work toward facilitating
the growth of the whole person and human relationships (MacKnee, 1997). Sexuality is
thought to foster or hinder one’s spiritual growth to some extent. Where spirituality and
sexuality converge is in their mutual striving toward wholeness and by connecting with
one another (Ullery, 2004). Spirituality incorporates the integration of all aspects of the
person and the resultant actualization of one’s fullest potential (Helminiak, 1987). Throne
2001).
actually cope also depend heavily on the resources that are available to them and
constraints that inhibit the use of these resources in the context of a specific encounter
(Lazarus & Folkman, 1984, p.157-158). A resourceful person is one who has many
resources and/is clever in finding ways to use them to counter demands. These resources
are properties of the person from which he or she draws upon in order to counter
demands or cope with stressful situations (Lazarus & Folkman, 1984, p.159). Research
by Bailey and his colleagues (2003) indicated that differences in age and social resources
exist between patients with colorectal cancer who do and do not receive adjuvant
9
Cancer, Treatment and Sexuality
Denney & Quadagno, 1992). Sexuality is not merely the identification of biological and
well-being (Shell & Smith, 1994). Sexuality is an important part of everyday life and it is
1986; Nye, 1999). The World Health Organization (WHO) (Mace, Banneman, & Burton,
1974) promotes the inclusion of sexuality within health care, arguing that all individuals
should be able to enjoy and control sexual and reproductive behavior with freedom from
fear, shame, guilt, and false beliefs (Mace Banneman, & Burton, 1974). Woods (1987)
A study by Tang and his colleagues (1996) described the Chinese beliefs about
sex, the harmonious balance and interaction between Yin (symbolizing women and
associated with interiority, deficiency and coldness) and Yang (symbolizing men and
associated with exteriority, excess and heat), the misconceptions the Chinese women with
gynecological cancer have about their sexual functioning and their fears related to
sexuality after a cancer treatment (Tang, Siu, Lai, & Chung, 1996). Self-treatments of
sexual problems by those Chinese women through traditional methods (e.g., use of
classic sexual manuals, such as the Sui Nui Ching, use of herbs, nutritious foods and
tonics, or use of sex aids) are discussed in their reports (Tang et al. 1996). Such cultural
10
issues can influence the individual’s perceptions of distressful events, and therefore affect
resourcefulness, and sexuality of rectal cancer patients leads to the identification of the
following gaps in knowledge. To date, most people with rectal cancer do try to return to
normal life and deal with daily life issues. However, cancer diagnosis and treatment may
have a significant impact on sexual activity, including functional, emotional and mental
effects (Katz, 2005). Much of the literature exploring sexuality in cancer patients focuses
on the physical problems that result from the disease process or treatment rather than on a
holistic perspective. However, sexual problems occurring in cancer patients are often
multifactorial. Emotional factors may interact with physiological factors to create and
maintain sexual dysfunction, that is, the loss of desire or ability to engage in a physical
relationship with one’s partner, which may in turn further affect other aspects of sexuality
(Schover, 1987).
Few studies have addressed sexuality issues for patients with colorectal cancer
(Shell, 2002). For the most part, prior studies have primarily focused on the
psychological impact of a colostomy (Bekkers, van Knippenberg, van Dulmen, van den
Borne, & van Berge Henegouwen, 1997; Sprangers, Taal, Aaronson, & te Velde, 1995;
Thomas, Turner, & Madden, 1988; Salter, 1992; Jenks et al., 1997). Several studies
function and quality of life after rectal cancer treatment (Schmidt, Bestmann, Küchler, &
Kremer, 2005; Hendren, O’Connor, Liu, Asano, Cohen, Swallow, MacRae, Gryfe, &
11
McLeod, 2005; Guren, Eriksen, Wiig, Carlsen, Nesbakken, Sigurdsson, Wibe, & Tveit,
adjustment and social support for colorectal cancer patients (Mo, 2002), and health care
demands of cancer patients receiving chemotherapy (Hsiao & Dai, 2001). There has been
no research on how Taiwanese patients with rectal cancer undergoing cancer treatment
adjust to the changes in sexual function over time. Very little is known about the impact
of perceived stress on rectal cancer patients’ sexual health/integrity. No research has been
done to investigate the role of spirituality and resourcefulness on sexual health in patients
To date, for the most part, our culture understands sexuality merely in terms of the
physical and the romantic (Helminiak, 1998). Health care professionals, patients, and
partners are often reluctant to discuss sexual functioning (Glasgow, Halfin, & Althausen,
1987; Ganz, 1990; Auchincloss, 1991). The World Health Organization (WHO) set the
goal to ensure that people can enjoy their sexuality and reproduction, and receive
appropriate care when needed (WHO, 1995). Nevertheless, clinical experience continues
to show that the majority of health care professionals do not ask most patients about
Research indicates that nurses wait for patients to raise sexual issues (Waterhouse &
Metcalfe, 1991). Barriers to discussing sexuality include cultural issues, discomfort about
the topic, and lack of educational preparation. Sexual response after colorectal surgery
12
Additionally, competent clinicians usually discuss sexual issues with their patients
from a medical, therapeutic perspective, yet not from a philosophical point of view. It is
important for health professionals to formulate their values and philosophy towards
sexuality. Exploring this issue is also important for nursing professionals because
A presumption exists that the issue of survival overrides the issue of sexuality
survival has been the primary issue (Schover, 1987). As a result, the sexual outcomes
following cancer diagnosis and treatment are often overlooked (Thaler-DeMers, 2002).
Professional nurses are in a unique position to explore the phenomenon in patients with
rectal cancer undergoing cancer treatments. It is important that the treatment of cancer
patients should look beyond survival and address the issue of sexuality. Currently, no
resourcefulness, and sexuality in patients with rectal cancer. Therefore, the investigation
paramount importance.
Significance
resourcefulness, and sexuality in patients with rectal cancer undergoing cancer treatments
about sexuality and its relationships with other phenomena and by demonstrating
13
relationships among demographic characteristics and cancer-related variables, perceived
From the theoretical viewpoint, this study extends knowledge of the phenomena
resourcefulness, and Lazarus’s stress and coping theory, through the examination of
cancer patients undergoing treatment in this study. In addition, the study results
contribute to filling the gap in scientific knowledge concerning the relationships among
perceived stress, spirituality, resourcefulness and sexuality that have been identified
From the clinical and academic perspective, the study’s findings serve as a
beginning point for establishing future assessment of sexuality before treatment for rectal
cancer patients, and for the development of relevant educational programs for nursing
function.
practice, nursing professional are in a unique position to identify stressors, prevent illness,
methodology, this study is the first step in providing data for future experimental and
qualitative research studies. Therefore, this descriptive and exploratory study is the first
step in investigating these phenomena of interest and in providing the foundation for
14
Purpose
The purposes of this study were: (1) to examine the relationships between
resourcefulness, and sexuality among rectal cancer patients, and (2) to explore the
Theoretical Framework
The Neuman Systems Model (Neuman, 1995) provided a coherent and systematic
theoretical framework for guiding the study. The Neuman Systems Model fits well with
the holistic concept of optimizing a dynamic yet stable interrelationship of spirit, mind,
and body of the client in a constantly changing environment and society (Neuman &
Young, 1972). Theoretically, the model is related to Gestalt, stress, and dynamically
organized systems theories (de Chardin, 1955; Cornu, 1957; Edelson, 1970; Selye, 1950).
The Neuman Systems Model is based on the two major concepts of stress and the
reaction to stressors within the total environment of the client system. Stressors are
tension-producing stimuli with the potential for causing the client system instability
(Neuman, 1995, p.22). In addition, The Neuman Model can be described in terms of the
(Fawcett, 1989).
Neuman (1982) views the client (person) as an open system, composed of five
spiritual (Neuman, 1995). Physiological variables are bodily structures or functions, for
15
and relationships, for example, family relationships or sexual relationships. Sociocultural
variables are combined social and cultural functions. Developmental variables refer to
The concept of “system” can apply to any defined whole. Therefore, the client
(Neuman, 1995, p.22). The client is capable of interacting with the environmental intra-,
harmony, stability, and balance between the client and environment (Neuman, 1995,
whether or not experienced as such by the client. In this study, the client system
Neuman (1982) suggests that the environment is the source of stressors and
provides resources for managing these stressors (Neuman, 1982). Stressors are occurring
within both the internal and external environmental boundaries of the client/client system.
include coping skills, education, and strong family support (Neuman, 1982). Other
important considerations are the time of stressor occurrence, past and present condition of
the client, nature and intensity of the stressor, and the amount of energy required by the
16
client to adjust. An individual’s reaction to stressors is determined by the
The flexible line of defense acts as a protective buffer system for the client’s
stable state and prevents stressor invasions of the client system. The normal line of
defense is impacted, while the invasion of particular stressor, a reaction to stress will take
place within the client system. In other words, when the normal line of defense has been
penetrated, the client presents with symptoms of instability or illness. Elements in each
line of defense and resistance are similar and related to the five variables: physiological,
patterns, life-style factors, and developmental, sociocultural, and belief system influences
perception and cognitions (Lazarus, 1981). Cognitive appraisal determines the degree of
stress felt (Lazarus & Folkman, 1984). The transaction model’s major focus on the
person’s perception of a stressor (such as life threat), which is extremely helpful for
dealing with feelings, attitudes, and beliefs that may affect the course of the disease and
the appropriateness of its management. Viewing oneself positively can also be regarded
as a very important psychological resource for coping. Those beliefs serve as a basis for
hope and sustain coping efforts in the most adverse conditions (Lazarus & Folkman, 1984,
p.159).
viewed on a continuum. Wellness and illness are on opposite ends of the continuum.
According to Neuman (1995), health is equated with optimal system stability, that is, the
17
client’s best possible wellness state at any given time. The health of the client is
manifested in various, changing levels within a normal range, rising or falling through the
preserve and enhance system integrity. The wellness-illness continuum implies harmony
or disharmony and that energy flow is continuous between the whole system of the client
nursing as a “unique profession.” The Neuman Systems Model views nursing as being
possible reactions within the client/client system; since environmental exchanges are
reciprocal, both the client and environment may be positively or negatively affected by
each other (Neuman, 1995, p.11). The goal of nursing in Neuman’s Model is to facilitate
client stability (Neuman, 1989) by using primary, secondary or tertiary prevention as the
encountering a stressor, and in some way, strengthen the individual’s flexible line of
defense in order to prevent a possible reaction (Neuman & Young, 1972). Primary
prevention occurs when stressors are suspected or identified, and varying degrees of
reaction to stressors have not yet taken place. The treatment of symptoms following a
18
in a desired state of wellness after reconstitution has occurred (Neuman & Young, 1972;
Spirituality
aware of the meaning, purpose, and values in one’s life (Carson, 1989, p.26). Spirituality
variables of the client (Neuman, 1989). The Neuman Systems Model (1989) emphasizes
that the spiritual dimension influences and is also influenced by all other variables. The
interrelationships of the spiritual variables, stressors, and reactions to stressors are seen as
the means to strengthen the spiritual nature of the person. For instance, suffering
(physical, mental, and spiritual) that occurs as a result of a stressor such as cancer and/or
cancer treatment may also have spiritual meaning and function as a source of motivation
for developing increase understanding and well-being (Neuman, 1989). Neuman (1989)
considers that the spiritual continuum can range from lack of awareness or denial of
client’s wellness and illness outcomes (Neuman, 1989). The physiological, psychological,
sociocultural, and developmental variables link with the spiritual variable to create a
unique individual person. In the ideal situation, there is a balance and harmony in all
variables that is seen as optimal wellness (Neuman, 1995, p.585). The relationship
19
between the spiritual variable and wellness can act as an energy source in achieving client
Spirituality is expressed and shaped by the accepted practices and by the beliefs
and values of a particular culture (Labun, 1988). Frankl (1952) views spirituality as a
person’s ability to give meaning to his or her life by creative values that facilitate the
attitudinal values affect how one chooses to endure unavoidable suffering (McSherry,
2000).
According to Frankl’s (1963) existential theory, people are able to find meaning
in their life and threatening circumstances by (1) what they take from the world (e.g.,
enjoying the pleasures of nature or receiving the love of others), (2) what they give to the
world (e.g., befriending and helping others), and (3) the attitude they choose for
themselves in response to suffering (Frankl, 1985). This theory may explain how
individuals with life-threatening illness such as cancer are able to attribute positive
Frankl (1987) and Travelbee (1966) suggest that spiritual needs are viewed as the
deepest requirements of self (McSherry, 2000, p.33). Several spiritual needs were
identified by authors, including meaning and purpose, love and harmonious relationships
(Shelly & Fish, 1988, Highfield & Carson, 1983; Narayanasamy, 1991), need for
forgiveness (Shelly & Fish, 1988; Narayanasamy, 1991), need for source of hope and
strength (Highfield & Carson, 1983; Narayanasamy, 1991), creativity, trust, maintain
spiritual practices, express one’s own belief in God or deity, and ability to express one’s
20
own personal beliefs and values (Narayanasamy, 1991). If the person’s spiritual needs
can be identified and fulfilled, then he or she can function harmoniously, find meaning,
value, purpose and hope in life even when life is threatened (Harrison, 1993).
care can strengthen the client defenses against stressors (Fulton, 1995). The spiritual
and stability despite physical deterioration and environmental distress (Mattison, 2006;
Chan, Ng, Ho, & Chow, 2006). Spiritual interventions involving techniques of
psychosocial care are life review, story telling, constructivist approach, narrative
approach, the use of play and expressive art and movement to facilitate spiritual
integration for patients and their family members that the (Walsh, 1999). In addition, the
creative, interactional (Tuck, 2004), religious activities (e.g., prayer, acts of worship and
rituals), forgiveness therapy (Butler, Dahlin & Fife, 2002), and spiritual reading
techniques.
21
Lazarus’s Stress and Coping Theory
constantly changing cognitive and behavioral efforts to manage specific external and /or
internal demands that are appraised as taxing or exceeding a person’s resources (Lazarus
& Folkman, 1984, p.141). Life-threatening illnesses, such as cancer, confront patients
with markedly different demands from one point in the illness to another (Lazarus &
Folkman, 1984, p.146). Lazarus and Folkman (1984) have asserted that various outcomes
appraisal of the stressor and his or her coping strategies and resources (Lazarus &
Folkman, 1984).
stressful event for meaning and significance to their own well-being (Lazarus & Folkman,
1984). Lazarus (1984) indicated that the cognitive process of appraisal is essential in
determines both the perception of stress (or appraisal), and the individual’s emotional
reaction to it. The perception of stress depends upon the extent of the environmental
demand and the amount of resources that an individual has to cope with that demand
(Lazarus & Folkman, 1984). Lazarus’s stress and coping theory proposes that stress
(Folkman & Lazarus, 1988; Lazarus & Folkman, 1984). In secondary appraisal, the ways
in which an individual actually copes depend heavily on the resources that are available
to him/her and the constraints that inhibit use of these resources in the context of the
specific encounter (Lazarus & Folkman, 1984, p.158). During secondary appraisal, an
22
individual assesses the availability and efficacy of resources for coping with the stressor
or altering the perceived threat or harm (Folkman & Greer, 2000). It would seem that to
cope with a situation is to attempt to control it by altering the environment, changing the
meaning of the situation, and/or managing one’s emotions and behaviors (Lazarus &
There are three forms of appraisal: irrelevant, benign-positive, and stressful. Also,
there are three types of stress appraisal: harm or loss, threat, and challenge (Coyne,
Aldwin, & Lazarus, 1981; Lazarus & Folkman, 1984; Lazarus, 1998). Lazarus and
Folkman (1984) indicated the meaning of stress in terms of appraisal; they asked whether
the stress-inducing event was perceived as a harm/loss, threat, or challenge, and whether
different types of coping strategies (Lazarus & Folkman, 1984). No research study has
addressed how patients with rectal cancer appraise their cancer and treatment and
sexuality.
of the stress) problem causing the distress (Lazarus & Folkman, 1984). Emotion-focused
coping is directed at dealing with the individual’s stressful emotional response to the
situation. Emotion-focused coping is more likely to occur when there has been an
environmental conditions.
23
Three major adaptation outcomes of coping are identified by Lazarus and
Folkman: well-being, social functioning, and somatic health / illness (Lazarus & Folkman,
1984, p.181). Social functioning refers to the individual fulfillment various roles, for
requisite dispositions and skills. The result of coping may be directed at changing the
environment, or coping directed inward that changes the meaning of the event or
Resourcefulness
(Rosenbaum, 1990). Zauszniewski (1996) reported that healthy elders with both self-help
and help-seeking coping strategies had better psychological well-being and physical
functioning than elders who did not use these two strategies or elders who used only one
of these strategies (Zauszniewski, 1996). Thus, it has been proposed that teaching
personal and social resourcefulness strategies is beneficial for promoting and maintaining
2006).
involve intrinsic and extrinsic factors. Based on empirical studies, intrinsic factors
24
include demographic characteristics (e.g., age, gender, race), number of chronic
conditions, presence of illness symptoms, and perceived stress (Fingerman et al. 1996;
LeFort, Gray-Donald, Rowat, & Jeans, 1998; Zauszniewski & Chung, 2001;
Zauszniewski, Chung, & Krafcik, 2001). Extrinsic factors involve social network size,
social support, and health care orientation (Dirksen, 2000; Rapp et al. 1998). The intrinsic
and extrinsic factors within this theoretical model include the situational, physical, and
Process regulators are seen as intervening factors that may mediate or moderate
the effects of the intrinsic and extrinsic factors on personal and social resourcefulness
affect resourcefulness. Other process regulators, including motivation, energy, and affect
with chronic pain and in healthy elders (LeFort et al. 1998; Zauszniewski, 1996),
perceived health in caregivers and in diabetic women (Rapp et al., 1998; Zauszniewski &
Chung, 2001), and health practices in women with type II diabetes (Zauszniewski &
The theory of resourcefulness has been applied in empirical research with healthy
college students, adults with various psychological and physical conditions, and
studies of resourcefulness in patients with rectal cancer undergoing cancer treatment are
25
Definition of Constructs, Concepts and Variables
stressful event for meaning and significance to their own well-being (Lazarus & Folkman,
judged as more stressful when linked to greater psychological distress (Folkman, Lazarus,
Gruen, & DeLongis, 1986). In this study, appraisal was operationally defined as a
situational factors (cancer and treatment) that are potentially threatening, harmful, or
challenging; the individual’s cognitions determine their perception of stress and their
The perception of stress depends upon the extent of the environmental demand
and the amount of resources that an individual has to cope with that demand (Lazarus &
Folkman, 1984). In this study, perceived stress was defined as the degree of subjective
perception of situational demands resulting from cancer and cancer treatment that exceed
specific external and/or internal demands that exceed a person’s resources (Lazarus &
coping by which the individual continuously appraises and reappraises the person-
26
environment relationship and changes his/her thoughts and acts to manage the stressful
attempt to control the environment and to find meaning in the situations (Lazarus &
Folkman, 1984, p.141-142). Coping strategies are intervening factors that may mediate
or moderate the effects of perceived stress on sexuality for patients with rectal cancer.
Spirituality is the unifying force of a person that permeates all of life and is
manifested in one’s being, knowing, and doing; the interconnectedness with self, others,
nature, and God / Transcendent (Dossey & Guzzetta, 2000). Spirituality refers to the
The operational definition of spirituality in this study was self-awareness in searching for
meaning or purpose of life and suffering, through the interconnectedness with others,
inner peace and harmonious status. Resourcefulness was defined as a repertoire of the
individual’s learned behavioral skills, which included personal (self-help) and social
(help-seeking) resourcefulness for coping with negative and stressful events that may
Wellness was the outcome variable and it was defined as a person’s subjective
perception of sexual health including sexual function, sexual self-concept, social role,
self-concept, and sexual relationships provided the focus for considering sexual health
throughout the life span. Because each dimension is interrelated with the other two
dimensions, a change in one dimension produces changes in the others. The integration of
27
the three dimensions of sexual health produces well-being (Woods, 1987). Sexual health
is defined as the integration of the somatic, emotional, intellectual, and social aspects of
the sexual being in a way that is positively enriching and enhances personality,
communication, and love (WHO, 1975). In this study, sexual health was operationally
defined as sexual integrity, which involved the perception of sexuality that influenced
personal and social behavior, the expression of self, and relationships with others that is
and beliefs (Yura & Walsh, 1983). Sexual function refers to the ability of a person to give
and receive sexual pleasure (Woods, 1987). The operational definition of sexual function
components, which includes the sexual response cycle (i.e., libido, arousal, and orgasm),
values, and beliefs. Sexual dysfunction is defined as the inability to express one’s
sexuality as consistent with personal needs and preferences. In men, this includes
Sexual self-concept is the image that one has of him/herself as a man or woman
and the evaluation of masculine/feminine roles, body image, and the evaluation of self
image against personal and cultural standards (Woods, 1987). A person’s self-views are
views of themselves as passionate / romantic, and open / direct to sexual experiences are
examples of positive sexual self-concept, while men’s views are passionate / romantic,
28
The operational definition of sexual self-concept in this study was a cognitive view about
sexual aspects of oneself derived from past experience and manifested in current
experience, and the evaluation of role function and body image based on personal and
cultural standards.
behaviors and feelings that are relevant to a person’s definitions of satisfaction. Sexual
relationships are the interpersonal relationships in which one’s sexuality is shared with
another (Woods, 1987), whereas the overall sexual relationship is a critical determinant
of sexual satisfaction (Wellisch, Jamison, & Pasnau, 1978). The operational definition of
sexual satisfaction in this study was the extent of one’s subjective perception and feelings
about the sexual behaviors, interpersonal relationships, and role function as well as
health/wellness were derived from the Neuman Systems Model (Neuman, 1995), and
Lazarus and Folkman’s stress and coping theory (1984). Stress and wellness/health
outcome are two major concerns in the whole client system (Neuman, 1995). Stress
(Lazarus & Folkman, 1984). An individual’s optimum state of wellness can be attained
through interactive adjustment process with the environmental stressors (Neuman, 1995).
evidence, Lazarus and Folkman’s stress and coping theory (1984), Zauszniewski’s
resourcefulness theory (2006) and Neuman’s Model (1995). The outcomes of stressful
29
situations depend heavily on an individual’s appraisal, coping strategies and resources,
whereas appraisal determines the degree of perception of stress. The process of cognitive
(i.e., primary appraisal), and therefore cognition further determine both the perception of
stress and the individual’s emotional reaction to the situation. During secondary appraisal,
an individual assesses the availability and efficacy of resources to cope with the stressor
or to change the perceived threat or harm (Folkman & Greer, 2000). The perception of
stress depends upon the extent of the environmental demand and the available and
efficacy resources that an individual has to cope with the stressor (Lazarus & Folkman,
1984). There are three types of stress appraisal: harm or loss, threat, and challenge
(Coyne et al. 1981; Lazarus & Folkman, 1984; Lazarus, 1998). Each type of appraisal
may stimulate different types of coping strategies (i.e., problem-focused and emotion-
functioning, and somatic health /illness (Lazarus & Folkman, 1984). In this proposal, the
regarded as coping strategies under this theoretical framework. Coping strategies can be
viewed as intervening factors that may influence an individual’s line of defense (Neuman,
and treatment (i.e., type of surgery, radiotherapy, and/or chemotherapy), were measured
30
by 10-item version Perceived Stress Scale (PSS; Cohen, Kamarck, & Mermelstein, 1983)
and Cognitive Appraisal of Health Scale (CAHS; Kessler, 1998). Spirituality was
(Ng, Yau, Chan, Chan, & Ho, 2005). Resourcefulness, which consisted of personal
(i.e., 16-item Self-Control Scale (SCS) and 12-item Help-Seeking Resource Scale
Index of Erectile Function (IIEF; Rosen et al. 1997) or Female Sexual Function Index
(FSFI; Rosen et al. 2000), Sexual Self-Schema Scale including female (SSSS-F;
Anderson & Cyranowski, 1994) and male versions (SSSS-M; Anderson, Cyranowski, &
Espindle, 1999), and two scales of Evaluating and Nurturing Relationship Issues,
31
Constructs Stress Adaptation Health/Wellness
CO SRS
Assumptions
Several assumptions supporting the guided theoretical framework for the study
system components, through regulation that changes the dynamics of the open
4. Stress has the power to disturb the equilibrium of the client system (Neuman,
1995).
32
5. The perception of stress (appraisal) depends upon the extent of external and/or
internal environmental demand and the amount of resources that an individual has
individual’s cognitive appraisals of the stressor and his or her coping strategies
7. The dynamics and change that characterize coping as a process are a function of
8. Spirituality is innate to the client system and involves subjective meaning that a
stressor has for the client and the attitude the client chooses in response to a
(Rosenbaum, 1990).
10. Nursing interventions attempt to assist the client to regain or maintain an optimum
Research Questions
1. What are the differences in or relationships of major study variables (perceived stress,
(i.e. age (A), gender (B), education (C), and religion (D) in rectal cancer patients? (Q1A-
Q4D)
33
2. What are the differences in or relationships of major study variables (perceived stress,
stage of disease (E), type of treatment (F), time since operation (G), and comorbid
3. What are the relationships between perceived stress and sexuality (Q5), spirituality and
sexuality (Q6), resourcefulness and sexuality (Q7), perceived stress and spirituality (Q8),
spirituality and resourcefulness (Q9), and perceived stress and resourcefulness (Q10) in
Demographic and Q4
Cancer-related
variables Q1
Perceived Stress Q5 Sexuality
A. Age
B. Gender
Q2 Q8 Q6
C. Education
D. Religion Spirituality
Q7
E. Stage of disease Q3
F. Type of Q9 Q10
treatment
G.Time since Resourcefulness
operation
H. Comorbid Figure 1.2. Study Model.
conditions
34
CHAPTER II: REVIEW OF LITERATURE
Introduction
of this study. Empirical studies of each concept of interest, including perceived stress,
spirituality, resourcefulness, and their relationships to sexuality are reviewed and their
strengths and weakness are evaluated. The Neuman Systems Model, a mid-range theory
frameworks for the study. Lastly, studies related to the demographic and cancer-related
Significance
Prevalence of Cancer
Cancer has been recognized as a life-threatening disease for many years and one
and spiritually. Colorectal cancer is the second most prevalent cancer and the third
leading cause of cancer death world-wide (Parkin, 2001). Every year approximately one
million new cases of colorectal cancer are diagnosed (Ferlay, Bray, Pisani, & Parkin,
2001). Colorectal cancer is currently the second most common cancer among females and
males in the United States (U.S.) (NCI, 2009) and Taiwan (Taiwan Report, 2006), and
third most common in Europe (Becker, Muscat, & Wynder, 2001; Weir et al. 2003).
Rectal cancer is one of the most prevalent cancers with an estimation of 146,970 new
cases annually in the U.S. (NCI, 2009). Incidence rates of colorectal cancer increase with
age and over 40% of cases occur in subjects over the age of seventy-four (Arveux,
35
Survival rates for colorectal cancer vary depending upon stage of the disease. The
Dukes staging system, devised in the 1930s and modified in 1978, was the most widely
used classification which uses the letters A, B, C, and D to describe the stage of the
cancer. Until 1987, the American Joint Committee on Cancer (AJCC) developed a new
classification for colorectal cancer, the TNM staging system, (T stands for the extent of
tumor invasion, N for the extent of lymph node involvement, and M for distant metastasis
(spread) to other organs or tissues), which is more precise than the other systems and is
consistent with the way many other types of cancers are staged (Levin et al., 2006, p.77-
93; Oncologychannel, 1998-2009). In the U. S., the five-year overall survival rate for
patients diagnosed with stage II and III colorectal cancer was 64% (stage IIB ~ IIIB:
72~64%) (O’Connell, Maggard, & Ko, 2004). About 90% of surviving five years was
reported for patients with localized disease that has not yet grown through the bowel wall
physiological stress, disrupting many organs and systems. For patients with advanced
colorectal cancers (i.e., disease confined to the pelvis), treatment consists of rectal
(Enker, 1992).
Surgery has been considered as the predominant treatment for patients with rectal
cancer over the past 20 years. In 1970, an abdominoperineal resection (APR) with a
permanent colostomy was the major treatment for most patients with a carcinoma of the
middle or low rectum (Chatwin, Ribordy, & Givel, 2002; Levin et al. 2006, p.180); the
36
surgeon performs a “sphincter-sacrificing” proctectomy by removing a portion or all of
the sigmoid colon, the entire rectum, the adjacent mesentery, and the anus. A permanent
colostomy is constructed and the patient wears a pouch to collect stool and gas from the
To date, because of the evolution of surgical techniques, most patients with rectal
cancer (80 to 90%) receive surgery of low or ultralow anterior resection (LAR) (Williams
& Johnston, 1984; MacFarlane, Ryall, & Heald, 1993; Frari & Tschmelitsch, 2002). The
anastomosis deep in the pelvis but may be concerned that the connection may not heal
properly and that feces could leak from the anastomosis. In such case, the surgeon may
decide to do a temporary proximal diversion will temporarily divert feces into an ostomy
pouch and prevent stool from going through the new connection. Once the anastomosis is
totally healed after six to 12 weeks, a second operation is done to reverse the temporary
LAR are physical, psychological and social comfort in comparison of APR (Chatwin et al.
2002). Avoiding a permanent colostomy is one of the goals of surgery for rectal cancer
In cancers of the mid- or low rectum, a total mesorectal excision (TME) is the
standard procedure, which inevitably leads to an anastomosis within 5 cm from the anal
verge (Heald, 1988; Heald & Ryall, 1986; Frari & Tschmelitsch, 2002). It achieves
complete excision of the rectum together with its draining lymphatics, and results in low
rates of local recurrence (Heald, 1988). This technique employs dissection in the tissue
plane that separates the mesorectal fascial envelope from the presacral fascia (Heald,
37
1988). In the process of total mesorectal excision, the rectum with its surrounding layer
of fatty tissue, the mesorectum, is resected as an intact capsule with negative tumor
margins in the majority of cases (Havenga, Maas, DeRuiter, Welvaart, & Trimbos, 2000).
However, care must be taken because excessive traction during the dissection or lateral
dissection outside this plane may lead to neuropraxia or permanent injury to the
sympathetic and parasympathetic nerves that course along the lateral pelvic side-walls.
Inadvertent damage to these nerves will result in postoperative bladder and sexual
dysfunction, the severity of which will be dependent on the extent of the injury and the
relative components of the autonomic supply affected (Masui, Ike, Yamaguchi, Oki, &
Shimada, 1996; Maas et al. 1998; Nesbakken, Nygaard, Bull, Carlsen, & Eri, 2000).
Nowadays, the use of adjuvant therapy has been recommended to decrease the
risk of local recurrence and improve survival. The local recurrence (defined as pelvic
patients undergoing adequate surgery alone range from 4% to 35% (Havenga et al. 1999).
(Martenson et al. 1999). Thus, curative radiation therapy may be used in colorectal cancer,
with the goal of eradicating disease that is local, or at most regional in character. In
for one year has proved to be effective after curative surgical resection of Duke’s stage C
colon carcinomas (Penna & Nordlinger, 1996). In the U.S., post-operative chemotherapy
plus radiotherapy is the most widely used approach, whereas in Europe there has been a
and chemotherapy has shown statistically significant improvement in local and distant
38
disease control as well as in overall survival for stage II and III rectal cancer (Tepper et al.
1997).
Complications
sexual problems caused by cancer and its treatment (i.e., surgery and adjuvant therapy)
were identified (Schover, Schain, & Montague, 1989; Tepper et al. 1997). The
the rectum (Chorost, Weber, Lee, Rodriguez-Bigas, & Petrelli, 2000; Pocard et al. 2002).
The incidence of sexual problems or dysfunction following various cancer treatments has
been reported to range from 40% to 100% (Derogatis & Kourlesis, 1981) or 15 to 100%
(Balslev & Haring, 1983; La Monica et al. 1985; Santangelo et al. 1987; Koukouras et al.
1991) or 18 to 50% (Quah, Jayne, Eu, & Seow-Choen, 2002), which varies greatly and
depends on the extent of resection and the surgical technique used (Quah et al. 2002).
(Butler, Banfield, Sveinsen, & Allen, 1998; Dunn, Croft, & Hackett, 1998; Schover, 1999;
Lemieux, 2004). Reports indicated that more than half of the respondents (56%) were
sexually inactive after a multimodality treatment for advanced rectal cancer (Mannaerts,
Rutten, Martijn, Hanssens, & Wiggers, 2002). Although these detrimental effects on
sexuality are not as immediately life threatening as cancer itself, as treatment goes on,
day to day stress becomes overwhelming and many concerns related to coping with
cancer and its treatment emerge for long term cancer survivors.
39
Inadequate / Inconsistent Assessment of Sexuality
100% may be the inconsistent approaches to the assessment of sexual dysfunction across
studies (Schmidt, Bestmann, Küchler, & Kremer, 2005a). The inconsistent assessments
of sexuality result in various outcomes that do not adequately indicate the extent of
perspective and behavior toward sexuality has greatly changed; nevertheless, the
societies such as Taiwan, China, Hong Kong, and Singapore (Tang et al. 1996).The
Taoist beliefs that a disharmony of Yin (represent for women) and Yang (represent for
emphasizes procreation and social order, whereas the Taoist sexual philosophy is related
to the balance among Yin (women) and Yang (men), personal health, and longevity
(Tang et al. 1996). Sexual dysfunctions of Chinese women with gynecological cancer are
deemed as an imbalance of Yin and Yang elements (Ngan, Tang, & Lau, 1994). The
preservation of energy for postoperative recovery, and the submissive and passive roles
of women in the patriarchal traditions of men rejecting their partners during illness,
which reflects the impact of cultural beliefs (Ngan et al. 1994). Similarly, Mo’s (2001)
40
study from Taiwan indicated that patients with colorectal cancer would stop or reduce
their sexual activities, because such activities may make their cancer worse.
issues. A retrospective review of the medical records indicated that the majority of
patients (37 of 52 or 71%) were not provided an opportunity to discuss the risk of sexual
dysfunction before treatment (surgery and radiation) (Chorost et al. 2000). Sexual
dysfunction of the patient is rarely taken into consideration not only in the preoperative
discussion, but also, in the postoperative treatment (Hendren et al. 2005). Health care
quality of life (Lemieux, 2004). Evidence supports that both health care professionals and
Sexuality is an integral part of every human being (Shell & Smith, 1994).
Sexuality refers to sexual integrity, which involves not only a physical perspective but
and beliefs (Steinke & Patterson-Midgley, 1998). Sexuality has received little attention in
the process of cancer care (Butler et al. 1998; Schover, 1999). Evidence demonstrates that
sexuality has been studied in prostate, breast, and gynecological cancer survivors.
Nevertheless, the sexuality of colorectal cancer patients has seldom been addressed in
studies (Shell, 2002). There are limited studies exploring the individual psychosocial
impacts of colostomy for patients with rectal cancer (Sutherland, Orbach, Dyk, & Bard,
1952; Sprangers, Taal, Aaronson, & te Velde, 1995). The issues of sexuality are actually
41
and clinically encountered by the subject. A tendency was reported for medicine to
dysfunction and quality of life undergoing rectal cancer surgery among the developed
countries since 2002 (Chatwin et al. 2002; Camilleri-Brennan & Steele, 2002; Hendren et
al. 2005; Schmidt, Bestmann, Küchler, Longo, & Kremer, 2005b). Moreover, sexuality
has recently started receiving attention in the palliative care of rectal cancer patients
(Lemieux, 2004). A qualitative study mentioned that only one subject (N=10) had
previously been asked about sexuality as part of clinical care, whereas all subjects
suggested that changes in sexuality resulting from cancer treatment should be addressed
sexuality and the feeling of romance (Helminiak, 1998) rather than viewing sexuality
area, particularly in view of the current high prevalence of this tumor in the population.
The Neuman Systems Model was developed in 1970 as a total person approach to
patient problems (Neuman & Young, 1972). The Neuman Systems Model (1995) has
is based on stress and reaction within the total environment of the defined client as a
system (Neuman & Fawcett, 2002, p.12). Four concepts of nursing’s metaparadigm --
42
person, environment, health, and nursing -- are composed of the content of the Neuman
Systems Model (Neuman & Fawcett, 2002, p.4), which is derived from and is explicitly
related to Gestalt, stress, and dynamically organized systems theories (de Chardin, 1955;
Cornu, 1957; Edelson, 1970; Lazarus, 1981, 1999; Selye, 1950). Theoretically, the
Neuman Systems Model has some similarity to Gestalt theory, which implies that each
word Gestalt literally means whole (Brallier, 1982, p.42). The Neuman Systems Model
also relates to field theories, which reflect that all parts of the system are intimately
interrelated and interdependent (Edelson, 1970). The organized system of the field is the
primary concern. In the wholistic Neuman Systems Model, the system considers (1) the
occurrence of stressors, (2) the reaction or possible reaction of the client to stressors, and
(3) the particular client as a system, involving the simultaneous effects of the interacting
Chardin (1955) and Cornu (1957) suggest that in all dynamically organized systems the
properties of a system part are determined by the whole. This means that no part can be
isolated and each must be viewed as part of the whole. A single part influences our
perception of the whole, and the patterns or features of the whole influence our awareness
wellness or stability. The Neuman Model describes the individual as having a basic
lines of resistance – homeostatic mechanisms that attempt to stabilize and maintain the
43
individual’s normal line of defense; 2) normal lines of defense – the stability factors
developed over time, including intelligence, coping abilities, outlook on life, and
Few studies address the application of the Neuman Systems Model to rectal
cancer patients. However, systems approaches are evident in the following publications.
The Neuman Systems Model was used in Molassiotis’s (1997) study to guide the
assessment of quality of life in clients with cancer who had a bone marrow transplant.
study, Weinberger (1991) described an analysis using the Neuman Systems Model to
determine the effects of a colostomy on a client with colon cancer (Weinberger, 1991). In
addition, applying the Neuman Systems Model and Rosenbaum’s learned resourcefulness
women’s health (Klainin, 2002). In a study by Nagia and Hoda (1989), the examination
postoperative state anxiety among Egyptian bladder cancer patients with urinary
diversion was based upon the Neuman Systems Model. The results revealed that stress
was associated with being cancer patients followed by the impact of surgery on their
bodies and on their social and marital life (Nagia & Hoda, 1989). However, there is no
study applying the Model on patients with rectal cancer undergoing treatment. This
model will be applicable to adult patients with rectal cancer as the presence of stresses
44
(i.e., cancer and cancer treatment) does not reduce the client system from
A conceptual framework provides a foundation for nursing practice and forms the
structure for organizing its systems, methods, and tools (Christmeyer, Catanzareti,
Langford, & Reitz, 1988). The Neuman Systems Model presents a comprehensive
systems-based conceptual framework for nursing (Neuman, 1989). There are a number of
reasons for choosing the Neuman Systems Model as a nursing model in this study. Since
the patient with rectal cancer receiving treatment is constantly impacted by his/her
environment, it is imperative and important that the nursing model chosen would view
the individual as a client system. What is included within the boundary of the system
must have relevance to nursing. One of the critical reasons for choosing the Neuman
Systems Model is the view of the client from a wholistic framework, in which five
interact harmoniously with the environment to mitigate possible or potential harm from
internal and external stressors (i.e., cancer and its treatment). Its conceptual breadth,
flexibility, and systemic properties will provide an integrated view of sexuality for rectal
People experience stress and cope with it by using learned patterns of thoughts,
feelings, and behaviors. Stress appraisal by the individual in the Lazarus’s stress
transaction model explicitly plays a significant role in the coping process. The word
stress was initially used by Hans Selye (1936) to describe a physiologic pattern that
prepared the individual for “flight or fight” or the defense reaction, involving the
45
sympathetic nervous system and the adrenal-medullary system (Brallier, 1982, p.42).
Since the 1960s there has been growing recognition that while stress is an inevitable
aspect of the human condition, it is coping that makes the big difference in adaptation.
adaptation (Lazarus & Folkman, 1984, p.11). Stress involves a cognitive process and a
consequences. There are wide individual differences in the perception of what is stressful
and when it is stressful (Eisdofer, Cohen, Kleinman, & Maxim, 1981, p.176).
Psychological stress involves a particular relationship between the person and the
environment that is appraised by the person as exceeding his or her resources and
endangering his or her well-being (Lazarus & Folkman, 1984, p.19). Grinker and Spiegel
(1945) indicated that appraisal of the situation requires mental activity involving
(Lazarus & Folkman, 1984, p.25). Appraisal processes illustrate the cognitive mediation
of the stress reaction and the coping process (Lazarus & Folkman, 1984, p.37). Cognitive
appraisal can be understood as the process of categorizing an encounter, and its various
facets, with respect to its significance for well-being. Because cognitive appraisal
psychological stress resides in both the situation and the person. It arises from the
46
termed a transaction, which means that not only does the environment affect the person,
but also that the person affects the environment; both influence each other mutually in the
Cohn and Lazarus (1979) indicated that illness can induce several threats
including threats to one’s self-concept (loss of autonomy and control, one’s self-image
changes), threats to bodily integrity and comfort (bodily disability, permanent physical
equilibrium, and threats to the fulfillment of customary social roles (separation from
family, friends, and other social supports), which the individual must cope with. In this
study, coping involves external stimuli such as dealing with threats of adjuvant
satisfaction and relationships. Coping strategies are the specific techniques that a sick
individual selects to deal with the illness and its consequences. Coping is context-specific
recovers from contact with a stressor, whether a minor daily hassle or a major life change
(Lazarus & Folkman, 1984). Coping consists of “efforts, both action-oriented and
internal demands and conflicts among them” (Lazarus & Launier, 1987, p.311).
Generally, the coping process may include a two-staged cognitive process of primary and
secondary appraisals (Lazarus & Folkman, 1984). With the primary appraisal, the
individual determines whether the adverse conditions or stressful events are a threat
(“Am I still okay with this situation?”), and the secondary appraisal includes a review of
47
choices of action if a threat is perceived (“What can I do now?”). Responses include
resources are important to an individual’s response to the diagnosis of cancer and its
subsequent treatment. Two coping resources that have been noted in the Zauszniewski’s
the individual’s perception of the stress (the process of cognitive appraisal of the situation)
and how the availability and the efficacy of resources to the individuals will influence the
ways (coping alternatives) they deal with adverse situations encountered. Thus, appraisal
of the situation and the coping alternatives are central to the transactional stress model of
Lazarus and Folkman (1984). In a transactional model, threat refers to the integration of
both separate personal and environmental factors in a given transaction to form new
meanings via appraisal. The transactional model is concerned with process and change
(Lazarus & Folkman, 1984, p.326). The meaning and significance of the stressful event
(appraisal) to the individual are key components of the model to determine the coping
strategies being used. However, Lazarus’s stress and coping theory only describes the
secondary appraisal that determines the perception of stress or the individual’s emotional
this study.
Studies of stress and coping. Measurements of stress and coping focus on three
types of major variables, that is, stress, appraisal, and coping (Lazarus & Folkman, 1984,
48
p. 306). In a study done by Dunkel-Schetter and colleagues (1992), five coping strategies
are examined: social support/direct problem solving, distancing, positive focus, cognitive
Schetter et al. (1992) study rated their coping efforts concerning the aspects of cancer and
found that one of the most stressful cancer-related problems was limitations in physical
abilities, appearance, and lifestyle (24%) (Dunkel-Schetter, Feinstein, Taylor, & Falke,
1992).
A qualitative study, Lev (1992) described the coping strategies that were used by
and radiotherapy). Results indicated that whether or not cancer treatments were
1992). Krause (1991) conducted an exploratory study to determine the coping process of
patients with cancer. The results showed that 68% of patients with cancer have feelings
of shock, fear, sorrow, and bitterness. The subsequent methods of coping included
emotional evaluation of their situation in life, in comparison with earlier experiences and
those of other cancer patients, and appeals for social welfare assistance (Krause, 1991).
(cancer and treatment) during appraisal process. One study addressed the adaptation of
adjuvant therapy on population of colorectal cancer. These findings indicate that coping
process of an individual involves cognitive appraisal and seeking for social resources.
49
Resourcefulness Theory
his or her appraisal process. Resourcefulness has been studied over two decades.
(Zauszniewski, 2006, p.3). Miller (1980) indicated that coping consists of the learned
repertoire learned not only through conditioning but also through modeling as well as
formal and informal instructions (Rosenbaum, Franks, & Jaffe, 1983, p.57). Rosenbaum
(1990) emphasized only the independently performed cognitive-behavioral skills that are
used for managing potentially disturbing internal processes, whereas the Zauszniewski’s
theory of resourcefulness also recognizes the importance of depending on others for help
or assistance in managing adversity. Nadler (1990) viewed seeking help from others as
the “other side of the coin” of resourcefulness, and Rapp and colleagues (1998) used the
term “social resourcefulness” to describe the behaviors used to establish and maintain
supportive relationships and obtain help from others (Zauszniewski, 2006, p.7). This
study of rectal cancer patients who are receiving treatment used this more recently
allow an individual to control the potential suffering associated with stressful events,
including the cognitions, emotions, and sensations that interfere with the performance of
50
daily activities (Rosenbaum, 1990). Self-control of internal processes following the
thoughts, feelings, or impulses so that the individual may function at an optimal level
changes within oneself, or within the environment. For instance, the result of rectal
cancer surgery and adjuvant therapy may cause temporal or permanent impaired sexual
style. Second, during the self-evaluation phase, the individual engages in Lazarus and
Folkman’s (1984) “primary and secondary appraisals.” In the primary appraisal, the
undesirable, the individual may ignore it, and no self-control behavior will happen as a
result. On the other hand, if the individual feels threatened or in danger by the disruption,
the individual may begin a secondary appraisal process. For example, the individual
receiving cancer treatment may appraise the availability of resources that he / she can use
to improve his / her sexual health. During the secondary appraisal stage of the self-
evaluation phase, the individual develops expectations for the future. According to
Bandura, (1977, 1982) there are two basic expectations that guide human behavior:
individual’s belief that a specific course of action will lead to a desired goal. On the other
51
hand, self-efficacy expectations refer to the individual’s belief that he or she is capable of
performing the necessary actions to attain the desired goal (Rosenbaum, 1990, p.7).
throughout life, which are labeled “learned resourcefulness” (LR), to reinforce the
resourcefulness (LR) proposes that resourceful individuals will not be affected by the
environmental and cognitive factors presumed to cause anxiety and depression, and that
they will be able to independently perform daily tasks despite potentially adverse
circumstances. Thus, learned resourcefulness (LR) serves as a basis for coping with
(Rosenbaum, 1983).
the use of positive self-instruction and cognitive restructuring of thoughts, mood, and
pain control to resume the normal functioning that has been disrupted. Second,
immediate gratification for better future outcomes and to disrupt the customary way of
functioning and, thereby, adopt a new behavior. Third, perceived self-efficacy involves a
52
general belief in one’s ability to cope effectively with internal processes or stimuli
viewed as the ability to seek help from others when unable to function independently
(Nadler, 1990). Social resourcefulness may involve formal help-seeking sources such as
should be viewed as two complementary dimensions, both of which are important for
physical and psychological health (Zauszniewski, 1996). Other major constructs of the
intervening variables, and quality of life or positive health outcomes (Zausniewski, 2006).
populations have included healthy college students, adults with various psychological and
2006). Empirical studies of resourcefulness have used research methods that range from
standard psychometric studies, to designs that characterize individuals with high or low
teach resourcefulness to elders (Zauszniewski, 2006). However, there are a few studies
related to resourcefulness among male and female patients with rectal cancer.
the use of self-help strategies for coping with adversity or challenge. Braden (1990)
arthritis-related conditions. The results showed that one of the self-help model variables,
53
enabling skill, was the strongest predictor of self-help (β = .42). The total explained
variance of self-help was 55% (R2=.55), which indicated that the greater the enabling
skill, the greater the ability for self-help and vice versa. Self-help was strongly related to
life quality (β = .62). Self-help and uncertainty explained 49% of the variance in life
A self-help model tested in Kreulen and Braden’s (2004) study supported the
and client morbidity. Client factors such as age, size of social network, disease stage,
predicted relationships. The patterns of relationships for women receiving treatment for
breast cancer (N=307) were examined, and the results revealed delayed behavioral
breast cancer survivors was tested; the findings indicated that social support and
In a sample of 137 chronically ill elders, Zauszniewski and associates (2001) used
model testing to examine the relationships among social cognitive factors reflecting
enabling skills (learned resourcefulness), internal motivation for health (health self-
54
psychosocial health for predicting health. The results indicated that learned
resourcefulness was associated with the use of informal help, which can be defined as
help from others including family, friends, and over-the-counter medications, whereas
health self-determinism was related to self-help and formal help. Resourcefulnesss had a
direct effect on the informal help response. Thus, resourcefulness (β=.24, p < .01) was a
resourcefulness in 25 female and 25 male subjects coping with epilepsy, the findings
demonstrated that subjects with greater resourcefulness coped better with their disability
and were emotionally impacted by depression and anxiety significantly less than subjects
resourcefulness perceived greater control over their health (Health Locus of Control
Scale (HLC), F(1,44) = 6.11, p < .05) and the occurrence of seizures (Perceived Control
of Seizures (PCS), F(1, 44) = 4.41, p < .05) (Rosenbaum & Palmon, 1984).
exposure to failure. Results revealed that the resourcefulness determines the subjects’
1985). These studies confirmed that the individuals with a greater resourcefulness can
55
self-reported coping behaviors were examined relative to changes in dysphoric affect
over time. The findings indicated that internal resourcefulness was the only significant
predictor of changes in dysphoric affect over time. In this study, internal resourcefulness
was defined as the individuals’ repertoire of skills and behaviors to deal with negative
affective states. Internal resourcefulness therefore involved the ability to use self-control
to combat difficulties that arise. Thus, internal resources may allow individuals to
enabling skills, self-help, and life quality or health. These results reflect the importance of
promoting independence and healthy, productive lifestyles in adults with cancer and
chronic illness.
the “buffer hypothesis” (Cohen & Wills, 1985), social support acts as an anti-stressor
In a study of 337 (a total sample of 383 subjects) older patients with colorectal
cancer before and after treatment, Bailey and colleagues in UK (2003) examined social
association existed between patients’ social resources rating and treatment with adjuvant
less likely to be impaired in social resources than Duke’s C patients who did not
56
(adjusted odds ratio 0.14-1.03, p= 0.06). In that study, the key social resources were
number of people whom the respondent knows well; 2) the number of home
relatives and friends, and 7) availability / amount of help during illness. After controlling
for age, patients who were treated with adjuvant chemotherapy were, in general, less
likely to be impaired in social resources. Thus, there were differences in age and social
resources between patients who receive treatment and who did not receive it (Bailey et al.
2003).
Hunter and colleagues (2003) explored symptom perceptions and health beliefs as
predictors of intentions to seek medical help in 546 women with breast cancer. Results
showed that the cognitive component of the self-regulation model accounted for
was a significant predictor of intention to seek help. Intention to seek medical help may
be mediated for potential breast-cancer symptoms (Hunter, Grunfeld, & Ramirez, 2003).
A qualitative study of social concerns of women with ovarian cancer (with a total
sample of 766), which was conducted by Betty and colleagues from 1994 to 2000 (2003),
examined social well-being; the theme of social support was the most common (N=251),
followed by support offered by family and friends (N=163) and support gained from
other ovarian cancer survivors (N=122). The statements related to social support were
addressed as follows: “the things that have helped me the most is my wonderful family
and some great friends;” “a number of our neighbors have offered to help in any way that
57
they can;” “I have learned to accept help and not to try to do this alone;” “people in
hospital has been so supportive of me..,” etc. (Ferrell, Smith, Ervin, et al. 2003).
influencing the psychological distress of breast cancer patients (n=210) and their
husbands during remission were identified. Results showed that women whose partners
refused to participate in the interview reported significantly less perceived family support
seeking may serve as mediator in the study. The social support resources include family,
friends, neighbors, and other cancer survivors. Patients learned to access resources not
only from within themselves or their own abilities, but also to seek help from others
(social support) that enhance greater adaptation toward adverse situations; patients,
thereby, maintain or promote physical and psychological health, and, eventually, life
satisfaction. Among these studies, the majority of the target population was cancer
survivors; however, there is only one study focused on colorectal cancer patients. Thus,
more empirical studies related to patients who are receiving treatment for colorectal
related quality of life (HRQL) as well as their predictive value to HRQL for 456 long-
term cancer survivors. The findings revealed a strongly positive relationship between
self-esteem and HRQL (r = .69, p=.00), a moderately strong inverse relationship between
58
learned resourcefulness and HRQL (r = -.32, p =.01), and a statistically significant
inverse relationship with HRQL (r = -.38, p=.00), which was only associated with the
resourcefulness, and the loss of social support explained over half the variance (R2 = .53)
relation to depressive cognitions, adaptive functioning, and life satisfaction among 120
healthy elders were examined. The results showed that self-help was significantly
correlated with greater adaptive functioning, but help-seeking was not. Additionally, the
study found that elders who used both self-help and help-seeking reported greater life
satisfaction. The study reported that elders who used both self-help and help-seeking
strategies had better psychological well-being and physical functioning than elders who
did not use these two strategies or elders who used only one of these types of strategies.
can explain about 50% of the variance of HRQL. Moreover, two forms of resourcefulness
play an important role for health promotion and maintenance, especially among elders.
(1980) developed a Self-Control Schedule (SCS), which was found to be both valid and
reliable and has since become the most widely used measure for assessing learned
59
resourcefulness/personal resourcefulness (Rosenbaum, 1980, 1990). Rosenbaum (1980,
1990) believed that three dimensions (redressive self-control, reformative self-control and
that 11 of the 36 items did not load on the expected factor, and 9 had significant cross-
loadings. These results suggested that the three dimensions of personal resourcefulness
are interrelated and not clearly distinct (Zauszniewski, 1997). In addition, LeFort’s (2000)
study indicated low correlations between self-efficacy and resourcefulness for both
pretest and posttest (r = .13 and r =.25, respectively). Both studies suggested that self-
(Zauszniewski, 2006).
was developed by Rapp et al. (1998), whereas personal resourcefulness (i.e., learned
to date, no published studies were found that use a measure that captures both personal
and social resourcefulness. However, in 2006, the development and testing of such a
Resourcefulness Scale (RS) by Zauszniewski and her colleagues (2006) is the only
measure that captures both personal and social resourcefulness and has been found the
importance for health promotion and maintenance for older adults (Zauszniewski et al.
60
associated to Rosenbaum’s Self-Control Scale (SCS) and 12-item social (help-seeking)
resourcefulness. The RS has been tested in the population of chronically ill elders from
U.S., however, it has not been tested in a diversity of sample ranged from young or
middle-age to older adults, such as male and female rectal cancer patients in Asia.
Stressful life events are assumed to increase the risk of disease when they are
insufficient to address that threat or demand (Cohen & Williamson, 1988, p.31). It is
generally believed that stressful events detrimentally influence health status. When
In this study, the concept of perceived stress was operationalized as the degree of
subjective perception of situational demands resulting from cancer and cancer treatment
that exceed the individual’s available and efficient resources for adjustment and are
cognitively appraised as stressful events. Measurements that have been used to capture
perceived stress include three versions of the Perceived Stress Scale (PSS4, PSS10, and
PSS14), and 32-item Cognitive Appraisal of Health Scale (CAVH; Kessler, 1998) or 13-
item CAVH (Ahmad, 2005). The Perceived Stress Scale-10 (PSS10) appears to provide
at least as good a measure of perceived stress as does the longer scale (Cohen &
Williamson, 1988).
health practices were reviewed and supported as below. Frequency of serious illness and
61
both serious and nonserious symptoms of illness were positively related to perceived
stress. Small correlations were also observed between perceived stress and health
frequent physical exercise, and increased frequency and variety of illicit drug use (Cohen
In Cohen and his colleagues’ (1993) study, data from a large (N=2,387
found between stressful life events and illness (Cohen et al. 1993). The results of a study
by Cohen and Williamson (1988) indicated that the relationship between Perceived Stress
Scale (PSS) scores and scores on measures of health and health behavior were not
definitive as to whether stress acted as the causal agent, whether stress resulted from
those related factors, or whether both factors were influenced by other variables (Cohen
& Williamson, 1988, p.45). The researchers used the Perceived Stress Scale 10-item scale
in this study (Cohen & Williamson, 1988). In another study, Ho and associates (2004)
suggested that cancer survivors with greater emotional control tended to have greater
stress, anxiety, and depression and tended to adopt negative coping strategies for the
mediator of the relationship between stressful events and health and health practices.
Associations between perceived stress and illness, symptoms of illness, and a wide range
62
of health behaviors were also demonstrated. No causal inference was illustrated from
Taiwanese adults who have been diagnosed with rectal cancer. Moreover, the
relationships between the perception of stress associated with rectal cancer and its
Sexuality
reproductive health care in medicine (such as contraception), sociology, and a few in the
palliative care literature. Empirical studies of sexuality include women with breast or
gender, and biology (Lamb & Woods, 1981). Sexuality is an essential component of an
individual’s wellness and personality throughout his/her life span (Waxman, 1996;
Fallowfield, 1992; Shell & Smith, 1994). Sexuality does not diminish in importance as a
result of chronic or terminal illness (Fallowfield, 1992; Shell & Smith, 1994).
need to be aware of and acceptance of our own body through all five senses; 2) intimacy,
described as our need and ability to experience emotional closeness to another human
being, and to have that emotional closeness predictably returned in kind; 3) sexual
63
sexuality; 4) reproductive aspects, deal involving how one deals with fertility and
Human sexuality is viewed as complex and pervades one’s biological being, sense
of self and interpersonal relationships; specifically, this includes sexual dimensions such
as sexual function (ability to give and receive sexual pleasure), sexual self-concept (self-
image as male or female and masculine or feminine roles, body image, and inclusion of
sexual sharing) (Woods, 1987). Sexuality is more than the sex urge and sex act; sexuality
is a way to express loyalty, passion, affection, esteem, and affirmation of one’s body and
being (Gordon & Snyder, 1980, p.272). Self-concept is the individual’s total thoughts and
feelings about self (Rosenberg, 1979). Self-concept is composed of physical self (body
image), functional self (role performance), personal self (moral self, self-ideal, and self-
foundation to taking action to achieve improved health. Chronic illness has an impact on
the self and represents a core component of one’s sexuality (Andersen, 1999). A sexually
schematic/conceptual man is one who views himself as loving and passionate, powerful
and independent, and open-minded in his sexual attitudes. Andersen’s (1999) study
suggested that schematic and aschematic men hold very different views of the sexual self,
64
and that these sexual self-views relate to differences in both sexual behaviors and
themselves as emotionally warm and passionate individuals who are behaviorally open to
romantic and sexual relationships. These women tend to be liberal in their sexual
through the means of sexual function, sexual self-concept, and sexual satisfaction
(Woods, 1987; Bulter & Lewis, 1993; Anderson, 1999; Miller, 2000; Steinke & Patterson,
1998).
Female Sexual Function Index (FSFI; Rosen et al. 2000), the International Index of
Erectile Function (IIEF; Rosen et al. 1997), women’s form of the Sexual Self-Schema
Scale (SSSS-F), men’s form of the Sexual Self-Schema Scale (SSSS-M; Andersen &
Studies of sexuality. Nosek (1996) studied the notion of wellness among women
with physical disability. Five themes related to sexuality emerged as follows: 1) having a
65
productive relationships; 4) managing barriers; and 5) maintaining optimal health and
physical and sexual functioning (Nosek, 1996). Additionally, in a qualitative study, the
poems from cancer patients’ experiences showed that the damaged bodies of cancer
patients are still sexual in nature. This implies that cancer patients still perceived their
bodies to be sexual (Van der Riet, 1998). Patient’s sexuality is encompassed in the whole
person.
Platell and his colleagues (2004) from Australia assessed women’s sexual health
(between 1996 and 2002) and compared study (n=50) and control groups (n=62)
undergoing pelvic surgery for rectal cancer (22 of 50 subjects in the study group
Results showed that compared with those in the control group, women who had
undergone pelvic surgery were significantly more likely to feel less attractive (p=0.039),
feel that the vagina was either too short or less elastic during intercourse (p=0.012), or
experience superficial pain during intercourse (p=0.012). Women in the study group were
concerned that these limitations would persist for the rest of their lives (Platell,
17 women diagnosed with gynecological cancer (Bultler et al. 1998). The study described
sexuality as a much broader construct. Sexual functioning was found to be one aspect that
contributed to the view of the self as a sexual being. Women’s experiences with changes
in sexual function were related to physical comfort, sexual satisfaction, and feelings of
intimacy post-treatment.
66
In a qualitative study of 10 palliative patients aged 44 to 81 years, face-to-face
interviews related to the meaning of sexuality were conducted (Lemieux, 2004). Two of
the ten subjects were diagnosed with colon cancer and received cancer treatment
including surgery and chemotherapy or/and radiation. Analysis of data revealed five
major themes: the meaning and expression of sexuality, sexuality and quality of life,
the study as a therapeutic intervention. Subjects’ statements indicated “If my partner sees
me as being sexual even though… you think you’re deformed, but you’re not. I think it’s
their attitude that helps me with my attitude about myself.” “Sexuality means more than
longitudinal study of 123 Taiwanese cancer patients receiving chemotherapy, Hsiao and
Dai (2001) assessed their health care needs upon discharge and 7-10 days after discharge.
Results showed that the information relevant to sexuality was cancer patients’ last
study by Gloeckner (1982), 60% of 40 patients with ostomy reported feeling less
attractive during the first year after surgery. Hurny and Holland (1985) reported that up to
one-third of the patients treated for bladder or colon cancer completely stopped any
sexual activity even though the majority of them did not suffer from physical impairment
of sexual function. The results of the study reflected that patients with the colostomies
In short, the concept of sexuality was used interchangeably with sexual health.
The review of these studies shows that sexuality is multidimensional including not only
67
physiological, but also psycho-sociological aspects. There are three qualitative research
studies involving women with chronic illness (i.e., gynecologic cancer or physical
disability), and only one experimental comparative study done from the Australia; all of
these studies had small sample sizes of rectal cancer patients. Nevertheless, the study
sexual self-concept, sexual function, and sexual satisfaction. Results revealed that sexual
self-concept was a core component of one’s sexuality. However, the majority of these
studies used qualitative designs with small sample sizes and focused primarily on
female’s sexual perspective related to wellness. Moreover, the results are not
generalizable to rectal cancer patients because of their small sample sizes. Finally, the
of studies regarding the associations among sexual self-concept, sexual function and
analyses, the results showed that only subjects’ sexual self-schema accounted for 34% of
the variance in predicting current sexual responsiveness and behavior after controlling for
frequency of pre-cancer intercourse, menopausal symptoms, and the extent of the cancer
and its treatment (Anderson, Woods, & Copeland, 1997; Cyranowski, Aarestad, &
Anderson, 1999).
68
In a quantitative and qualitative study, Caldwell (2003) explored the
gynecological cancer survivors’ (n=21) experiences of sexuality and body image. The
significant mood disturbance and sexual problems involving sexual desire, frequency of
sexual desire, pleasure, arousal, and orgasm. The most common themes that emerged
the issues of sexuality and body image were: loss of pleasure (33%), feelings of isolation
(44%), loss of wholeness (56%), loss of desire (67%), a dramatic and abrupt shift in self-
identity due to loss of physical integrity (67%), a reluctance to initiate discussions about
sexual concerns (67%), a negative impact on body image (89%), and a negative impact
Yurek (1997) tested a model for predicting sexual and psychological morbidity
among women (n= 133) following surgical treatment of breast cancer. The results
indicated that sexual self-concept appears to mediate women’s stress reactions. Moreover,
women with a negative sexual self schema reported increased frequency of avoidant
behaviors and greater distress in sexually-relevant situations than women with positive
sexual self schemas. Sexual self schema also contributed significantly to the incremental
variance -- 55% in the reported frequency of sexually intimate behaviors following breast
cancer surgery. Measurements related to sexuality involved in this study included the
Body Satisfaction Scale, Sexual Response Cycle, and Sexual Self Schema measure
(Yurek, 1997).
program on sexual functioning in a study group (n=10) and a control group (n= 10) of
69
women with breast cancer was explored (Curran, 1999). Results found that there is a
sexual self-schema and improvements in global sexual functioning in women with breast
cancer. Measurements related to sexuality involved in this study are Sexual Self-Schema
Scale (SSS), Global Sexual Rating Scale (single item), Sexual Relationship Assessment
Scale (SRA), and Profile of Mood States (POMS) (Curran, 1999). The study results do
breast cancer.
A cross-sectional study done by Ananth and colleagues (2003) from the United
Kingdom indicated that patients with all types of cancer in palliative care (n=64) and
oncology care (n=56) groups reported more sexual dysfunction than general practice
patients (n=67) (control group). In addition, despite lower strength and frequency of
sexual relationships in oncology patients than in general practice, there was little
difference in sexual satisfaction. In conclusion, patients in both cancer groups were found
to be significantly more willing to talk about their sexual lives (χ2 = 18.4; df =2, p<
0.001). The impact on sexual function was significant in comparison with the control
group of the same age. This result may promote greater awareness in health care
professionals, which is quite different from before (Ananth, Jones, King, & Tookman,
2003). In this study, the Derogatis subscale on sexual satisfaction, the General Health
Questionnaire (GHQ12) and the European Quality of Life (EuroQOL) were used.
In summary, there is evidence from the reviewed research studies that the
individual’s sexual self-schema accounted for 34% to 55% of the variance in predicting
70
current sexual responses/behaviors for women with gynecologic or breast cancer
(Anderson, Woods, & Copeland, 1997; Yurek, 1997). Results support the association
between stress reactions and sexual self-schema, and the association between sexual self-
schema and sexual function (Yurek, 1997). Only one study focused on all types of cancer
experimental pilot study with a small sample indicated that a stress management program
was not effective for improving sexual dysfunction in female breast cancer patients
(Curran, 1999).
design, uses a comparison group that has not been designated by a randomization
procedure. The problem with the use of such a comparison group is the possibility that
the groups are initially different, which will most likely affect the study results (Ananth et
al. 2003). Those studies in which there was no control group may collect data at regular
time points (i.e., time series design). In addition, the triangulation technique, which uses
qualitative and quantitative data sources, was utilized in one study to improve credibility
studies (i.e., breast cancer or gynecological cancer) were relatively homogeneous with
respect to the variables of interest, a small sample size may have been adequate. However,
the accessible population for these studies was restricted to female cancer survivors; thus
the external validity was affected and the findings are not generalizable to Taiwanese
71
Perceived Stress and Sexuality (from medical studies)
dysfunction) was supported by the review of the relevant evidence-based medical studies.
In a retrospective study of the quality of life (QOL) between 1994 and 1999, Chatwin and
colleagues (2002) evaluated the indicators of sexual activity among 43 patients with LAR
surgery. Sexual dysfunction was reported by 9 of the 13 sexually active men and 2 of the
trial conducted in the UK (1996 and 2002), sexual function of laparoscopically assisted
surgery (using TME technique) was compared with conventional open surgery among
male and female rectal cancer patients (N=794), using the International Index of Erectile
Function (IIEF), and the Female Sexual Function Index (FSFI) at 4 time points (pre-
surgery and 3, 6, and 18 months after surgery) (Jayne et al. 2005). Additionally, the
comparisons. Results showed that overall sexual function in males tended to be worse
after laparoscopic rectal surgery (with TME technique) than after conventional open
rectal surgery. However, there were no differences in sexual function of females (Jayne et
al. 2005). In another study conducted in the UK, Camilleri-Brennan and Steele (2002)
reported on QOL before surgery for rectal cancer, on discharge home and at 3-month
intervals after operation for 1 year from 1997 to 1999 in a sample of 82 patients. Results
indicated that sexual enjoyment and sexual function of males on the QLQ-CR38 had
postoperative period) and remained poor thereafter (Camilleri-Brennan & Steele, 2001).
72
In Canada, Hendren and his colleagues (2005) also used the IIEF, FSFI, and
and female (n=81) sexual dysfunction following rectal cancer surgery (from 1980 to
2003). Reports indicated that 32% of women and 50% of men were sexually active
postoperatively, compared with 61% and 91% preoperatively (p<0.04); 29% of women
and 45% of men reported that “surgery made their sexual lives worse.” Specific sexual
problems in women were: decreased in libido (40%), arousal (29%), lubrication (56%),
orgasm (35%), and dyspareunia (46%); sexual problems in men were: decrease in libido
(47%), impotence (32%), partial impotence (52%), and decreased in the frequency of
Schmidt and colleagues from Germany (2005) investigated quality of life and
sexuality in a ten-year cohort (from 1992 to 2002) of 516 rectal cancer patients. Results
showed that sexuality was most impaired for patients receiving APR. Significant
differences were seen in symptom and function scales between males and females
(Schmidt, Bestmann, Küchler, Longo, et al. 2005). However, both genders experienced
limitations in their sexual life; males had significantly higher cores for physical function
than female and felt more distressed by this impairment. Younger females felt more
(Schmidt, Bestmann, Küchler, Longo, et al. 2005). Schmidt and colleagues’ (2005) study
from Germany indicated that adjuvant therapy had no influence on sexuality but did have
an impact on quality of life one year after surgery (Schmidt, Bestmann, Küchler, Longo,
et al. 2005). In another prospective study from Germany, Schmidt and colleagues (2005)
evaluated the impact of age, gender, and type of surgery on sexual function for 819 rectal
73
cancer patients (412 males, 407 females) using the EORTC-QLQ-C30 questionnaire at 6
time points (i.e., before surgery, at discharge, 3, 6, 12, and 24 months postoperatively)
(Schmidt, Bestmann, Küchler, & Kremer, 2005). Comparisons were made across three
types of surgery (APR, LAR with / without Pouch and Sigmoid resection). The findings
confirmed that factors like type of surgery, gender, and age have tremendous impact on
sexual function and sexual enjoyment. Type of surgery such as APR and AR with Pouch
affect sexual function more than AR and resection of the lower sigmoid. Men experience
greater strain with impaired sexual enjoyment than women. Patients aged 69 years and
younger experience more stress from deteriorated sexual function (Schmidt, Bestmann,
Allal and his colleagues (2005) from Switzerland prospectively evaluated the
QOL of 53 patients with advanced rectal cancer following preoperative radiotherapy and
patients). Two questionnaires, the EORTC QLQ-C38 and the EORTC QLQ-C30, were
used to measure QOL. The results showed that the sexual dysfunction scores increased
significantly, particularly in men (17 vs. 83, p=0.0045), and a lower body image score
(100 before RT, vs. 89 after RT (p = 0.068) was observed. In summary, one year after
combined treatment for locally advanced rectal cancer, patients exhibited statistically
In addition, Ness and his associates from the US (1998) identified outcome states
of colorectal cancer and cancer treatment based on the stage and the location of the
disease at diagnosis using six patient focus groups (n=38). Results revealed that problems
74
with social interaction and cognition, changes in bowel habits, and sexual dysfunction are
associated with colorectal cancer (Ness, Holmes, Klein, Greene, & Dittus, 1998).
function after pelvic nerve-sparing radical surgery in mailed survey using the American
pleased, mostly satisfied, mixed mostly dissatisfied, unhappy and terrible) with 68 rectal
cancer patients. The results showed that 88% (28 of 52) of the men had some
postoperative deterioration in the erectile function, and 83% of the men had ejaculation,
regardless of the types of surgical procedures. Overall, 64% of men were unsatisfied with
their current sexual function (Ameda et al. 2005). Moreover, Guren and colleagues (2005)
from Norway assessed QOL and functional outcomes by using the EORTC QLQ-C30
and QLQ-CR38 questionnaires with female and male rectal cancer patients (N=319)
following anterior resection (AR) and APR. Results showed that mean QOL scores for
body image and male sexual problems improved following AR (e.g., LAR) than APR
(p<0.01), but there was no difference in QOL. However, this study emphasized that
because only 33% of the women responded to questions regarding female sexual function.
Thus, it is difficult to compare the sexual function across the two genders (Guren et al.
2005).
In summary, the impact of types of surgery (LAR, APR, APR with/without Pouch)
on sexual function or dysfunction or sexual health for rectal cancer patients was
Europe (UK, Germany, Norway), North America (Canada, United States), and Asia
75
(Japan). Retrospective studies were conducted over periods ranging from 5 to 26 years
Ten empirical studies examined the relationship between cancer treatment (i.e.,
surgery and adjuvant therapy) and sexuality. The majority of these studies (retrospective
and prospective) indicated a significant association between cancer treatment and sexual
function, indicating that those undergoing cancer treatment, including types of surgery
(LAR, APR, APR with / without Pouch) and radiation therapy, reported sexual
dysfunction or impaired sexual life. The only report indicating no differences in sexual
function among females was a randomized clinical trial in the UK (Jayne et al. 2005).
sexual function, sexual problems, sexual life, and sexual enjoyment, dissatisfaction with
sexual function, dissatisfaction with appearance (less attractive), pain during intercourse,
impaired social interaction and cognition. Precision in defining the terms conceptually
and operationally has the advantage of communicating exactly what the terms mean
(Polit & Hungler, 1999, p.25). If each variable under consideration is not operationally
and explicitly defined, it is difficult for readers to understand the full meaning and
Research has shown that despite these reports of sexual dysfunction from surgery
(LAR), most patients were satisfied with quality of life (QOL) or reported no difference
in their quality of life (Chatwin et al. 2002; Schmidt, Bestmann, Küchler, Longo, et al.
2005; Hendren et al. 2005; Allal et al. 2005; Guren et al. 2005). This implies that the
individual may have developed effective coping strategies for sexual problems. In
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addition, the validity of the measures used needs to be considered. Instruments involving
IIEF, FSFI, and / or EORTC QLQ-C30 / QLQ-CR38 were used in two studies to assess
the sexual function or dysfunction for men and women (Jayne et al. 2005; Hendren et al.
2005). Other questionnaires, including the EORTC QLQ-C30 or / and the EORTC QLQ-
CR38, were used in four studies (Camilleri-Brennan & Steele, 2001; Schmidt, Bestmann,
Küchler, Longo, et al. 2005; Allal et al. 2005; Guren et al. 2005). Other studies adopted
approaches for measuring concepts related to sexual function has resulted in a variety of
When random procedures have been used to select a sample from an accessible
population, there is no difficulty in generalizing the results to that group (Polit & Hungler,
1999, p.260). The only experimental study of sexual function to be found was a
randomized clinical trial (RCT) conducted in the UK (Jayne et al. 2005). The findings
from that study can only be generalized to that group in the UK with a sufficiently large
sample size and small sampling error (Polit & Hungler, 1999, p.240). The findings in a
particular situation in the UK may not be representative of all other rectal cancer patients
(target population) in the UK; furthermore, it also may not be representative of rectal
cancer patients in other countries, including Taiwan; one study is not adequate to
adjuvant therapy may vary across studies. Questionnaires / measurements used in the
studies and questions used in the interviews were not standardized, and cultural
77
differences may influence the outcome; therefore, a direct comparison of results and
adjuvant therapy and sexuality (sexual function or dysfunction) were also examined in
the literature. Long-term QOL study of 165 anal cancer patients receiving radiotherapy
with chemotherapy or radiotherapy alone was assessed by Allal and colleagues (1999)
from the Netherlands. Results indicated a higher level of problems in sexual functioning
scales on the QOL-CR38 (Allal et al. 1999) and adjuvant therapy had significant
detrimental effects on the patient’s sexual function (Allal et al. 1999). In the U.S., Heriot
function (between 1998 and 2004) in 201 male patients undergoing oncologic resection
for rectal cancer at 7 time points (preoperatively, 4 months, 8 months, 1 year, 2 years, 3
years, and 4 years after surgery). Radiotherapy had an adverse effect on domains of
sexual function, including the ability to have an erection, maintain an erection, attain
orgasm, and being sexually active in comparison with patients undergoing surgery alone
(7.4%, 12.6%, 16.2%, and 13.7% reduction 8 months after surgery respectively; p<0.05)
In short, adjuvant therapy had an adverse effect on sexual function. The advantage
of this study was the evaluation of sexual function at 7 time points which provide for
making comparisons over time; however, this study only focused on male patients.
(2000) assessed the pre-surgical and pre-radiation discussion of the risk of sexual
78
dysfunction after curative treatment among 53 consecutive patients (37 men and 16
women; age ranged from 38 to 85 years old) who underwent potentially curative therapy
for rectal cancer. Results showed that pre-surgical discussion of the risk of sexual
dysfunction was not documented in the consent of 37 of 52 (71%) patients (Chorost et al.
2000). Of the 6 males who received LAR, only 1 complained of sexual dysfunction after
surgery. Five of 15 males (33%) who were treated with APR alone reported post-therapy
sexual dysfunction, whereas 6 of 8 males (75%) who were treated with APR and
radiation reported sexual dysfunction. Of the entire group of female patients, only 1 of
the 16 reported sexual dysfunction post therapy (Chorost et al. 2000). Another review of
the medical literature focused on the anatomy, physiology, and surgical aspects of rectal
cancer (through the Medline database) done by Keating (2004) from New Zealand; the
review indicated that the incidence of permanent impotence remained higher (> 40%)
after APR but declined in the use of LAR. In addition, patient age was the most important
predictor of sexual dysfunction after surgery for rectal cancer (Keating, 2004).
Temple and colleagues in the U.S. (2003) reviewed the published data on sexual
and functional changes associated with radiation in rectal cancer patients and sphincter
preservation. These published data were from small retrospective studies. Results
indicated that sexual function was poorly studied, but radiation had a negative impact on
sexual function in both men and women (Temple, Wong, & Minsky, 2003).
In summary, the type of surgery (LAR or APR) had a substantial impact on the
extent of the individual’s sexual function, which has not been widely explored. The effect
79
Spirituality
characteristic of humanness in human health and well being (Reed, 1992). Spirituality is
referring to relatedness to the social and physical environment (Stool, 1989). To these
individual to the world and gives meaning and definition to existence. Watson (1988)
indicated that spirituality encompasses in the nature of human needs and involves
multiple dimensions of connectedness within and beyond the self. Similarly, the themes
of development of a connectedness within and beyond the self are integral to Newman’s
identified that a harmonious interconnectedness within self, with others, a higher power,
connectedness to God, to one’s neighbor, to one’s inner self” was addressed in Ley and
Corless’ (1988) definition of the concept of spirituality. Newman (1989) explicated the
nature of healthy human development in terms of human spirit. Watson (1999) believes
that a greater sense of harmony within a person’s mind, body, and spirit, or between the
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Differentiation of spirituality and religion. Spirituality is derived from the Latin
word spiritus, spirit, which implies the essential part of the person (Piles, 1990).
Spirituality is the nature of human beings, spans the entire developmental life process
(Reed, 1992). However, the term religion and spirituality have been often used
perspective, the results of the empirical studies found that most of their respondents
identified themselves as both spiritual and religious (ranged from 52% to 74%) (Shahabi
et al. 2002; Zinnbaner et al. 1997; Corrigan, McCorrde, Schell, & Kdder, 2003). From
these studies, most people view themselves as both religious and spiritual and spiritual
development for most may occur within the context of a supportive religious environment.
The splitting of religiousness and spirituality into compatible opposites does not reflect
McSherry (1997) and Burnard (1988) point out that if spirituality is defined only
synonymously with religion, then the use of spiritual coping strategies is restricted to
individuals who hold religious beliefs, as a result, all people who are irrespective of
The word religion is derived from the Latin word relegare, which implies “to bind
fast, or tie together” (Mansen, 1993, p.141). Religion is concerned with public
participation in a faith community with specific practices and doctrines (Walker, 1992).
conduct, values, practices, and beliefs about God or a higher power (Smith, 1995).
81
1989; Heriot, 1992; Mickley et al. 1992). From the psychological perspective, religion
may promote self-control which is viewed as the master virtue (Paloutzian & Park, 2005).
Draper, & Kendrick, 2002). Spirituality applies to both believers and nonbelievers,
including the presence of diverse cultural beliefs (Cawley, 1997) and religious beliefs
and separation anxiety are solved (Belcher et al. 1989). Hafen and colleagues (1996)
producing way” (Hafen, Kauen, Frandsen, & Smith, 1996). A spiritual perspective is
Thus, spirituality is a much broader concept than religion (Cawley, 1997; Nagai-
Jacobson & Burkhardt, 1989; Oldnall, 1996; Peri, 1995; Fehring, Miller, & Shaw, 1997)
and may or may not incorporate religious rituals, behaviors, or association with religious
82
1993), a belief in and a relationship with a higher power (Mickley, Carson, & Soeken,
1995), and transcendence (Reed, 1987, Smith, 1994). Spirituality was described as the
desire to identify some meaning and purpose in our lives and existence that will assist us
2000). Other definitions found in the literature review defined spirituality as whatever a
person takes to be the highest value in life (Dyson, Cobb, & Forman, 1997). In this study,
purpose of life and suffering through the interconnectedness with self, others, nature or
mechanism for patients. Spirituality is a resource that chronically ill patients use to cope
with the physiological and psychosocial challenges of illness (Fryback & Reinart, 1999;
Perspective Scale (SPS), formerly called the “Religious Perspective Scale” (Reed, 1986),
the Spiritual Well-Being Scale (Ellison, 1983), the Spiritual Health Inventory, and the
1989), and the Patient Spiritual Coping Interview (PSCI); these were designed to
with God or a higher being (McCorkle & Benoliel, 1981). The Spirituality Assessment
connectedness, and purpose and meaning (Howden, 1992). However, no studies to date
83
have examined the effect of spirituality on individuals dealing with potentially life-
cancer patients dealing with the advanced stages of cancer, faith and prayer were ranked
175 women with breast cancer, Mickley and her associates (1992) examined the role of
indicated that patients classified as intrinsically religious were found to have significantly
higher scores on SWB than those classified as extrinsically religious (Mickley et al.
1992). An extrinsically motivated person uses his/her religion for one’s own benefit,
whereas the intrinsically motivated lives religion according to his own beliefs in an
Using a sample of 603 patients with various types of cancer, Dunkel-Schetter and
his associates (1992) identified five coping patterns, including “seeking or using social
uncertainty about the future was the most frequent problem associated with cancer. The
mean rating on stressfulness of cancer problems indicated a moderate level of stress (3.04,
SD=1.49). The specific cancer-related problem (e.g., fear of future) was also not
associated with how individuals coped. Although “type of cancer,” and “currently
receiving treatment” had few or no association with coping; perceived stress from cancer
was significantly related to coping through social support and both cognitive and
behavioral methods of escape avoidance. More religious patients were likely to use
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coping methods involving cognitive reframing of the stressful situation and focusing
more on the positive. Religiosity was associated with greater cognitive escape-avoidance
African American women with breast cancer. The findings indicated that over for 75% of
these women, religion predominated as a coping strategy in all aspects of their lives. In
addition, many women reported that breast cancer was not the most difficult stressor in
their lives, which appeared to make it less burdensome (Lamban et al. 1997).
In short, the existing research suggests that religion plays a positive role in
patients’ adjustment to stress of chronic illness including cancer and treatment. Religious
Studies of religiosity and spirituality. Miller (1985) compared the spiritual well-
being of 64 rheumatoid arthritis patients with that of 64 healthy adults. Although there
was no difference between the groups in the level of existential well-being (i.e., a sense
of life purpose and satisfaction), those with arthritis reported a significantly higher level
Miller (1985) concluded that chronic illness may be a factor in stimulating the value a
study of search for meaning with 50 patients within 6 months of diagnosis of breast, lung,
or colorectal cancer), two significant factors, faith and social support, were found to assist
these patients in their search for meaning (O’Connor et al. 1990). Religious faith, prayer,
and the healing power of God helped 50% of the respondents to cope with their illness,
85
while faith was described as “the strongest support.” Approximately one-third (30%)
patients described their spirituality or God as a source of hope. One contradiction that
arose from this study was that although these subjects reported a frequent reliance on
faith, 87% of the sample reported that religion was not important in their lives. Since the
breast cancer, the women were interviewed to identify and examine religious and
spiritual coping strategies (Feher & Maly, 1999). Three themes emerged: religious and
spiritual faith provided respondents with the emotional support necessary to deal with
their breast cancer (91%), with social support (70%), and with the ability to make
meaning in their everyday life, particularly during their cancer experience (64%) (Feher
In sum, based on the review of the existing studies, religion and spiritual faith
were acted as coping strategies in healthy adults and patients with chronic illness
including arthritis, breast cancer, lung, and colorectal cancer. However, faith in God or a
relationship with God was described as an important factor in their lives rather than their
religion which was inconsistent with the results of previous studies of religion.
strategies.
relationship between spirituality and psychosocial adjustment during illness. Using two
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groups of 57 adults, Reed (1986) compared terminally ill ambulatory patients (having
stages III or IV cancer) with healthy adults. Regardless of age, terminally ill patients had
significantly greater religiousness (i.e., the levels of one’s beliefs and behaviors
associated with spiritual dimensions). Similar findings were reported by Reed (1987);
based on a comparison of 100 terminally ill hospitalized cancer patients, 100 non-
significantly larger number of terminally ill cancer patients indicated greater spirituality
hospitalized cancer patients. The results showed that 88% of patients used a variety of
spiritual activities (e.g., personal prayer, reading religious books, television, etc.) and
resource people (e.g., health care professionals including nurses and physicians) while
coping with cancer. They found their meaning and purpose in illness through their belief
1994 to 2000, Ferrell and colleagues (2003) described that spirituality in women with
deriving meaning from the cancer experience (Ferrell, Smith, Juarez, & Melancon, 2003).
U.S. who had been diagnosed with breast cancer. Six themes emerged: family closeness,
traditional Chinese values, religion, alternative therapy, art, prose, and literature and
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In summary, evidence from the existing studies illustrates that spirituality not only
exists among healthy, chronic or terminally ill adults, but also may function as a coping
adjustment, low levels of fear and discomfort, and positive attitudes among cancer
sexual function, sexual self-concept, and sexual satisfaction, of rectal cancer patients
receiving treatment, has not been previously examined in a quantitative analysis. In the
Laubmeier and her colleagues (2004) examined whether the degree of perceived
life threat moderated the relationship between spirituality and emotional well-being in
various types of cancer patients (N=95). In addition, the importance of religious versus
findings showed that spirituality, particularly the existential well-being component, may
be associated with reduced distress symptoms in cancer patients regardless of the degree
from 14 world-wide countries was completed by Lin (2003); three of the six themes that
emerged from that work were: “coping and adjusting effectively with stress,”
“relationships and connectedness with others,” and “living with meaning and hope.”
Tuck and colleagues (2001) conducted a pilot study in persons (N=52) living with
HIV; in their study, the relationships among spirituality and psychosocial factors were
examined (Tuck, McCain, & Elswick Jr., 2001). Spirituality was measured by using the
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Spiritual Perspective Scale, the Spiritual Well-Being Scale, and the Spiritual Health
Inventory. Aspects of stress and coping were measured by five psychosocial instruments
(the Mishel Uncertainty in Illness Scale, Dealing with Illness Scale, Social Provisions
Scale, Impact of Events Scale, and Functional Assessment of HIV Infection Scale). The
results showed that the Existential Well-Being (EWB) subscale of the Spiritual Well-
Being Scale was positively related to social support and effective coping strategies and
and uncertainty.
examined the moderator role of spiritual activities on the adaptative outcomes of HIV-
related stressors. The study findings indicated that spiritual activities lessened emotional
distress (b= -.21, p< .05) and improved HIV-positive women’s quality of life while
A study tested the assumption that perception of racist experiences would predict
an objective measure of health (Bowen-Reid & Harrell, 2002). The report indicated that
psychological health symptoms. Kim and Seidlitz (2002) examined the relationship of
spirituality with emotional and physical adjustment over time (time one and two) in 113
college students. Spirituality was measured by the 8-item Spiritual Transcendence Index
to assess individuals’ differences in spirituality at time one only. The results revealed that
spirituality buffered the adverse effect of stress on adjustment while controlling for the
use of various coping strategies. In a study of stress and physiological outcomes in older
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adults and among gynecologic cancer patients, Lutgendorf (2005) found that several
physiological factors correlate with the stress response. Moreover, social support and
physiological effects.
between stress (from racial, college students) and psychological and/or physical
adjustment/health. Stress in these studies resulted from minority groups, college students,
and HIV patients; only three of them focused on the cancer population including various
However, no existing study demonstrated the effects of spirituality on stress (cancer and
There are limited studies that include spiritual interventions. Tuck (2004)
indicated that the lack of consensus in definitions of spirituality has made it difficult to
capture the essence of the spiritual phenomenon and to develop interventions (Tuck,
2004). Kristeller and associates (2005) evaluated the feasibility and acceptability of the
religious concerns, and the impact on satisfaction with care and on QOL among patients
with mixed cancers. The results showed that improvement in Functional Well-being was
accounted for primarily by patients lower on baseline spiritual well-being (beta = .293,
p<.001). The study supports the acceptability of the spiritual intervention approach
related to coping with cancer (Kristeller, Rhodes, Cripe, & Sheets, 2005). In another
90
study, Erwin and colleagues (1992) applied spirituality as prevention program in terms of
sharing the experience of African American women who suffered from breast cancer
(Erwin, Spatz, & Turturro, 1992). Additionally, in Margolin and associates’ (2006)
motivation of 72 drug users for HIV prevention. The results showed a positive
significance related to spiritual practice and to motivation among participants for HIV
& Avants, 2006). Similarly, the Spiritual Self-Schema therapy for HIV-positive drug
abusers promoted a spiritual self view that reduced negative beliefs and behaviors
spiritual struggles, forgiveness and hope (Philips, Lakin, & Pargament, 2002). In a study
involving the use of meditation, affirmation, imagery and rituals, a sample of 191 breast
cancer women was assigned to the CAM group and sharing group. Levine and Targ
(2002) reported that measures of spirituality and spiritual well-being accounted for 40%
of the variance in functional well being of breast cancer patients. Both groups
experienced better QOL, decreased depression and anxiety, and increased spiritual well-
being.
decreased physical and psychological symptoms and increased the sense of self-control
and spiritual awareness among the participants. Germer (1996) provided a spiritual
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awareness group in a sample of 17 adults. The findings showed that learning from others,
and gaining motivation to work on spiritual dimensions of one’s life were unanticipated
women with early stage breast cancer were examined (Vos, Garssen, Visser,
Duivenvoorden, & de Haes, 2004). The results revealed that in the period shortly after
surgery, coping style, especially illness-specific coping, was of high relevance for
found in other studies was not confirmed in this study (Vos et al. 2004).
Schulz and Mohamed (2004) from Germany examined personal and social
resources in 105 cancer patients one month after surgery and their perception of positive
life changes as a consequence of illness. Using correlational and path analyses, the results
resources (received social support) and benefit finding. In addition, the mediating role of
coping was supported between the resources and benefit finding when the effect of self-
efficacy disappeared. Social support had a direct effect on benefit finding. In this study,
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social support was measured by the Berlin Social Support Scale (BSSS) to assess various
In summary, women with early stage breast cancer use the illness-oriented coping
styles most commonly. Although both personal and social resources were used in these
two studies, however, the effect/role of social support on psychosocial adjustment of the
individual was inconsistent, based on the review of these two research studies (Schulz &
Mohamed, 2004).
The literature to date has suggested that social support, self-help and cognitive
appraisal of current adverse/stressful events play a significant role in how well patients
adapt to their situation. Studies related to the relationship between perceived stress and
A test of four competing theories completed by Gifford (1987) indicated that the
learned resourcefulness factor, enabling skill, demonstrated the mediating effect that
enhanced self help (B= .44; R2 =.29). The Self Help Model operationalizes self help as a
learned response to chronic illness, which was found to explain 50% of the variance in
perceived self help and self help had a direct, positive impact on life quality (B = .61; R2
associates (1990) on 30 patients involving breast, lung, and colorectal cancer revealed
that over half (53%) the respondents suggested that inner resources, such as a positive
attitude and a determination to “hold myself up” and “lick it” helped them cope with their
situations. Forty-seven percent of the respondents coped with their illness by drawing on
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the support of others. Family members were a frequent source of support (O’Connor et al.
1990).
women with ovarian cancer, conducted from 1993 to 2000 by Ferrell and colleagues
(2003a), significant stressors that were identified within all phases of diagnosis, treatment,
remission and recurrence were described (Ferrell, Smith, Cullinane, & Melancon, 2003a).
optimism/perseverance by sharing with others about their coping strategies for various
behavior problems, resourcefulness, and coping efforts between 25 African American and
Alzheimer’s disease. The results indicated that African American caregivers reported
benign appraisals of disruptive behavior in the impaired elders. Gonzalez’s (1997) study
results support the assertion of Lazarus and Folkman (1984) that appraisal and
In summary, stressors are identified during the disease process, and cognitive
appraisal and resourcefulness are crucial for the individual in dealing with stressors.
resourcefulness which accounted for 50% of variance to chronic illness, and from help
(Zauszniewski, 2006). However, the majority of the existing studies with small sample
94
size have focused on chronic illness (i.e., breast, lung, colorectal cancer and Alzheimer’s
disease) and their findings cannot be generalized and applied to persons with rectal
cancer in Taiwan.
Evidence from the review of relevant nursing studies demonstrated the association
between perceived stress (cancer and cancer treatment) and sexuality. In Ferrell and
colleagues’ (2003) qualitative study of women with ovarian cancer, results did address
the concept of sexuality. The statements related to sexuality as a theme in the following
quotes: “I felt great stress that I could not accommodate my husband;” “It has been
extremely hard accepting all of these changes and it’s has been hard on my sex life;” “It
is usually a taboo subject, but I am only 39 years old;” “Sexuality? no one seems to want
to talk about this topic because I don’t feel that many doctors feel comfortable or have the
program on sexual functioning in two groups of women (n=10 per group) with breast
cancer. The results showed that the stress intervention was not associated with
significant difference between the two groups on satisfaction with the sexual relationship.
image. The results of the quantitative study from 21 cancer patients demonstrated that
patients experienced significant mood disturbance and sexual problems. The themes that
emerged from the qualitative study showed loss of desire (67%), a reluctance to initiate
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discussion about sexual concerns (67%), a negative impact on intimate relationships
(100%), and heightened emotions (100%). The qualitative data provided some message
related to the real threat, loss or harm in this specific population. In this study,
measurements included the Sexual Arousal Index (SAI), Changed in Sexual Functioning
Questionnaires (CSFQ), and the Body Image and Sexuality Scale for Women Who Have
Had Cancer (BISSWC), which were used to evaluate how sexuality and body image of
following treatment for 58 women with early-stage gynecological cancer was examined
by Leenhouts and colleagues (2002). The results showed that patients who had a higher
frequency of sexual problems reported a lower sexual satisfaction (Leenhouts et al. 2002).
with bladder cancer post-cystectomy in the USA emphasized the importance of negative
patients who negatively appraised their sex lives and body image were at risk of
among patients with ovarian, gynecological and bladder cancer. The findings from these
studies describe changes in sexuality and stress, real threat, and loss or harm were
identified in the female patients. Additionally, changes in sexual function were found to
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communication and understanding. Stress management programs seemed to have no
effect on enhancing sexuality (sexual function, self-esteem, and satisfaction with the
sexual relationship) based on one controlled study with a small sample (Curran, 1999).
However, the external validity of this finding is threatened and generalization is limited
because of the small sample size. The fact remains that the association between perceived
stress and sexuality in rectal cancer patients has not been explored.
From the perspective of the psychologists, social support may partly mediate
religion and/or spiritual involvement-health associations (Paloutzian & Park, 2005). For a
longitudinal study of religion and/or spiritual factors and social support, Strawbridge and
colleagues (2001) reported that frequent service attendees over 28 years were less likely
to become or to remain socially isolated, and were more likely to remain married
(Paloutzian & Park, 2005, p.445). Thus, religion and/or spiritual factors are considered as
affecting bodily conditions through mediating factors, such as social supports. Changed
bodily conditions in turn can affect physical health and disease outcomes. From the
not be appropriate for the nonbelievers for this study. The causal pathway (religious
and/or spirituality factors → mediators (e.g., Social Support) → physical health) also
Moreover, very little empirical evidence and few studies have demonstrated
cancer patients. Potter and Zauszniewski (2000) examined variables reflecting reaction to
stress, lines of defense and resistance, and the basic core of humans in the context of the
97
Neuman Systems Model in a convenience sample of 47 elders with rheumatoid arthritis.
The study findings showed that the social impact of arthritis was a significant
spirituality and health perception were significantly correlated (Potter & Zauszniewski,
2000).
play a crucial role in spirituality. However, spirituality and personal and social
(Mclllmurray et al. 2003). Eighty-three percent of the 354 respondents with religious
faith had less need for help with their sexuality than those without religious faith. Thus,
heterosexual women (n=96) ranging in age from 18 to 50 years. The majority of the
women in this study were from church or church-related institutions. The study findings
98
suggest that there is a relationship between a woman’s feelings about her appraisals of
her sexual thoughts, feelings, and behaviors, and her awareness and experiencing of
and spiritual orientation were also supported. In this study, measures included the
Spiritual Orientation Inventory (SOI) and the Attitudes Toward Women Scale (AWS);
these measures were used to assess spirituality and sexual self-esteem, respectively.
Kong with gynecological cancers was assessed (Molassiotis et al. 2000). The results
indicated that sexuality and spirituality (meaning in life) are two of the most distressing
aspects in a patients’ life. Sexual relationships among the respondents were moderately
affected by reduced sexual desire and satisfaction with sex and activity. However, the
patients’ relationships with their partners were minimally affected, suggesting the men’s
understanding and support in the cancer trajectory of their female partners. Other
Additionally, in a qualitative study, the meaning of QOL and the areas of life most
affected by cancer and its treatment were examined. Almost half of 19 sample subjects
reported problems with their sexual life as a result of the cancer or its treatment. One
woman’s statement described her situation as “not having harmony in sex life.” Two of
groups and cancer patients in two studies. In a study from Asia, spirituality was defined
as the meaning in patient’s life in Chinese culture. This different operational definition
requires the investigator to choose a specific measurement to assess the selected variables
99
accurately. The results supported that the association between religion and psychosocial
sexuality (sexual thoughts, feelings, and behaviors) and awareness of herself as a spiritual
being when the use of spirituality and religious faith are interchangeable. Specifically, the
study indicated that sexuality and spirituality are two important dimensions in a Chinese
female cancer patient’s life. Although sexual relationship was moderately influenced, the
relationship between the patient and her partner was little affected. This may reflect the
role of spirituality on the adjustment of sexuality. Of particular interest, it is the first time
the importance of “harmony in sex life” has been mentioned in a series of studies. The
target population of the Chinese study focused on a mix of ovarian, endometrial and
cervical cancers; thus, the generalizability of the study was limited. Moreover, one third
of the sample did not complete the sexual relationship assessment; for this reason, the
accuracy of the results was also questionable. However, the findings were associated with
the Chinese culture, and important consideration for the study proposed here.
individuals with lung cancer, Shell (2002) reported that between time 1 and 2, mood
status was significantly related to the subjects’ sexual function (r =.691, p = .004; r
= .936, p = .002, respectively). Social support was found to significantly affect mood
status at three time points (r = .620, p = .003; r = .557, p = .000; r = 1.0, p = .000,
respectively). However, social support did not significantly affect sexual function at any
of the three time points (Shell, 2002). Kennedy (1996) tested a model of social support,
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The results revealed that optimism and self-efficacy played a role in mediating the effect
of social support on adjustment. Social support had a direct effect on sexual functioning
and also had an indirect effect on physical adjustment through self-efficacy. Mo (2002)
cancer patients. The results indicated that there was a mild to moderate degree of
In short, these findings suggest that social support may play an indirect or direct
role on sexual function of cancer patients. However, the results cannot be applied to the
Age. Although sexuality declined over the decades of life, Brecher (1984) found
that older adults’ sexuality is “manifest in the high proportion of those who are sexually
active, and the quality, quantity, variety and enjoyability of their sexual activities”
(Brecher, 1984, p.403). Societal attitudes about sexuality in aging tend to convey a
particularly that of youth. The elderly are rarely portrayed in matters related to sexuality.
Because of the stereotypes, myths, and unanswered questions, older adults may withdraw
from any form of sexual expression (Steinke, 1994). Steinke (1994) compared the results
of two studies using mailed questionnaires to separate samples (759 subjects in the first
study and 400 wellness subjects for males and females in the second study) that explored
the knowledge and attitudes about sexuality of older males and females. The findings
showed that males and females are comparable on their knowledge and attitudes about
sexuality in ageing and although sexual satisfaction and sexual activity were variable,
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most were sexually active. In addition, Steinke (1994) reported that many healthy older
adults were seeking further information on the impact of chronic illness and medications
on sexuality (Steinke, 1994). Their study suggested that even as people approach older
age, they still seek resources to deal with sexual problems that may result from disease or
treatment.
described the multidimensional nature of sexuality in men (n= 69) and women (n= 92)
and also compared both gender groups on selected dimensions of sexuality. Gender
differences were found for satisfaction of sexual activities (i.e. interest, participation, and
satisfaction) (Johnson, 1996). The report indicated that dyspareunia and loss of vaginal
radiation therapy (Havenga et al. 2000). However, there is limited information on female
Belief. Most older adults approach old age with the belief that sexual desires and
physical function cease (Steinke, 1994). Tang and colleagues (1996) examined five
studies of sexual adjustment after gynecologic cancer in Chinese women from Hong
Kong (aged from 18-75 years; sample size ranged from 10 to 115) that were conducted
from 1984 to 1996. The results suggested that in contemporary Chinese societies, the
effect of Confucian and Taoist traditional beliefs on one’s sexuality is still evident;
therefore, these beliefs further influence one’s sexual attitudes and behavior. Chinese
women show decreased sexual activities, interest, drive, and satisfaction after
gynecologic cancer and its treatment. The sexual disorder rates are around 30-50%, but
marital relationships are minimally affected (Tang et al. 1996). The findings suggested
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that Chinese women might experience negative situations / outcomes after gynecologic
cancer, which they do not perceive as problematic or stressful events under prevailing
cultural sexual beliefs about sexuality. Stamogiannou and associates (2005) reported that
sexual function and beliefs about consequences were significantly correlated with QOL.
Better sexual functioning was the strongest predictor of higher quality of life (β = 0.323,
cancer survivors (Gall, 2000). Relationship with God and religious coping behaviors, and
the greater use of the nonreligious coping behavior were positively related to cognitive
appraisal of the cancer situation. Gall (2000) concluded that religious resources predicted
emotional and spiritual well-being for these long-term breast cancer patients. The results
reflected that religious factors are important resources for adjustment to long-term breast
cancer survival.
Conclusion
among female and male patients with rectal cancer undergoing cancer treatments has
been systematically reviewed. Neuman Systems Model (1995), Lazarus’s stress and
coping theory (Lazarus & Folkman, 1984), and Zauszniewski’s (2006) mid-range theory
are conceptual frameworks that provided guidance for the study reported here. The
studies that were reviewed identified that resources and coping strategies available to
cancer patients determined their perception of stress (cancer and treatment) during the
appraisal process.
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Sexuality is an integral part of multidimensional, which encompasses not only
physiological (sexual function), but also pychosocial aspects (sexual self-schema and
from medicine across countries focused on the impact of cancer treatment (i.e., surgery
and / or adjuvant therapy) on quality of life including sexual function and the prevalence
approaches for measuring concepts related to sexual function has resulted in a difficulty
nursing tended to focus on the association between stress reactions and sexuality (i.e.,
gynecologic or breast cancer. Only one study from Australia focused on rectal cancer and
women’s sexual health undergoing surgery and a few studies focused on psychosocial
effects of colostomy on colorectal cancer patients. In other words, the male perspective
toward sexuality was excluded in these studies. Therefore, the aim of this study was to
examine the association between perceived stress and sexuality including sexual self-
schema, sexual function, and sexual satisfaction among female and male adults with
deal with adversity or stressful situation. Several studies have identified the important
promoting health and life quality in adults with cancer or chronic illness; whereas these
studies have not explicitly addressed the effects of personal resourcefulness on stress and
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sexual health. Social (help-seeking) resourcefulness involves the ability to seek help /
support from others such as professionals, family, or friends. The existing studies have
hypothesized that social resourcefulness may mediate the relationship between perception
of breast-cancer symptom and health. However, these studies have not demonstrated the
effects of social resourcefulness on stress and sexual health. Very few studies have
and psychological health and life satisfaction. In addition, the moderating or mediating
stress and sexuality among rectal cancer patients in Taiwan has not been investigated.
Currently, Resourcefulness Scale is the only measure that captures both forms of
resourcefulness, which have been found important for health promotion and maintenance
in older adults (Zauszniewski et al. 2006). However, the scale has not been used in
patients.
Numerous studies have found that spirituality is an inner resource and serves as
coping mechanism for healthy adults and chronically ill persons, including cancer
patients. However, these studies have not explicitly addressed the relationships among
perceived stress, spirituality, and resourcefulness, and their associations with sexuality.
Accordingly, the study reported here addressed the gap in scientific knowledge with
resourcefulness, and sexuality among female and male patients with rectal cancer
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important first step. In the future the investigation of the mediating or moderating effects
Finally, based on the evidence in the review, the effects of the extraneous
variables for this study including age, gender, beliefs, and religion cannot be ignored and
were also examined. Considering their potential associations, these variables and other
Contribution
The relationship of sexuality to rectal cancer and its treatment is at the center of a
growing body of knowledge. This study’s findings extend the knowledge of the
theory of resourcefulness, and Lazarus’s stress and coping theory, while the relationships
relationships among these variables will provide direction and inform the future
development and testing of interventions for persons with rectal cancer. Health policy
Furthermore, the study provides direction for future research with the hope of inspiring
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CHAPTER III: METHOD
Introduction
the sample and sampling issues including sample specification, inclusion and exclusion
criteria, the approach to recruitment, protection of human rights, and sample size
determination by power analysis. The measures and measurement issues were addressed,
A description of a pilot study and the procedure for data collection were also addressed.
Lastly, the methods of data management and statistical analysis were discussed.
Design
Designs guide investigation (Wood & Catanzaro, 1988). The general outline of a
study design can be established based on the research purpose and the nature of the
research question or hypothesis (Prescott & Soeken, 1989). The purpose of this study was
stress, spirituality, and resourcefulness, and sexuality in Taiwanese rectal cancer patients.
Cross-sectional studies are appropriate for describing the status of phenomena at a fixed
point in time (Polit & Hungler, 1999). Cross-sectional designs involve measurements of
the variables of interest at one single point in time, with no follow-up period (Polit &
Hungler, 1999; Newman, Browner, Cummings, & Hulley, 2001). Cross-sectional data
can most appropriately be used to infer temporal sequence when there is evidence
indicating that one variable precedes the other; and when there is a strong theoretical
framework guiding the analysis (Polit & Hungler, 1999). Thus, a cross-sectional,
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correlational design was appropriate to achieve the study goal of examining associations
between variables and for describing variables and their distribution patterns (Burns &
Grove, 1997; Newman, Browner, Cummings, & Hulley, 2001). Type of treatment was
radiation, postoperative chemo- and radiation therapy and no adjuvant therapy. Sexual
dysfunction was defined as the inability to express one’s sexuality that is consistent with
personal needs and performance (Clark, 1993). In men, this definition includes impotency
Setting
Kaohsiung, a city of 1.5 million people. There were several reasons for selecting the
Medical Center as a target hospital of this study. First, the colorectal department at the
Medical Center located in southern Taiwan has more than 100 potential subjects
diagnosed with colorectal cancer every year. This report was confirmed by the colorectal
department of the Medical Center and is based on the prevalence of colorectal cancer in
2005. Second, the Medical Center has been qualified as a teaching hospital for more than
ten years. Third, because this Medical Center has colorectal specialists, the Medical
Center has attracted patients not only from urban and rural area of Kaohsiung but also
from mid-southern Taiwan. The sources of patients were also from small islands away
from Taiwan, such as PenHu. Moreover, the majority of patients with rectal cancer
usually returned to the outpatient department of this Medical Center for follow-up due to
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the good quality of care. The attrition rate of patients at the Medical Center is less than
10%.
Specification of the population for this study involved consideration of the problem
and purpose of the study, the study design, and accessibility of the potential participants
of interest (Wood & Catanzaro, 1988, p.99). With regard to the problem and the purpose
of the study, participants included female and male patients previously treated for rectal
cancer in the Medical Center who are making regular follow-up visit at the outpatient
department. Because patients with rectal cancer are normally instructed to refrain from
sexual activities for 3 months post-surgery, thus, patients were recruited for this study
Type
Review of the literature has indicated that sexuality has been a sensitive issue for
most people within the western and eastern culture. Thus, obtaining a sufficient sample
was used for accessing individuals that were easy to identify and contact. Available
subjects were entered into the study until the desired sample size was reached. This
method saved time, money, and effort (Wood & Catanzaro, 1988; Burn & Grove, 1997)
and it was useful for this exploratory study that was not intended for generalization to
large population, but to build knowledge in a substantive area of study (Burn & Grove,
1997). Recruitment of eligible participants was based on the sampling criteria that were
derived from the problem and the purpose of the study, the conceptual and operational
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definitions of the study variables, and the study design. In correlational study designs in
general, the sampling criteria are determined to ensure a heterogeneous population with a
Inclusion and exclusion criteria are used to identify the desired sample (Burns &
Grove, 1997). In this study, exclusion criteria were 1) A prior history of sexual
dysfunction, 2) A prior history of any type of cancer, because patient with more than one
type of cancer might receive different regimen from the rectal cancer patient does.
Dukes’ A to C: patients with rectal cancer classified as Dukes’ D usually have metastasis
and would have had modified surgery that differs from lower anterior resection (LAR) or
male or female who are making regular follow-up visit; 7) having a history of sexual
response cycle) with his / her sexual partner; 8) age 20 years old and older. The majority
of the population with rectal cancer tends to be older aged persons, thus the age criteria
will be 20 and older. Sexual interest and activity does not automatically diminish with
advancing age and may continue almost indefinitely (Kofoed, 1982). In addition,
extraneous variables such as age, gender, marital status, education, stage of diagnosis,
number of children, comorbidity, etc. will be taken into account within the specified
demographic characteristics.
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Sample Size Determination
Cohen (1988) indicated that the reliability of a sample value depends upon the
size of the sample (Cohen, 1988, p.6). Statistical power analysis is an effective approach
that can be used determining optimal sample sizes (Cohen, 1965, 1988; Goodwin, 1984,
Kraemer & Thiemann, 1987; Polit & Sherman, 1990; Yarandi, 1994; Burns & Grove,
2001). In determining the sample size, factors affecting power are the effect size, the
number of variables, the types of research questions, and the statistical analysis (Cohen,
1988; Burns & Grove, 2001). Power is the long-term probability, given the ES of
population, alpha, and N (sample sizes) of rejecting null hypothesis (Cohen, 1990).
Statistical Power is a function of three parameters: 1) the significant level, or alpha (α), 2)
sample size (N), and ES of population (Cohen, 1988, p.4, 1992; Polit & Sherman, 1990).
The significance criterion of alpha for this study was set at .05, which meant that
the investigator was willing to assume the risk of committing such an error 5 times out of
100 (Polit & Sherman, 1990). The reason for setting alpha level of .05 was that the study
the individual’s sexuality. Moreover, the effects of spirituality and resourcefulness on the
relationship between perceived stress and sexuality were not known from prior studies.
Thus, the conventional 5 % risk of committing a Type I error was accepted in this study.
That is, the investigator would attain a correct conclusion 95 times out of 100, meaning
The beta (β) was set at .20 for this study, which meant that the risk of committing
a Type II error was .20. For a type II error, the investigator would fail to reject the null
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hypothesis (Ho) when it is false. That is, the researcher confirms a finding that should
have been rejected. For example, claiming that there is no association between two
variables, when in fact, an association truly exists. In the case of this study, a type II error
would occur if the investigator mistakenly indicated that there was no relationship among
and sexuality. Accordingly, statistical power (that is 1-β) set at .80, was the probability of
Effect size is the degree to which the phenomenon exists or the degree to which
the null hypothesis (Ho) is believed to be false (Cohen, 1988, p.4, 1992). In this study, ES
represented an index of the strength of the association among the study variables (e.g.,
and sexuality). The value of the ES differs depending on the statistical test to be
performed (Polit & Sherman, 1990). The statistical analyses conducted in this study to
answer research questions involved Pearson’s correlation, t-test, and analysis of variance.
A more reliable ES value can be calculated on the basis of prior studies that have
examined similar phenomena. Also, conducting a small pilot study or pretest can be used
to estimate the value of ES (Polit & Sherman, 1990). One prior study that was similar to
the one reported here, which included spirituality and resourcefulness, was found. Potter
(1997, p.78) reported that spirituality and learned resourcefulness were significantly
correlated in patients with rheumatoid arthritis (r =.44, p < .001). According to Cohen
(1988), the conventional parameters for ES for correlational analysis are .10 (small), .30
(medium), and .50 (large) Cohen, 1988, p.83). Therefore, a correlation coefficient of .44
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reflected a medium to large effect size. In addition, one study examined variables similar
sexuality outcomes (e.g., sexual behaviors and responses), sexual satisfaction, sexual
function. Yurek (1997) reported that relationships between sexual self schema and
sexuality outcomes, stress reaction (r = .26 ~.31) and sexuality outcome (r = - .29 ~ - .42)
were significantly correlated, indicating medium to large effect sizes (Yurek, 1997).
However, this study focused on persons with gynecological cancer and chronic illness as
When no prior information is available and pretests are not feasible, the
investigator may estimate the effect size by considering the value of small, medium, or
large (Polit & Sherman, 1990). Since the effect size of the relationship among
disease, type of treatment, time since operation, and comorbidity of illness), perceived
stress, spirituality, resourcefulness and sexuality was not available for Taiwanese patients
with rectal cancer, a conservative estimate for a medium to large effect size, r = .40 was
used. Based on Cohen’s sample size table (p. 102), in order to detect the correlation
spirituality, and resourcefulness) this study required a minimum of 46 subjects per group
For the t-test, the effect size was estimated on the basis of means and standard
power of .80 at alpha .05, conventional estimation of medium to large effect size (d= .65)
for sexuality would yield a sample size of 39 per group (Cohen, 1988, p.55).
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With respect to the ANOVA, Curran’s (1999) study findings did not support the
effectiveness of the stress management program on sexual functioning and sexual self-
schema (SSS) in one group of women with breast cancer, one group healthy women.
Analysis of variance on the total SSS did not report significance for the factor of time,
F(2,22)= 3.05, p = .06 with a large effect size and a power of .53 (Curran, 1999, p.50).
However, the previous study focused on the effectiveness of the intervention between
breast cancer and healthy women, which may not apply to the present study. Based on
Cohen’s (1988, p. 275) power table for ANOVA with a conservative estimation of
medium to large effect size (f = .33), alpha .05, power .80, degrees of freedom equal 1
(df= 2 (gender) -1= 1), a maximum estimation of sample size of 40 per group was needed
spirituality and sexuality were needed. Considering a possible nonresponse rate of 25%,
the required minimum sample size for this study was 120 subjects.
The study was approved by the institutional review board (IRB) at the Medical
University Cancer IRB. First of all, the investigator met with the chief of colorectal
department to explain the purpose of the study. The investigator then obtained permission
from the colorectal department to attend the meeting of colorectal department. In the
meeting, the investigator gave a brief presentation of the study that included the research
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questions, the methods and procedures to be used, and the duration of the study. The
researcher obtained a list of eligible subjects including names and contact information
through the colorectal specialist’s referral with the subject’s permission. The name list
was available for the researcher to directly contact subjects and obtain their consent to
The researcher or data collector contacted eligible subjects by phone and provided
for them an introduction to the study. Recruitment strategies were based on eligible
subjects’ OPD follow-up visit. For those who came to OPD visit in the near future, the
researcher or data collector asked whether they would be interested in participating in the
study. The researcher or data collector obtained oral consent from the subjects and set an
interview time followed by the visit. One week before the interview, the researcher or
A thoroughly trained data collector was needed in case several eligible subjects
arrived on the same day for follow-up. A face-to-face interviewer training session was
conducted so that the researcher and data collector would ask the questions in a consistent
and standardized way so as to not influence the subjects’ answers (Fowler, 1993; see
Appendix I). The procedures for training the interviewers involved several steps: 1) The
contacting subjects and method of introducing the study; 2) Role-playing: the researcher
playing the respondent and interviewer roles; 4) Practice included handling the question-
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and-answer process; 5) The researcher accompanied and observed the interviewer first
The selected female data collector was qualified as a nursing research assistant in
colorectal surgery department with the certificate of the hospital IRB. Basically, the data
collector was available enough to persist in making contact with subjects in this study.
Before or after their outpatient follow-up visit, the researcher or data collector
interviewed the subjects in a private room at the OPD to ensure the subject’s
comprehension of the questions. The purpose of the study was further explained to
eligible subjects and written informed consent was obtained at that time. This research
focused on the individual’s sexuality, a sensitive issue that might have the potential to
were organized to broach the topic gradually. The demographic data (Appendix C) was
first collected by a structured interview to warm subjects up to the issue and so that
subjects will feel more at ease with answering questions. At the same time, medical data
from the chart was collected by the researcher or data collector. Then, the subjects
completed the instruments in order: the Cognitive Appraisal of Health Scale (CAHS),
Perceived Stress Scale (PSS), the Resourcefulness Scale (RS), Body-Mind-Spirit Well
The researcher or data collector gave the eligible subjects the option to either
complete the instruments independently or have the data collector read the questionnaire
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items to them, which would save face for those with no or low literacy skills. This
allowed for immediate detection of misinterpretations by the data collector, and was less
anxiety producing (Frank-Stromborg & Olsen, 2004, p. 53). Adequate time to complete
instruments was allowed during one-to-one interviews. The questionnaires were returned
in sealed envelopes without names. Afterwards, the researcher or research assistant gave
them gift cards (Figure. 3.1. Flow chart for data collection).
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Protection of Human Subjects
The subjects were informed about the purpose of the study and signed a consent
form indicating their willingness to participate in this study. Subjects were informed that
their responses would be kept confidential. Their lack of participation would not
influence treatment decisions or jeopardize their future care. Due to the sensitive nature
of the study, a minimal risk of emotional upset or embarrassment was expected during
resourcefulness and sexuality was not previously reported. To minimize these risks, the
investigator monitored the participant’s emotional status during data collection. If study
participants became emotionally distressed during the data collection, the investigator
Subjects were directly compensated with a gift card of Taiwanese Dollar $100
information. The data obtained for the study was believed to help health professionals to
and sexuality, specifically in patients with rectal cancer. Based on the research findings,
relevant interventions might be developed for the specific population in order to retain or
one type of content validity, test-retest reliability, internal consistency reliability, and at
least one type of criterion-related or construct validity (Norbeck, 1985). The variables in
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the study were measured using eight instruments that provided a sufficient basis for
Independent Variables
demanding and insufficient resources are available to cope with the situation. Perceived
stress had been defined as the level of a person’s experienced stress (Cohen, Kamarck, &
Mermelstein, 1983). In this study, perceived stress was operationally defined as the
event is perceived as a threat / loss, harm or challenge and the perception of situational
demands resulting from cancer treatment as exceeding his/her resources for adjustment.
Stress has been measured as perceptions or appraisals (Cohen et al. 1983; Sarason,
and secondary appraisals associated with health-related events (Kessler, 1998). This self-
report revised 32-CAHS was originally tested in a convenience sample of 201 women at
0.3-21 years after diagnosis with breast cancer and reduced to 28 items following
psychometric testing. Four separate scales that measure the cognitive appraisal
dimensions of threat, challenge, harm / loss and benign / irrelevant were supported by a
principal component analysis (PCA). A four-factor structure explained 60% of the total
variance (Kessler, 1998). Three of these four items (i.e., threat, challenge, harm / loss)
represent the coping options described within Lazarus and Folkman’s (1984) theory. The
fourth item, benign / irrelevant appraisal, was added to the instrument by Kessler (1998)
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to represent another coping option. The standardized alpha and theta correlations for each
primary appraisal scale following factor analysis ranged from .72 to .88 and .76 to .88,
respectively. However, the benign / irrelevant appraisal showed no effect on the outcome
variables (coping and health status) in a prostate cancer study (Bjorck, Hopp, & Jones,
1999). Because the structure of CAHS was considered as a new instrument to measure
cognitive appraisal and only analysed by exploratory factor analysis (EFA), Ahmad
(2005) performed confirmatory factor analysis (CFA) using structural equation modeling
and an Analysis of Moment Structure procedure on a sample of 133 patients with prostate
cancer. Before doing the EFA, Kaiser-Meyer-Oklin (KMO) in the 13-item three factors
model was .82, which was greater than .50, and considered acceptable (Kaiser, 1974).
between pairs of variables (Munro, 2001). In addition, Bartlett’s Test of Sphericity was
significant (p < 0.001) in Ahmad’s study indicating that enough shared variance was
present. Confirmatory factor analysis was implemented for the 23-item, 16-item, and 13-
item three-factor models. Finally, the 13-item model yielded highly acceptable fit indices
including the goodness of fit index of .93 (GFI), comparative fit index of .99 (CFI), and
incremental fit index of .99 (IFI), all with a range 0-1 and with values > 0.90 indicating a
good fit (Wang et al. 1996). The root mean square of approximation (RMSEA) of 0.02
indicated a “close fit” (less than .05) (Browne & Cudeck, 1989). Accordingly, the results
support the three factor 13-item model for the CAHS to measure the cognitive appraisal;
it has a robust structure and excellent goodness-of-fit indices. Moreover, in the Principal
Components Analysis with Varimax rotation, the reduced version of 13-item, three factor
model accounted for more than half of the variance (55.48%) (Ahmad, 2005).
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The Cronbach’s alphas for the 13-item three factors model of CAHS in Ahmad’s
study were 0.79 for harm / loss appraisal, 0.74 for threat appraisal, 0.70 for challenge,
and 0.70 for the total scale. Internal consistency coefficients were acceptable in the
reduced version. Using CFA to evaluate the appropriateness of the CAHS in examining
how patients with prostate cancer appraise their diagnosis provided evidence for
construct validity for the instrument by assigning the items to their respective factors
was established by principal component factor analysis. Construct validity was confirmed
observed variables on latent variables. All the items had t-values above 4.23 (p < 0.01),
which indicated that the three-factor model has strong constructs. This finding is
consistent with Lazarus and Folkman’s theory (1984), which states that coping strategies
are stimulated when an event is appraised as stressful (threat, harm/loss, and or challenge)
but not as benign/irrelevant (Ahmad, 2005). In the proposed study, the 19-item version of
CAHS was used to measure perceived stress. All items are scored on a 5-point Likert
scale from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicate more
Perceived stress. Perceived stress was also measured by Perceived Stress Scale
(PSS), which was developed based on Lazarus’s concept of appraisal (Lazarus, 1966;
Lazarus & Folkman, 1984) and was used to assess the degree to which situations during
the past month in a person’s life are appraised as stressful (Cohen et al. 1983). PSS items
were designed to measure the degree to which respondents found their lives unpredictable,
uncontrollable, and overloading. These are central components of the experience of stress
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(Cohen, 1986). Psychometric properties of the scale of three versions of PSS, the PSS-14,
the PSS-10, and the PSS-4, were established for studying perceived stress on a large
sample (N=2387 respondents) across gender, social economic status, age, race and other
those of a 14-item version (Cohen & Williamson, 1988). Although, the three versions
provide strong psychometric data and are related to relevant outcomes in expected ways,
the relative superiority of the 10-item version is cited by Cohen and Williamson (1988).
In the present study, the self-report 10-item version PSS (Cohen et al. 1983) was
used to assess globally perceived stress of patients with rectal cancer. Six of the items are
negative, and the remaining 4 items are positive. Scale items have a 5-point Likert-type
response (0 = never to 4 = very often). In scoring the measure, the 4 positive items are
reversed scored (i.e., 0=4, 1=3, 2=2, 3=1, 4=0), and then all the items are summed (total
scores range from 0 to 40). A higher total score indicates greater perceived stress. The
measure has demonstrated adequate validity (Cohen et al. 1983). The 10 items are
invariant with respect to race, sex, and education (Cole, 1999). The scale had good
internal consistency reliability, using Cronbach’s alphas, that ranges from .86 to .92 and
is consistent with previous studies (range from .75 to .91; Cohen et al. 1983; Cohen &
Williamson, 1988; Glaser et al. 1999). Test-retest reliability for a 12-month interval on
this measure ranged from .53 to .61, which was similar to those reported .55 for 6 weeks
analysis, which supports the construct validity of the instrument (Golden-Kreutz, Browne,
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Frierson, & Anderson, 2004). A factor analysis of the 10-item version PSS was first
assessed in 111 women following breast cancer surgery and at 12 and 24 months later by
Golden-Kreutz and his colleagues (Golden-Kreutz et al. 2004). One-, two-, and three-
factor solutions were calculated, which enabled the evaluation of alternative factor
models for the PSS. The RMSEA values, the magnitude and pattern of the factor loadings,
and confidence intervals were used to assess goodness of fit for each model. The data
showed that the one-factor solution had poor fit and the three-factor solution was unstable.
The two-factor solution provided the best fit and was stable over time. That study
proposed that PSS-10 perceived stress may be composed of two dimensions, one positive
(Factor 2/Counter Stress was composed of four positive items) and the other negative
(Factor 1/ Stress composed of six negative items). The longitudinal design allowed for a
replication of the findings. The finding showed that the two factors were highly related
manifestations of a single factor (perceived stress). This is consistent with the stress and
essence of being that permeates all of life and is manifested in one’s being, knowing, and
doing; the interconnectedness with self, others, nature, and God or Transcendent (Dossey
& Guzzetta, 2000). Spirituality refers to the propensity to make meaning through a sense
God, or a higher being that draws one beyond oneself (Emblen, 1992; Hungelmann et al.
1989; Reed, 1992). Spirituality provides a sense of meaning, purpose, and self-integration,
enables transcendence, and empowers individuals to be whole and to live life fully
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(Emblen, 1992). Spirituality was operationally defined as the individual’s harmonious
through the connections with self, others, environment, heaven, or a higher being which
enables one to go beyond oneself and to live life fully (Reed, 1992; Emblen, 1992;
Spirituality (BMSWBI-Sp) (Ng et al. 2005). The BMSWBI was based on the Body-
Mind-Spirit (BMS) model which has been applied to divorced women, infertile couples,
and most extensively, and cancer patients. The MBSWBI was developed by a
multidisciplinary task force and tested within a sample of 674 Chinese adults from Hong
Kong through exploratory factor analysis. The MBSWBI contains 56 items that are
divided into four components: physical distress, daily functioning, affect, and spirituality.
The BMSWBI-Spirituality scale contains three factors which accounted for 65%
of total variance. The factor loadings of all of the items were above .45. The first factor,
Tranquility, contains 5 items and measures peace of mind. The second factor,
Disorientation, consists of 5 items that related to loss of direction and a lack of vitality.
The third factor, Resilience, consists of 3 items that pertained to being grateful and
self-rating scale that assesses respondents’ core values, philosophy and meaning of life.
Eight items of the scale are positive and five items are negative. The items are scored on
a 10-point scale with response ranks from 0 (totally disagree) to 10 (totally agree).
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Negative items are scored in the reverse direction, and then the scores are summated over
items. The spirituality subscale yields scores from 0 to 130. The higher total scores
The MBSWBI scales and the subscale have high internal consistency reliability.
The Cronbach’s alpha coefficients for the BMSWBI total scale, the spirituality subscale
were .95, .89, .89, .83, and .76, respectively (Ng et al. 2005).
Spirituality) were strong positively correlated between .66 and .73 with the SF-12 mental
health subscale. Moreover, there were strong correlations between the BMSWBI-Sp and
the Post-Traumatic Growth Inventory Scale. The total BMSWBI scales and its subscales
Stress Scale, with correlations ranging from .40 to -.72. This indicates the higher the
well-being in daily functioning, affect, or spirituality, the lower the perceived stress (Ng
et al. 2005).
The reason for selecting the BMSWBI-Sp as a measure of spirituality was that the
subscale is not biased or is neutral for a particular religious group. Furthermore, the
in the population of Asia (Hong Kong). Thus, this subscale is most culturally relevant to
independence in daily tasks despite potentially adverse situations (Rosenbaum, 1990) and
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help-seeking skills to obtain assistance from others when one is unable to function by
cognitive and behavioral skills that involve self-help and help-seeking behaviors that are
resourcefulness for coping with stressful events such as cancer and its treatment that may
(2006) was used to assess resourcefulness in this study. The RS was originally developed
from Rosenbaum’s (1980, 1990) 36-item Self-Control Scale (SCS) and a parallel 12-item
measure called the Help-Seeking Resource Scale (HSRS) (Zauszniewski, 1998). The 28-
item Resourcefulness Scale (RS) (Zauszniewski et al. 2006) comprises two dimensions
resourcefulness. The items are scored on a 6-point scale with response options ranks from
0 (not at all like me) to 5 (very much like me). The Resourcefulness Scale yields total
Cronbach’s alpha .85 for total scale and .84 and .80 for the personal and social
reformative self-control. This subscale is highly correlated (r = .85; p < .001) with
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Rosenbaum’s SCS (1980, 1990). Construct validity was demonstrated by factor analysis
The reason for selecting the Resourcefulness Scale was that it is the only measure
that taps both personal and social resourcefulness. Although this measure has been tested
in elderly persons with chronic conditions, including cancer, it has not been tested for
diverse sample of younger and middle-aged adults, or specifically in persons with cancer.
Therefore, this study was the first to examine this resourcefulness scale in a population of
Dependent Variables
beliefs (Yura & Walsh, 1983). In this study, sexuality involves sexual function, sexual
person to give and receive sexual pleasure (Woods, 1987). The operational definition of
physiological components that included the sexual response cycle (i.e., sexual desire,
erectile function, lubrication, arousal, orgasm, and intercourse satisfaction) (Clark, 1993;
Rosen et al. 1997; Rosen et al. 2000). Sexual dysfunction was defined as the inability to
express one’s sexuality in a way that is consistent with personal needs and preferences. In
men, this includes impotency and retrograde ejaculation; in women, this includes
Male’s sexual function. Male’s sexual function was assessed by the International
Index of Erectile Function (IIEF), which addresses the five domains of male sexual
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function, that is, erectile function (EF), orgasmic function (OF), sexual desire (SD),
intercourse satisfaction (IS), and overall satisfaction (OS) were identified by principal
components analysis with eigenvalues greater than 1.0 (Rosen, Riley, Wagner, Osterloh,
with 10 items that are rated on a five-point from 0 (none) to 5 (almost always) and 5
items rated from 1 (very low) to 5 (very high/almost always) (Kim et al. 2001). This
questionnaire is easily self-administered in research and clinical settings and has been
for the five domains and for the total scales (Rosen et al. 1997). Responses on total scales
and on the erectile and orgasmic function domains were highly consistent, with
Cronbach’s alphas between .91 and .96. In addition, Cronbach’s alpha ranged from .77
to .91 for the domain of sexual desire (SD), from .73 to .88 for the domain of intercourse
satisfaction (IS), and from .74 to .86 for the domain of overall satisfaction (OS) in the
population studied. Overall, the IIEF was shown to have strong internal consistency for
both the total scale and the individual domain scores. Test-retest reliability was examined
by computing correlations between the individual domain scores and total scores at
baseline and at four weeks. Correlations ranged from .64 to .84 (.64 for orgasmic
function, .71 for sexual desire, .81 for intercourse satisfaction, .77 for overall satisfaction,
and .84 for erectile function), and all were significant (Rosen et al. 1997).
The IIEF demonstrated adequate construct validity, and all five domains showed a
patients with erectile dysfunction (Rosen et al. 1997). Discriminant validity was assessed
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by comparing the responses from patients with erectile dysfunction and with those from
control condition in two studies. Highly significant differences were obtained between
the patients with erectile dysfunction and age-matched controls for most domains.
Differences between domain scores for the two groups were greatest for the erectile
function domain (p≤ 0.0001), followed by intercourse satisfaction (p≤ 0.001) and overall
satisfaction (p≤ 0.001). The least degree of difference between patients and controls was
the subscale score of five domains and sexual function of Lock-Wallace Scale. The
subscale scores for all five domains were significantly correlated with independent
Scale) (Rosen et al. 1997). Divergent validity was supported by no significant correlation
Female’s sexual function. Female’s sexual function was measured by the Female
Sexual Function Index (FSFI) (Rosen et al. 2000). A brief, multidimensional self-report
scale consists of 19 items that assess six domains of sexual function over the past 4 weeks.
The six domains of sexual function include desire (2 items), arousal (4 items), lubrication
The FSFI was developed on a sample of 128 women with female sexual arousal
disorder (FSAD) and a control sample of 131 women without sexual difficulties (Rosen
et al., 2000). Moreover, the FSFI was also found to discriminate between women without
sexual dysfunction and women who met the criteria for female sexual orgasmic disorder
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(FSOD) or hypoactive sexual desire disorder (HSDD; Meston, 2003). Significant
discriminant validity has been supported between women with sexual dysfunction and
with non-dysfunction on the six domains of sexual function and in the total scores in both
The internal consistency indicated by Cronbach’s alpha was .82 for 131 normal
controls and 128 age-matched subjects with female sexual arousal disorder (FSAD) in
Rosen and his colleagues’ study (Rosen et al. 2000). In Wiegel and his colleagues’ (2005)
study, the total FSFI score and six domain scores were found to have good to excellent
internal consistency with Cronbach’s alpha greater than .90 for the combined sample and
greater than .80 for the sexually dysfunctional and nondysfunctional samples (Wiegel,
Meston, & Rosen, 2005). Overall, test-retest reliability coefficients for the individual
domains ranged from .79 to .88 (Rosen et al. 2000). Correlations between the FSFI and
the Locke-Wallace Marital Adjustment Test (Locke & Wallace, 1959) were generally
modest in magnitude (.53 and .22 for control and FSAD groups, respectively), with the
Divergent validity with a scale of marital satisfaction was supported (Rosen et al.
2000). Good construct validity was established by highly significant mean difference
scores between the female sexual arousal disorder (FSAD) and control groups for each of
the domains (p≤ 0.001) (Rosen et al. 2000). The reliability and validity of the FSFI were
The psychometric properties of the FSFI were further investigated by Wiegel and
his colleagues (2005) in order to develop diagnostic cut-off scores using the
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Classification and Regression Trees (CART) methodology (Wiegel et al. 2005). Their
resulting cut-off scores. An FSFI total score of 26.55 was reported to be the optimal cut
score for differentiating women with and without sexual dysfunction (Wiegel et al. 2005).
about self as sexual well-being. This view is derived from past experience, manifested in
Female’s sexual self concept. Female’s sexual self concept was assessed by a self-
report measure of Sexual Self-Schema Scale-Female (SSSS-F) for women. The Sexual
self schema scale was developed by Anderson and Cyranowski (1994) using trait
adjective methodology and extensive psychometric study. Some of the most common
response to items, and over- and under-reporting (Catania, Gibson, Chitwood, & Coates,
1990), were avoided by using the trait adjective format. The 50-item Sexual Self-
eigenvalues and scree plot, three factors were identified: Passionate-Romantic, Open-
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Direct and Embarrassed-Conservative. Respondents rate the trait adjectives items on a 7-
point rating scale, ranging from 0 “not at all descriptive of a sexual woman” to 6 “very
much descriptive of a sexual woman”, with higher ratings indicating greater descriptive
relevance and lower ratings indicating no descriptive relevance (Anderson & Cyranowski,
1994). The total Sexual Self-Schema Score is obtained by calculating the sum of factors 1
and 2 then subtracting them from factor 3. The total scores range from -42 to 102.
the total score, with correlations ranging from .65 to .80. This indicates that the factors
are related, but not redundant. The internal consistency estimate, Cronbach’s alpha, for
the total Sexual Self-Schema scale was .82, for Factor 1 (Passionate/Romantic) was .81,
for Factor 2 (Open/Direct) was .77, and for Factor 3 (Embarrassed/Conservative) was .66.
These data along with the factor intercorrelations indicate adequate homogeneity of the
scale and the contribution of each factor to the overall score. Test retest reliabilities of the
overall measure over 2- and 9-week intervals were .89 (p< .0001) and .88 (p<.0001),
correlations with the Marlowe-Crowne Scale (r = .11), which assesses social desirability,
and with negative and positive affect (r’s = -.13 and .26, respectively). Convergent
validity was supported by the correlation but distinguishable both from a broad band of
sexual construct and measures focusing on current sexual functioning (sexual desire,
excitement, and orgasm) (Anderson & Cyranowski, 1994). Discriminant validity was
found with personality measures, Rosenberg Self-Esteem Scale (Rosenberg, 1965) and
Factor I of Big Five Measure (Goldberg’s, 1992) (Anderson & Cyranowski, 1994).
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Male’s sexual self-concept. Sexual Self-Schema Scale-Male version (SSSS-M;
Anderson, Cyranowski, & Espindle, 1999) assessed the positive versus negative valence
with an oblique rotation. With the 7-point scale, the respondent rates himself on a scale
ranging from 0 (not at all descriptive of me) to 6 (very much descriptive of me). Higher
ratings indicate greater descriptive relevance, and lower ratings indicate not at all
descriptive of male sexuality. The measure provides equivalence of word chosen and
ratings for men ranged in age from 20 to 70. The three factor scores were calculated by
summing item scores on each factor to obtain three factor scores. The three factor scores
are then summed to obtain a total sexual self-schema score (Anderson et al. 1999).
the total score, with factor/total correlations ranging from .58 to .82, which indicate that
the factors are related, but not redundant. The measure has a full scale internal
homogeneity of the scale and the contribution of each factor to the overall score. Test-
retest reliability over a 9-week interval was .81 (p = .0001), reflecting the stability of the
measure (Anderson et al. 1999). In Jenkins and his colleagues’s study of patients with
(Passionate/Loving) was .94 for African-American, .88 for White male respondents;
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Cronbach’s alpha of Factor 2 (Powerful/Aggressive) was .78 for African-American, .77
was .39 for African-American, .62 for white male respondents. Cronbach’s alpha of the
total score was .92 for African-American and .86 for White male respondents (Jenkins,
The men’s sexual self-schema scale has convergent yet incremental validity with
(Anderson et al. 1999). Discriminant validity has been shown with measures of
Sexual satisfaction. Sexual satisfaction includes attitudes and affect states (Moret,
Glaser, Page, & Bargeron, 1998). The conceptual definition of sexual satisfaction was the
extent of one’s subjective perception and feelings about sexual behaviors, interpersonal
relationships and role function as well as communication with partners (Woods, 1987).
Sexual satisfaction was operationally defined as the extent in which one verbally and
nonverbally communicates sexual feelings, perceptions and attitudes, and is satisfied with
the overall intimate sexual relationship with his/her partners (Wellisch et al. 1978; Moret
et al. 1998). Sexual satisfaction was measured by two scales of ENRICH (Evaluating &
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Communication. ENRICH Communication is a 10 item self-report scale that
relationship. Items focus on the level of comfort felt by the partner in sharing and
receiving emotional and cognitive information (Fowers & Olson, 1989). The Cronbach’s
alpha reliability of the communication scale was .82 and the test-retest reliability was .90.
The highest correlation between Communication and Conflict Resolution was .83. The
results of the study were based on a national sample of 25,501 married couples.
(ENRICH-SRS) is taken from the 14 scales of ENRICH Marital Inventory (Olson, 1996),
which assesses theoretically and clinically the dimensions of marital relationship (Olson,
Fournier, & Druckman, 1983). The 10-item ENRICH Sexual Relationship Scale
examines the partner’s feelings related to his/her affection and sexual relationship
(Fowers & Olson, 1989). Respondents rate their level of agreement on a 5-point scale
with five positive statements and five negative statements which reflect his/her attitudes
about sexual issues, sexual behavior, birth control, and sexual fidelity (Fowers & Olson,
1989). The total score is obtained by summing these positive items and all the reversed
negative items. The range of scores is from 10 (strongly disagree) to 50 (strongly agree)
(Olson, 1996), with higher scores indicating greater satisfaction of expression of affection
and feeling about sexuality and lower scores corresponding to greater dissatisfaction of
The ENRICH Sexual Relationship Scale (ENRICH-SRS) has been found to have
good reliability, concurrent and discriminant validity (Fowers & Olson, 1989). In Olson
and his colleagues’ (1983) study of 7,261 couples (15,522 individuals), the ENRICH-
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SRS has good internal consistency with a mean alpha coefficient of .85. The test-retest
reliability at 4 week was .92 among 115 individuals (Fowers, & Olson, 1989).
couples (Olson, McCubbin, et al. 1983). There were strong correlations for individual
scores (r = .73) and for couple scores (r = .81) between the ENRICH Marital Satisfaction
scale and the classic Locke-Wallace Marital Adjustment scale. Discriminant validity was
established by distinguishing the satisfied couples from the dissatisfied couples with 85 ~
95% of considerable accuracy (Fowers, & Olson, 1989) using either the individual scores
or couples’ scores. The results showed that the ENRICH scales are very good predictors
of satisfaction. The regression analyses confirmed that the most important predictors
were the Communication, Sexual Relationship, and Conflict Resolution scales (Fowers,
These measurement tools were selected for the study because they represent
perceived stress and sexuality undergoing cancer treatment and also because their good
Instrument Translation
The goal of the study guided the translation procedures and interpretation of
research findings (Jones & Kay, 1992). Because the goal of the study was to measure the
an appropriate method for cross-cultural studies due to its faithfulness to the original text
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Ten instruments (PSS, CAHS, RS, BMSWBI-Sp, SSSS-F / SSSS-M, ENRICH-
Communication, ENRICH-Sexual Relationship Scale, IIEF / FSFI) that were used in this
study were developed and validated in English. However, only three of them (PSS,
BMSWBI-Sp and IIEF) have been translated into Chinese, which is a formal language in
Taiwan and only the PSS and IIEF were tested in the Taiwanese population (Note:
guided by Brislin’s translation model (1986), which is a reliable approach and has been
used for the translation of the Medical Outcomes Study Social Support Survey (MOS-
SSS) into the Chinese (Yu, Lee, & Woo, 2004). The preferred translation procedure
involves use of panels of experts and multiple interpreters who engage in multistage back
translation procedures (Werner & Campbell, 1970). First, three bilingual health care
professional translators who were knowledgeable about the content of the instruments
and understood the population were invited to translate seven instruments from English
(original language) into Chinese (target language). Second, the Chinese version was
reviewed by a monolingual layperson who was not aware of the content of the original
this procedure. Third, the reviewed Chinese versions were back-translated into an English
who were blinded to the original English version. The purpose of blinding in this step
was to ensure that the meaning of the original English version was adequately translated
into the Chinese language. Finally, the investigator compared the two versions (English
and back translation of the instruments) for linguistic congruence and cultural relevancy
(Yu et al. 2004). In addition, distortion in translation was identified to ensure the
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equivalent meaning of items in both languages. This involved an item that may used
different words, the intent must be to convey an exact concept that has meaning and is
(Chinese), changes were made and the back translation process was repeated until the
investigator and the interpreters were satisfied that the original language (English) and
target language (Chinese) are concept equivalence (Jones & Kay, 1992; Varricchio,
2004).
Pilot study
Pilot testing the translated instrument was conducted with members of the target
population culture to check not only for the quality of the translation, but also for
practical aspects of test administration (Jones & Kay, 1992). The final Chinese version of
the seven instruments was tested in a small pilot group of patients with rectal cancer to
ensure that persons representative of the target population comprehend the meaning and
the content of the items. A sample of five patients with rectal cancer was recruited for the
pilot testing. The results of this pilot testing were used to revise the Chinese version of
instruments as needed.
Data Analysis
Data Management
The investigator immediately and carefully examined each datum and the clarity
of each questionnaire, and edited it for completeness after each interview. The
investigator entered the data from instruments into a computer file and carefully checked
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it to minimize errors during data entry. Entering data and analysis were performed using
First, the investigator developed a code book in order to guide the data coding and
entry into the computer. To safeguard confidentiality, subjects were assigned a code
number at the time of data collection. Only this subject code number was on the data
sheets or computer file, and each form for each subject was checked to ensure they were
all present. Each questionnaire was assigned an identification number to ensure that the
investigator could attribute data to the correct subjects. The key linking the name to the
code number was placed in a locked file that was separated from the consent forms and
the data were stored on disk. All errors and discrepancies were corrected and the validity
checks were completed, then the edited records were stored using the Statistical Package
for Social Sciences (SPSS) software master and back-up files. All computer data files
were password protected, and access to data stored was restricted to the researcher’s
personal computer. These files were accessible only to the investigator and they will be
retained for three years after the completion of the study or final publication of the data in
Second, before conducting the data analysis, the investigator performed the data
cleaning (i.e., check on accuracy of data entry), identified missing data, considered
transformation of the data for skewness or nonlinearity, and kurtosis through SPSS
FREQUENCIES and examined means, standard deviations for plausibility, and out-of-
range numbers (Tabachnick & Fidell, 2001). With a sample of 120 subjects, the
investigator performed data screening to ensure the accuracy of the data entry by
proofreading the printing computerized data against the actual data (Mertler & Vannatta,
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2005, p.25; Tabachnick & Fidell, 2001). In addition, the investigator used the SPSS
Frequencies procedure to examine the data for distribution and to obtain descriptive
statistics.
Third, during data analysis, appropriate handling of missing data was important.
Missing data may occur when measurement equipment fails, subjects do not complete all
items of questionnaires, or errors occur during data entry (Mertler & Vannatta, 2005,
p.25). The investigator examined the patterns and amount of nonresponse / missing data.
If 5% to 10% of the data were missing, this is believed to have only a small influence on
results, particularly in light of the descriptive / exploratory nature of this study (Cohen &
Cohen, 1983). Missing data was managed by several methods, including mean
substitution, deletion, and regression. However, if the variable had more than 40%
nonresponse / missing data, the study results on outcome variable may have limited
sufficient data to perform analysis with specific study variables was needed (Burn &
Grove, 2001). Repeating data analysis with or without missing data was also
Fourth, an outlier can distort the results of a statistical test so that assessing the
effects of extreme values in the analysis was essential. Outliers are extreme values on one
variable or on a combination of variables that distort the result of the study. The
investigator used visual inspection of the data by examining frequency distributions and
corresponding histograms, and by looking for unusual values that appeared far from the
others in the sample data set (Mertler & Vannatta, 2005, p.27). Also, extreme values that
were located far away from the box plot were considered as outliers. In addition,
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univariate outliers can also be detected through statistical methods by transforming the
within (or excess) three standard deviations of the mean (99.7%), then presence of an
identify both univariate and multivariate outliers (Mertler & Vannatta, 2005, p.29).
to see whether they were violated was essential to ensure that the results of the analysis
Statistical Analysis
The purpose of statistical analysis was to make quantitative data meaningful and
intelligible (Polit & Hungler, 1999). Determining the appropriate statistical analysis
nature of variable, whether they are nominal, ordinal, interval or ratio variable, and all of
which influence the nature of the research questions being posed (Mertler & Vannatta,
2005, p.20).
Measurement of Variables
resourcefulness and one dependent variable, sexuality, were all classified as ordinal or
interval level of measurement (e.g., five-, six- or seven-point likert scale). The
investigator treated these variables as interval level data so as to use statistics (linear
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Demographic characteristics including gender (nominal), marital status (nominal),
education (ordinal), employment status (nominal), religion (nominal), and one of sexual
history questions (8-3 interval) were classified as categorical level of measurement. Other
demographic characteristics for age (interval), number of children (interval) and others
The medical data from chart review including present surgery received (nominal),
Other medical data for length of being diagnosed cancer (interval), time since operation
(interval), type number of treatment received (ordinal), and stage of disease (ordinal), and
(ordinal), type of treatment (ordinal), time since operation (interval), and comorbid
Both descriptive and inferential statistics were performed in data analysis process.
First of all, descriptive statistics were used for all quantitative / interval variables of the
demographic characteristics and the study variables (i.e., independent and dependent
variables) in terms of frequency distributions (e.g., histogram with normal curve), shape
distribution), central tendency (e.g., mode, median, and mean), and variability (range,
standard deviation) to describe the overall picture of the data (Polit & Hungler, 1999;
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p.444-454; Munro, 2001, p.4). Four major inferential statistics, Pearson’s correlation,
were used to address the research questions (Table. 3.1 Research Questions and Required
Statistical Tests).
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Table. 3.2. Summary of Measurements
Variables/ Empirical Indicators Psychometric Items Level of
Concepts Properties Measurement
Independent / Cognitive Appraisal of Construct validity 19 Ordinal/
Perceived Health Scale (CAHS) Alpha: .72 to .88 interval
Stress (Kessler, 1998)
Perceived Stress Scale Construct validity 10 Ordinal/
(PSS-10) (Cohen, Alpha: .86 to .92 interval
Kamarck, & Test-retest: .53
Mermelstein, 1983) to .61
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Table 3.2. (Continued)
Variables/ Empirical Indicators Psychometric Items Level of
Concepts Properties Measurement
Sexual ENRICH Couple Scale- Construct validity 10 Ordinal/
Satisfaction Communication (Olson, Alpha: .92 interval
1996) Test-retest: .93
ENRICH Sexual Alpha: .85. 10 Ordinal/
Relationship Scale Test-retest .92 interval
(Olson, 1996)
Correlation
between the variables. The relationships were measured by the Pearson’s product
moment correlation coefficient and Spearman’s rho analysis. This coefficient was
computed when the variables being correlated have been measured on either an
interval/ratio or ordinal scale; the higher the absolute value of the coefficient, the stronger
is the relationship (Polit & Hungler, 1999, p.458). Also, from a scatter plot, the
investigator may determine both the positive or negative direction and approximate
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magnitude of a correlation (Polit & Hungler, 1999, p.458). The maximum value of r is
|1.00|; r = +1.00 means a perfect positive correlation; r = -1.00 means a perfect negative
correlation; and r = .00 means no linear relation. The closer r is to 1, the stronger the
relation between the variables under consideration (Pedhazur & Schmelkin, 1991, p. 370).
major assumption underlying in the correlation coefficient is the relation between the
variables under consideration is linear, which indicates the points depicting scores on
both variables follow a trend that can be characterized by a straight line (Pedhazur &
Schmelkin, 1991, p.37). A unit change in the independent variable is associated with an
expected constant change in the dependent variable (Pedhazur & Schmelkin, 1991, p.371).
The assumption of linearity was examined to determine there was a relatively straight
line relationship within the scatterplot. In addition, the variables that were being
correlated must each have a normal distribution; that is, the distribution of their scores
must approximate the normal curve. The assumption of residual normality (normal
probability plot. The assumption of normality was met if a normal distribution was
evident on histogram and a straight line on the P-P plot (Mertler & Vannatta, 2005,
p.173). Skewness and kurtosis would be problematic if the values were greater than +/- 3
constant variance) was examined to make sure that the bivariate scatter plot was
randomly distributed (or dispersed evenly) around the reference line (zero line) (Mertler
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In terms of the research questions 1E to 4E (1E- stage of disease and perceived
stress, 2E- stage of disease and spirituality, 3E- stage of disease and resourcefulness, 4E-
stage of disease and sexuality), 1F to 4F (1F- type of treatment and perceived stress, 2F-
type of treatment and spirituality, 3F- type of treatment and resourcefulness, 4F- type of
treatment and sexuality), Spearman’s rho analyses were used to determine whether
significant relationships existed between the levels of cancer treatment (i.e., surgery,
surgery plus chemotherapy, and surgery plus chemotherapy and radiotherapy) and each
between time since operation and perceived stress, spirituality, resourcefulness, and
The independent-samples t test was used to determine whether there were gender
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simultaneously test the significance of group mean differences on the dependent variables
one-way ANOVA are same as those for the independent-sample t test. First, dependent
must be categorical data. This can simply look at the distribution of the data in each cell
by obtaining histograms and boxplots of the dependent variable. If there are no marked
extreme values departures from normality, then the assumption of normality will be
assumed met. Second, the groups should be mutually exclusive; that is one group must be
independent of one another. Lastly, the variances of the groups should be equivalent
indicates homogeneity of variance among groups (Mertler & Vannatta, 2005, p.78). The
variances assumptions (Mertler & Vannatta, 2005, p.70). In general, violation of the
assumption.
The data were presented under the one-way program in SPSS for Windows. The
descriptive statistics were given first. The number of subjects in each group, group means,
standard deviations, standard errors, and 95% confidence interval for mean were listed in
the descriptive box. Levene’s test was showed for the test of homogeneity of variance
(equal variances). The ANOVA summary table was reported as between groups, within
groups, and total. Moreover, sums of squares, df, mean square, F ratio, and level of
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significance were reported. The F test indicated the ratio of between groups to within
group variance. If overall F test was significant (the significance level is significant),
which indicates at least one group is significant than others (one of the group mean is
different from the others). Since overall F test in ANOVA can indicate only group
differences and not identify which groups are different, the Scheffe post hoc test was
conducted to compare all group combinations and determine the significantly different
groups (Mertler & Vannatta, 2005, p.78). The homogenous subset was reported. Mean
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CHAPTER IV: RESULTS
Introduction
This chapter focuses on the presentation of data analyses, research findings, and
interpretation of the results. It also contains the results of the pilot study conducted before
the larger study and the preliminary data analysis for the larger study, which encompasses
the major study variables and the testing of assumptions for statistical analyses used to
Pilot study
A pilot study was conducted on a sample of five rectal cancer patients undergoing
questionnaire items. No missing data were found. The subjects included one female and
four male rectal cancer patients undergoing cancer treatment; all were married. Ages
ranged from 46 to 75 years, with a mean of 59.20 (SD = 11.35). Forty percent of the
subjects completed elementary school, 20% completed middle school, and 40%
completed high school. They reported having between 2 and 4 children. The length of
time since their operation related to the rectal cancer diagnosis ranged from 14 to 123
months, with a mean of 66.6 months (SD = 41.22). Sixty percent (n=3) of five patients
were diagnosed at stage A, reflecting cancer had grown into the colon wall, but it had not
spread outside of the colon wall. The five patients sampled in the pilot study were
representative of the larger study sample, but were not included in the analysis for the
larger study.
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Eighty percent (n=4) of the pilot study subjects understood the meaning and the
content of all items on the study questionnaires. Only one patient asked for clarification
on one item (#19) on the Resourcefulness Scale, which stated “If I would not have
enough money to pay my bills, I would borrow money from someone.” During the 45
minute data collection interview, subjects were observed for signs of fatigue; none
Preliminary Analyses
Recruitment into the study, using physicians’ referrals took seven months.
Approximately 21% of those who were recruited (n=34) did not meet the inclusion
criteria regarding having sexual activity before surgery. Two female subjects (1.3%) had
lost a loved one within the past year and one (0.6%) was single; hence, these women
were sexually inactive. The other ten female subjects (29.4%) also reported not having
sexual activity before surgery. Almost 59% (n=20) of the males were sexually inactive
before surgery and one man experienced erectile dysfunction after transurethral resection
of the bladder (TURB) six months ago. Approximately 79% of those recruited (n=125)
met all inclusion criteria. However, of those who met all study criteria, five (4%) refused
to participate; one male participant stated that he did not want to be reminded of his
cancer diagnosis because it made him uncomfortable. The other man and three women
stated they did not want to participate in the study. Data collection ended with
recruitment of 120 subjects who met all study criteria and completed the study measures;
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Transurethral resection of bladder
Male (3%), n= 1
(61.8%)
n=21 Sexually inactive (58.8%), n= 20
Female (2.4%), n= 3
Refused (4%)
n=5 Male (1.6%), n= 2
Meet (78.6%)
n=125 Female (25.6%), n= 32
Enrolled (96%)
n=120 Male (70.4%), n= 88
Taiwan was interviewed and completed all the study questionnaires. With respect to the
demographic characteristics of the sample, the continuous variables were age (in years),
number of children, length of time since cancer diagnosis (in months / year), time since
operation (in months / years), and number of comorbid conditions. Categorical variables
were gender (female or male), marital status (never married, married, divorced, and
widowed), educational level (elementary, middle school, high school, undergraduate, and
graduate degree), employment status (retired, full-time, part-time, and others), religion
(Atheism, Buddhism, Catholicism, Christianity, Taoism, and other folk beliefs) , sexual
history (question #1 to #7, see Appendix D), stage of disease (Duke A, B1, B2, C1, and
C2), present surgery received (LAR or APR), presence of colostomy (yes or no), type of
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chemotherapy and radiation), type of chemotherapy received, lubricant use for female
subjects (yes or no), Viagra use for male subjects (yes or no).
Age. Of the total respondents, 32 (26.7%) were female and 88 (73.3%) were male.
The age of the respondents ranged from 29 to 85 years, with a mean of 60.81 (SD = 9.98)
and a median of 59 years. In comparison with the population statistics described in 2005
by the government of Taiwan, this sample was fairly representative of the larger
population in terms of age (Taiwan Report, 2005). According to the Taiwan government,
the age range for the population (N= 4,047) was 20 to 85 years with less than 10%
ranging from 40 to 49 years, 18% ranging from 50 to 59 years, 27.2% ranging from 60 to
69 years, 28% ranging from 70 to 79 years, 13.5% were above age 80 and older, and
3.8% were below 40 years of age. In the study reported here, less than 1% of the
participants (n=1) ranged from 20 to 29 years of age, less than 10% (n=9) ranged from 40
to 49 years of age, and 27.5% (n=33) ranged from 60 to 69 years of age, which were
similar to the government study (27.2%). About 43% (n=51) ranged from 50 to 59 years
of age, 18% (n=22) ranged from 70 to 79 years of age. Only 3.3% (n=4) were above age
Marital status. The majority were married (95.8%) while a little more than 4%
were not currently married. Less than 2% (n=2, 1.7%) were never married, less than 2%
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Number of children. The range for number of children was 0 to 6 or more, with a
distributed. The largest categories were those who completed high school (36.7%) and
those who completed elementary school (30%), followed by those who completed
education beyond high school (24.1%). The category with the lowest percentage (9.2%)
Employment status. About half of subjects were retired (50.8%), followed by full-
time workers (35.8%), part-time workers (9.2%), and 4.2% were housewives.
(52.5%), Taoism and other folk beliefs (30%), Christianity and Catholicism (7.5%); 10%
Time since cancer diagnosis. The length of time since cancer diagnosis ranged
from 3 to 180 months. The average length of time since cancer diagnosis was 36.61
months (SD = 38.36; median = 27.5). Over 33% (n=40) were diagnosed less than 1 year
ago. Thirty percent (n=36) were diagnosed with cancer between 2 and 3 years ago; nearly
22% (n=26) were diagnosed between 4 and 5 years ago, 5% (n=6) were diagnosed
between 6 and 7 years ago; and 3.3% (n=4) were diagnosed between 8 and 9 years ago.
Less than 7% (n=8) were diagnosed with cancer more than 9 years ago. The average
length of time since diagnosis was 3.16 years and the median was 3 years.
Time since operation. The length of time since their operation ranged from 3
to180 months. The average length of time since their operation was 36.39 months (SD =
38.46). Over 34% (n=41) were diagnosed less than 1 year ago. Thirty percent (n=36)
154
were diagnosed between 2 and 3 years ago; about 21% (n=25) were diagnosed between 4
and 5 years ago, 5% (n=6) were diagnosed between 6 and 7 years ago; and 3% (n=4)
were diagnosed between 8 and 9 years ago. Less than 7% (n=8) were diagnosed with
Sexual history. On the items measuring sexual history, scores could range from 1
(not at all) to 5 (very much). Approximately 91 % (n=109) subjects reported that their
incisions did not make them uncomfortable at all during sexual activities (question #1);
about 81% (n=97) were not anxious at all when they think of sexual issue (question #2).
Only 9% (n=11) of the subjects, including both men and women, used medicine or other
substance to improve their sexual function (question #3). Among the male participants,
about 8% (n=7) were using Viagra (sildenafil) and 13% (n=4) of the female participants
present (questions #4 to 6), 25% (n=30) of the subjects rated their sexual life in general
as not important at all, 12% (n=15) rated their sexual life before treatment as not
important at all and 27% (n=32) rated it as not important at all at present. Only 4% (n=5)
of the subjects viewed their sexual life in general as very important, nearly 6% (n=7) and
4% (n=5) of the subjects viewed their sexual life as very important before treatment and
at present, respectively. With respect to the importance of their sexual relationship with
their partners right now, nearly 26% (n=31) indicated it was not important at all, while
155
Stage of disease. In terms of the stage of the disease, 32% (n=39) of the 120
study participants were in stage A, 24 % (n=28) were in stage B1, 3% (n=4) were in stage
B2, 5% (n=6) were in stage C1, and 36% (n=43) were in stage C2 (see Table 4.2).
Type of treatment and surgery. As for the type of treatment received, 52% of the
study participants received surgery only, 37% (n=44) received surgery and postoperative
chemotherapy, and 11% (n=13) received surgery and both postoperative chemotherapy
and radiotherapy. As for the type of surgery they had, about 84% (n= 101) underwent a
low anterior resection (LAR) and 16% (n = 19) had an abdominoperineal resection (APR).
One forth (25%) of the study participants (n = 30) also had a colostomy performed.
Type of chemotherapy. With regard to the type of chemotherapy that the rectal
5-Flurouracil, Leucovorin and Camptosar. The other 52% did not receive chemotherapy.
Comorbid conditions. Over half of the study participants (52%; n=62) reported
having no comorbid conditions. Over one third (35%, n=42) of them reported one
comorbid condition; 10% (n=12) had two comorbid conditions, and 3% (n=4) had three
hypertension (31%; n=37) and diabetes mellitus (17%; n=20), followed by heart disease
(7.5%; n=9). The demographic characteristics of the sample are summarized in Table 4.2.
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Table 4.2. Description of Characteristics of the Sample (N=120)
Continuous Variables M (SD) Range
(Min-Max)
Age (in year) 60.81 56 (29 – 85)
(9.98)
Number of children 2.77 6 (0 – 6)
(1.19)
Number of comorbid conditions .65 (.79) 3 (0 – 3)
Continuous Variables
N %
Educational Level
Completed elementary school 36 30.0
Completed middle school 11 9.2
Completed high school 44 36.7
Completed undergraduate degree 25 20.8
Completed graduate degree 4 3.3
Stage of Disease (in Duke staging system)
A (tumor penetrates into the mucosa of bowel wall) 39 32.5
B1 (tumor penetrates into, but not through the 28 23.5
muscular layer of the bowel wall)
B2 (tumor penetrates into and through the muscular 4 3.3
layer of the bowel wall)
C1 (tumor penetrates into, but not through the 6 5
muscular layer and spread into lymph nodes)
C2 (tumor penetrates into and through the muscular 43 35.8
layer of bowel wall and spread into lymph nodes)
Time since cancer diagnosis (year)
<1 40 33
2-3 36 30
4–5 26 22
>5 18 15
Time since operation (year)
<1 41 34
2-3 36 30
4–5 25 21
>5 18 15
Type of Treatment Received
Surgery only 63 52.5
Surgery plus chemotherapy 44 36.7
Surgery plus chemotherapy & radiatiotherapy 13 10.8
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Table 4.2. (Continued)
Continuous Variables N %
Type of Chemotherapy
5 Fluorouracil+Leucovorin 33 27.5
5 Fluorouracil+Leucovorin+Camptosar 9 7.5
5 Fluorouracil+Leucovorin+Oxaliplatin 15 12.5
N/A 63 52.5
Categorical Variables N %
Gender
Female 32 26.7
Male 88 73.3
Marital Status
Never married 2 1.7
Married 115 95.8
Divorced 2 1.7
Widowed 1 0.8
Employment Status
Retired 61 50.8
Full-time 43 35.8
Part-time 11 9.2
Non-employee (housewife) 5 4.2
Religion
Atheism 12 10
Buddhism 63 52.5
Taoism and other folk beliefs 36 30.0
Catholicism and Christianity 9 7.5
Present Surgery Received
LAR 101 84.2
APR 19 15.8
Colostomy Received
No 90 75
Yes 30 25
Lubricant use (female)
No 28 87.5
Yes 4 12.5
Viagra (Sildenafil) use (male)
No 81 92
Yes 7 8
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Relationships between Demographics and Cancer-Related Variables
Age and stage of disease. Because age was continuous measure/interval level data,
and stage of disease (tumor stage) was ordinal data, Spearman’s rho analysis was used.
No significant association was found between age and the stage of disease (rho= -.04,
Age and type of treatment. Age was continuous data and type of treatment was
ordinal data. The types of cancer treatment included: surgery, surgery plus chemotherapy,
and surgery plus chemotherapy and radiotherapy. Therefore, Spearman’s rho analysis
was performed to see if there was a significant association between them. The results
revealed that age was significantly and negatively correlated with type of treatment
received (rho= -.20, p= .027), indicating that younger patients tended to have more types
of treatment, i.e., surgery plus chemotherapy and radiotherapy, while older patients
tended to receive fewer additive treatments as shown Table 4.3. Moreover, the type of
treatment received was significantly associated with stage of disease (rho= .81, p=.000).
Age and time since operation. Because both age and the time since operation were
interval level data, a Pearson’s product moment correlation analysis was used to
determine if a significant relationship existed between age and time since operation. Age
was found to be positively and significantly correlated with the length of time since
operation (r= .25, p= .006), indicating younger patients had a shorter length of time since
Age and comorbid conditions. Because both age and the number of comobid
condition were interval level variables, a Pearson’s product moment correlation analysis
159
was used. There was no significant correlation found between age and number of
positively associated with the length of time since operation (p=.006). Thus, younger
patients tended to have more types of treatment and had a shorter length of time since
operation, while older patients tended to receive less types of treatment and had a longer
length of time since operation. There was no significant relationship found between age
Gender and stage of disease. Because gender is dichotomous and stage of disease
(tumor stage) is an ordinal variable comprised of five stages, a Mann-Whitney U test was
used to examine the gender difference in the stage of disease. The findings indicated
there was no significant difference between men and women by stage of disease (U=
1251.0, p > .05). Females and males’ mean ranks were 65.41 and 58.72, respectively.
Gender and type of treatment. Because the type of treatment is ordinal measure
(i.e. surgery, surgery plus chemotherapy, and surgery plus chemotherapy and
radiotherapy), a Mann-Whitney U test was used to examine gender differences in the type
of cancer treatment. No significant gender difference by the type of treatment was found
(U = 1189.5, p > .05). Women’s mean rank was 67.33, while men’s mean rank was 58.02.
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Gender and time since operation. Because gender was a dichotomous variable
and time since operation was interval level data, an independent-samples t test comparing
the mean scores between men and women was used. A significant gender difference
(t(1,118) = -2.16, p = .03) was found. The men’s mean scores on the length of time since
operation was significantly higher (M=2.50, SD =1.49) than women’s mean scores
(M=1.88, SD =1.10), indicating the length of time since operation for rectal cancer was
was treated as an interval variable, an independent-samples t test was used to compare the
mean difference on number of comorbid conditions between males and females. There
was no significant mean difference on comorbid conditions between males and females
(t(1,118)= -.97, p= .33). The mean scores for men (M= .69, SD= .82) was not
men and women with the length of time since operation being longer for male rectal
cancer patients than for female rectal cancer patients. No significant gender differences
161
satisfaction, including communication and relationship. The measures of all study
Missing Data
Very few cases were found to have missing data on a single item on the study
measures. The measure of Sexual Self-Schema for Males (SSSSM) had one piece of
missing data (.5 %) out of 120 cases and the measure of Cognitive Appraisal of Stress
Scale had one piece of missing data (.5 %). The ENRICH-communication measure had
two missing data items (1.0 %), and the measure of Resourcefulness had two missing
data items (1.0%). There were no missing data on the remaining study variables.
Therefore, mean substitution was used to replace the missing data described above.
Because there were so few missing data and because it was scattered randomly
throughout the data set, the generalizability of results was not expected to be affected
Study Variables
The independent variable, perceived stress was measured by the Perceived Stress
Scale (PSS-10) and the Primary Appraisal subscale of the Cognitive Appraisal of Stress
(RS). The dependent variable, sexuality was measured by six measures: Sexual function,
was measured by the International Index of Erectile Function (IIEF) for men or the
Female Sexual Function Index (FSFI). Sexual self concept was measured by Sexual Self-
Schema Scale for males (SSSSM) / Sexual Self-Schema Scale for females (SSSSF).
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(ENRICH-Co) and ENRICH- Sexual Relationship Scale (ENRICH-SRS). The
descriptive statistics (i.e., central tendency and variability) for all study variables are
Perceived stress. Perceived stress was measured by the Perceived Stress Scale
(PSS-10). The PSS-10 was used to assess global stress experienced by the rectal cancer
163
patients. The total sample mean on the PSS-10 was 9.72 (SD=6.32). Possible scores
ranged from 0 to 40 with higher scores indicating perception of greater stress. Less than
13% of the participants indicated they had been upset because of something that
happened unexpectedly. About 21% of the participants reported they felt nervous and
“stressed” fairly often or very often. Less than 10% of the participants felt they were
unable to control irritations or important things in their life or that they never felt that
things were going their way. Also, less than 10% reported that they could not cope with
all the things they had to do and fairly often felt that difficulties were piling up so much
that they could not overcome them. Approximately 14% reported feeling angry because
of things that happened outside of their control. In summary, the majority of the study
participants reported low levels of global stress. However, over one fifth of them felt
stressed and nervous, while only about 10% revealed their inability to face difficulties in
their life. The Cronbach’s alpha for the PSS-10 in this sample was .84.
Appraisal of Health Scale (CAHS) was used to measure the cognitive process of stress
appraisal. More specifically, these 19 items reflected stress appraisal as threat, challenge,
or harm/loss, as described within Folkman and Lazarus’ model of stress (Lazarus &
Folkman, 1984). The total sample mean on the 19-item cognitive appraisal of stress
items taken from the CAHS was 55.08 (SD=9.83) with possible scoring range from 19 to
95. The cognitive appraisal of stress scale comprised of three subscales, that is threat,
challenge, and harm/loss. Higher scores on each scale or item indicated greater agreement
with that form of appraisal. The internal reliability coefficient of these 19 items in this
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The possible scores on the threat scale can range from 5-25; in this sample, the
mean was 10.81 (SD =4.31); one fifth (20%) of the participants agreed or strongly agreed
their current health condition was frightening to them, whereas 60% disagreed with that.
Thirteen percent of the participants agreed or strongly agreed and 80% disagreed that
things got worse because of their disease. Eighty percent of the participants disagreed or
strongly disagreed and only 10% agreed that their health conditions did not go well. In
summary, 20% assessed that the rectal cancer disease was frightening to them and 10%
agreed their disease did not progress well, and more than 10% agreed things got worse
Possible scores on the challenge scale can range from 6-30; in this sample, the
mean was 24.18 (SD=3.35). Approximately 28% agreed or strongly agreed and 63%
disagreed that they felt a loss due to this disease. Thirty percent agreed or strongly agreed
and 60% disagreed that that they worried about what happened to them. Over 30% of the
participants disagreed or strongly disagreed and 48% agreed that they had no control over
what happened to them. About 16% of the participants disagreed or strongly disagreed
and 78% agreed or strongly agreed that their disease would not get them down.
Approximately 88% of the participants agreed or strongly agreed and less than 10%
disagreed that they could fight their disease in spite of difficulty. About 97% agreed that
they could handle their health condition. Moreover, About 93% agreed or strongly agreed
that their disease helped them learn more about themselves. Sixty-eight percent agreed or
strongly agreed and 20% disagreed that there was a lot they could do to overcome their
health condition. In summary, over 90% of the study participants reported they were able
to manage their disease, which helped them to learn more about themselves. About 30%
165
of them felt a sense of loss because of their disease; they worried about what would
Possible scores on Harm/ Loss scale can range from 8-40; in this sample, the
agreed that they felt hurt or harmed in some way by their current health condition. About
35% of the participants agreed or strongly agreed and over half (56%) disagreed or
strongly disagreed that their disease damaged their lives. Over 85% of the participants
disagreed or strongly disagreed that their relationships with their family and friends had
suffered, while only 7% agreed or strongly agreed with that. About 30% agreed or
strongly agreed and about 62% disagreed or strongly disagreed that they had not been
able to do what they wanted to do because of their disease. Over 75% disagreed or
strongly disagreed that they had lost interest in the things around them, while 15% of
them agreed or strongly agreed they had lost interest. More than one fifth (22%) agreed
or strongly agreed and 66% disagreed or strongly disagreed that they had to give up a
great deal because of their disease. Moreover, about 30% of the participants felt a sense
of loss over the things they could no longer do and 63% disagreed or strongly disagreed
which assesses the participants’ core values, philosophy, and meaning of life. The total
sample mean score on the BMSWBI-Spirituality was 85.56 (SD=12.64). The scores
ranged from 51 to 100 with higher total scores indicating better spirituality. The internal
166
Approximately 83% of the participants disagreed that they lost direction of life or
did not know how to love themselves. Eighty percent of the participants disagreed that
they lacked vitality in life. Approximately 55% indicated they understood why
predicaments occurred, while about one third (31%) did not understand why they
encountered predicaments. About 75% of the participants felt a sense of calm and
harmony deep in their hearts and agreed that predicaments strengthened them, while 10%
of them did not feel peace and harmony in their mind. Moreover, about 80% agreed that
facing a predicament was a challenge and a learning opportunity and they were able to
manage it. About 70% of the participants disagreed with blaming heaven for being unfair
to them; less then 10% of the patients agreed to blaming heaven. Over 90 % of the
participants were grateful to people who had done things for them; they felt content with
whatever happened to them, were able to deal with difficulties, and were able to face life
as usual.
seeking). The total sample mean on the resourcefulness scale was 97.51 (SD=20.73). The
scores ranged from 39 to 138 with higher scores reflecting greater resourcefulness. The
Cronbach’s alpha on the Resourcefulness in this sample was .88. The 120 subjects
instance, they did not like to seek help from others in certain situations, e.g., when
167
Sexual function. Male sexual function was measured using a 15-item International
Index of Erectile Function (IIEF) in the 88 male study participants. The IIEF is
comprised of five domains: erectile function (EF, 6 items), orgasmic function (OF, 2
items), sexual desire (SD, 2 items), intercourse satisfaction (IS, 3 items), and overall
satisfaction (OS, 2 items). The total scores on the IIEF scale are unevenly distributed into
five domains. Six of the15 items represent the domain of EF, while the other domains
have two or three items as shown in Table 4.4. Moreover, the IIEF questionnaire has 10
items rated on a 6-point scale and five items rated on a 5-point scale. The possible total
scores on the IIEF ranged from 5 to 75 with a mean of 46.03 (SD=22.25). Cronbach’s
alpha was .97. Thirty-six percent (n=32) of the male participants had scores less than the
average of IIEF indicating more dysfunction, while more than half (64%) of them had
Possible scores on the EF domain range from 1 to 30; in this sample, the mean of
10= severe erectile dysfunction, 11-16= moderate dysfunction, 17-21= mild to moderate
dysfunction, 22-25= mild dysfunction, 26-30= no dysfunction). The range for the
remaining domains, OF, SD, IS, and OS were 0-10, 2-10, 0-15, and 2-10, respectively.
Over 27% (n=24) of the men had scores less than 10, indicating severe erectile
dysfunction, 8% (n=7) had moderate dysfunction (scores 11-16), 4% (n=4) had mild to
moderate or mild (n=4) dysfunction with scores 17-21 and 22-25, respectively. Over 55%
(n=49) of the men reported no erectile dysfunction with scores 26-30. Approximately one
quarter (n=22, 25%) of the men indicated they had no sexual stimulation/intercourse
168
(orgasm function, OF) and did not attempt intercourse (IS) (n=23, 23.1%) in the past 4
weeks, while 62% (n=52) had higher scores than the average of 6.83 on the domain of
intercourse satisfaction. As for the domain of sexual desire (SD), 52% of the male
participants had scores less than the average of 6.44. For overall satisfaction (OS), 59%
Table 4.5. International Index of Erectile Function and Score Distribution (N=88)
Domain (item) N % Mean Possible Skewness/ Alpha
(SD) range Kurtosis
Erectile Function (EF) 19.85 1-30 -.68/ -1.29 .97
(6) (11.05)
<10 24 27.3
11-16 7 7.9
17-21 4 4.5
22-25 4 4.5
26-30 49 55.6
Orgasmic Function 6.44 0-10 -.64/ -1.44 .98
(OF) (2) (4.32)
0 22 25
2-5 10 11.3
7-10 56 63.7
Sexual Desire (SD) (2) 6.44 2-10 -.17/ -.61 .79
2-6 46 52.3 (1.91)
7-10 42 47.7
Intercourse Satisfaction 6.44 0-15 -.44/ -1.28 .91
(IS) (3) (4.69)
0 23 23.1
2-7 13 14.7
8-15 52 62.2
Overall Satisfaction 6.47 2-10 -.59/-.01 .94
(OS) (2) (2.18)
2-7 52 59
8-10 36 40.9
IIEF Total Score (15) 46.03 5-72 -.59/-1.37 .82
< 47 32 36 (22.25)
49-72 56 64
Female sexual function was measured by the Female Sexual Function Index
(FSFI) for the 32 study participants who were women. The 19-item FSFI included six
domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. The items
comprising these subscales contributed almost equally to the total scale score as shown in
Table 4.6. The FSFI questionnaire contains 15 items that are rated on a 6-point scale and
169
four items that are rated on a 5-point scale. To determine the FSFI score, scores on the 6
domains are multiplied by a weighted score. Possible total scores ranged from 2 to 36; in
these women, the mean was 18.99 (SD=10.42). Higher scores reflected less sexual
Table 4.6. Female Sexual Function Index and Domain Score Distribution (N=32)
Domain (item)
Actual Skewness /
/Actual range N % Mean (SD) Alpha
range Kurtosis
Desire (2) 2.78 (1.11) 1.2-5.4 .39 / -.12 .79
1.20 – 2.40 13 40.6
3.00 - 3.60 15 46.9
4.20 - 5.40 4 12.5
Arousal (4) 2.45 (1.92) 0-5.4 -.14 / -1.40 .97
0.00 10 31.3
1.20 - 2.70 5 15.6
3.00 - 5.40 17 53.1
Lubrication (4) 3.19 (2.31) 0-6.0 -.51 / -.14 .97
0.00 10 31.3
3.00 1 3.1
3.30 - 6.00 21 65.6
Orgasm (3) 3.11 (2.30) 0-5.6 -.43 / 1.51 .97
0.00 10 31.3
2.00 - 2.80 2 6.2
3.60 3 9.4
4.00 - 4.40 7 21.9
5.20 - 5.60 10 31.3
Satisfaction (3) 3.92 (1.55) 0.8 -6 -.77 / -.21 .75
2.80 - 3.60 12 37.4
4.00 - 6.00 20 62.6
Pain (3) 3.54 (2.58) 0- 6 -.58 / -1.57 .98
0.00 10 31.3
1.60 1 3.1
4.00 - 6.00 21 65.6
FSFI Total Score 18.99 (10.42) 2.00-32.30 -.53 / -1.31 .93
(19)
< 10 10 31.2
11 – 20 3 9.3
21 – 30 14 43.5
31 – 32.5 5 15.5
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Forty percent (n=13) of the women reported a lower level of sexual desire than
the average (M=2.78, SD=1.11). Thirty-one percent (n=10) of them reported no sexual
activity when they were asked about arousal, lubrication, orgasm, and pain/discomfort;
thus, their FSFI scores were less than 10. Over one third (n=12, 37%) of the women
participants indicated a low level of sexual satisfaction shown in Table 4.6. However, in
comparison with the average score, more than half of the women indicated that they had
experienced or felt sexual desire (59 %), arousal (53%), lubrication (65%), orgasm (62%),
sexual satisfaction (62%), and never experienced pain or discomfort (65%) during sexual
activity in the past 4 weeks. Approximately 59% (n=20) of the women had FSFI scores
that exceeded the average of 18.99, indicating that they has lower sexual dysfunction.
Sexual self concept. Sexual self concept was measured by Sexual Self-Schema
Scale for Males (SSSSM) or Sexual Self-Schema Scale for Females (SSSSF). The SSSS-
M was used to assess the positive versus negative characteristics of a man’s self-image as
a sexual person (Anderson, et al., 1997). The SSSS-Male Scale is comprised of three
minded/liberal (factor 3). Use of the total score is recommended (Andersen &
Cyranowski, 1994). The internal reliability coefficient for the total scale was .69 which is
close to the minimal requirement for reliability, i.e., .70 (Nunnally & Bernstein, 1994).
Among the 45 items constituting the total scale, 27 items, written in italics, were relevant
143; in this sample, the mean was 102.48 (SD=13.65). Higher scores indicated greater
men’s self image as a sexual person. Fifty-three percent (n=47) of 88 male participants
had scores less than the average of 120, indicating they had a less positive perception of
171
themselves as a sexual person, while approximately 47% of the men had a more positive
Table 4.7. Sexual Self-Schema Scale-Male and Domain Score Distribution (N=88)
Domain/item Mean (SD) Skewness / Score N % Alpha
Kurtosis Range
Factor 1 (10) 41.74 (6.69) -.09/-.57 27 - 58
Sexual Self-Schema Scale for Females (SSSSF) contains two positive factors and
(factor 1), directness/openness (factor 2), and embarrassment or conservatism (factor 3).
The possible scores ranged from -42 to 102 with higher scores interpreted as positively
schematic and low scores negatively schematic. Use of the total score is recommended
(Andersen & Cyranowski, 1994). The internal reliability coefficient for the total scale
was .72. Among the 50 items, 26 written in italics were relevant to a woman’s self-image
description. The SSSSF total scale scores ranged from 31 to 77, with a mean of 54.34
(SD=12.86). An equal percentage (n=16, 50%) of the female participants had scores
172
Table 4.8. Sexual Self-Schema Scale-Female and Domain Score Distribution (N=32)
Domain / items Mean (SD) Skewness / Score N % Alpha
Kurtosis Range
Factor 1 (10) 42.88 (7.81) -.14 / -.70 28 - 56
male and female participant’s feelings and attitudes toward communication in their
relationship. The range of scores is from 10 to 50, with higher scores indicating more
positive feelings about the quality and quantity of communication. In comparison with a
national survey of 21,501 married couples (N=43,002), the mean was 31.6 (SD=9.2) and
alpha reliability was .90 (Fowers & Olson, 1989), while the Cronbach’s alpha reliability
of ENRICH-Communication scale in this study was .86 and the mean was 35.4 (SD=8.2).
Approximately 27% of the study participants indicated they had very high positive
feelings (n=32) and high positive feelings (n=34, 28.4%) about the quality and quantity
of their communication, while over 20% of the participants had low positive (n=17,
14.2%) or very low positive (n=8, 6.6%) feelings about the quality and quantity of their
173
Table 4.9. ENRICH-Communication Scale and Score Distribution (N=120)
Cutting points Possible Actual N % Mean (SD) Alpha
range range
Total Score 10 - 50 11 - 48 120 100 35.37 (8.24) .86
Very high 41 - 50 41 - 48 32 26.8
High 36 - 40 36 - 40 34 28.4
Moderate 29 - 35 30 - 35 29 24.1
Low 23 - 28 23 - 28 17 14.2
Very low 10 - 21 11 - 19 8 6.6
the partner’s feelings related to the other’s affection and sexual relationship. The total
expressing affection and feelings about sexuality and lower scores reflecting greater
dissatisfaction in expressing affection and feelings about sexuality. In the national sample
of 21,501 married couples, the mean on the scale was 33.7 (SD=9.1) and internal
consistency was .88 (Fowers & Olson, 1989), while in the study reported here, the mean
was 38.29 (SD=7.09) and internal reliability coefficient was .81. Approximately 35%
(n=42) of the participants were very satisfied with their expression of affection and had
very positive feelings about sexuality; 28% (n=34) were satisfied with their expression of
affection and had a positive feelings about sexuality, 28% (n=33) were somewhat
satisfied with their expression of affection and had a few concerns about sexuality. Only
affection and had some concerns about sexuality in their life (Table 4.10).
174
Table 4.10. ENRICH-Sexual Relationship Scale and Score Distribution (N=120)
Cutting points Possible Actual N % Mean (SD) Alpha
range range
Total Score 10 - 50 24 - 50 120 100 38.29 (7.09) .81
Very high 41 - 50 41 - 50 42 34.9
High 36 - 40 36 - 40 34 28.3
Moderate 29 - 35 29 - 35 33 27.5
Low 23 - 28 24 - 28 11 9.1
analysis of variance (ANOVA) were the statistical methods needed for addressing the
research questions posed in this study. Prior to inferential data analysis, testing
underlying assumptions was required in order to make accurate inferences about the
population. The primary assumptions for Pearson’s correlation and Spearman’s rho
using exploratory analysis with SPSS, which provided graphical displays (histogram with
a superimposed normal curve, and P-P probability plots) and descriptive statistics (i.e.,
skewness and kurtosis values with standard errors) to insure adequate variation in the
variables, since lack of variance will weaken correlations with other variables.
existed among the study variables. The scores on the independent variables and four of
six scales of dependent variable were nearly normal distributed. The P-P plots of the male
sexual function (n=88) and the female sexual function (n=32) showed some deviation
175
between the expected and the observed values. Although there was a gap between two of
the cases on the two variables, the male sexual function and the female sexual function,
the gap was not found for the residual normality, and none of the skew values were
greater than +/- 3. None of the kurtosis values were greater than 8. Thus, no evidence of
skewness and kurtosis was demonstrated in Table 4.2 (skewness = +/- 3, kurtosis < 8 - 20,
overcome violation of this assumption (Daniel, 1995; Agresti & Finlay, 1997). In larger
sample sizes (i.e. 120), means scores should be considered as normally distributed,
according to the Central Limit Theorem; hence, the assumption of normality was met
relationship between two variables (X and Y). Linearity was assessed through the
straight line relationship was found among the scatterplots of all major study variables.
nearly linear; one pair of variables, the perceived stress and the communication, showed a
non-linear trend with R2 differences exceeding 2% while comparing the linear and
quadratic lines of best fit. Thus, the original independent variable and squared
independent variable were simultaneously used on partial regression plots to counter the
non-linear effect; the difference was less than 1% of additional explained variance, which
176
In addition, multicollinearity was examined to determine if there existed a linear
association between the dependent variable and independent variables. The numeric
statistic indicated there was no evidence of multicollinearity for all study variables. None
of them had values of tolerance equal or less than .20 (all tolerance values > .50) and
values of VIF (Variance Inflation of Factor) were larger than 10 (all VIF < 2) (Stevens,
1992).
the residual variance of the other variable. This assumption was assessed by examining if
the differences between the Studentized Deleted Residuals (Y axis) and the Standard
Predicted value (X axis) scores form a relatively constant distribution around the
prediction line (i.e., constant error variance). If the data points reached a 3:1 ratio of
highest to lowest error variance scatter, a non-constant error variance would be indicated
(Fox, 1991). In this study, the assumption of homosecedasticity was not violated.
analysis included:
skew and kurtosis tests of SDR (i.e., normal errors). Normal errors were assessed using
numeric statistics and graphic outputs by plotting the probability plot (P-P) of
and dependent variables were normally-distributed. Two variables, the male sexual
function and the female sexual function were examined and the probability (P-P) plots of
regression SDR were showed the deviation of the “normal line” superimposed on the plot.
177
However, non-skew and non-kurtosis were demonstrated (skewness = +/-3, kurtosis < 8-
2) Absence of influential cases. Unusual cases (i.e., outliers and influential cases)
were also identified before conducting the statistical analysis. Univariate outliers were
initially examined using SPSS Explore; one and four subjects/cases were considered as
possible outliers on the variables of age and time since operation, respectively. The
outlier(s) on age and time since operation were examined and revealed that it was the
youngest participant in the sample and the one with the longest time since operation,
respectively. Because they are probably the most interesting cases providing more
information of the sample, thus, these cases were kept in the data set. Moreover, three
scores (i.e., three ID cases) on the communication and one score (i.e., one ID case) on the
(communication and male sexual self-concept). Analysis for deletion of outliers and /or
variable transformation were/was conducted and the results were compared. Since the
findings were not found to be substantially different, these outliers were retained in the
data set.
residuals (error variance) and related diagnostic statistics for multivariate outliers through
SPSS linear Regression were performed, including Cook’s Distance (≥ 1.0 indicates
indicates outliers on X & Y), and the Covariate ratio (close to 1 is good).
178
Cases were considered as possible outliers on the variables, communication, male
sexual self-concept, respectively. No differences were found in the graphical results upon
deletion of the suspected outliers. And none of the diagnostic statistics showed a Cook’s
D or SDFBETA greater than 1 or Covariate ratio close to 1. Therefore, the cases were
retained in the data set for further analysis. Moreover, the bias is generally less serious in
larger samples (i.e. 120) because of the increased likelihood of having a relatively higher
number of normal cases to offset the few deviant ones (Fox, 1991). Thus, the assumption
two or more means to see if there are any reliable differences among them (Tabachnick &
Fidell, 2001). Independent-samples t test is used to compare two group means. The
assumptions for a one-way ANOVA are generally identical to those for an independent-
samples t-test; these assumptions are: normality, linearity, proper levels of measurement,
testing of normality and linearity, which was discussed in the previous section of testing
assumptions for correlational analysis, the other required assumptions for one-way
Each one was measured as a continuous variable. Although items were scaled on an
ordinal scale, because multiple items comprised each scale, it was treated as interval level
179
data. The independent variables in these analyses included education and religion; these
dependent variable and a single independent variable. As described above, the categorical
variables, which were the independent variables in these analyses, did not allow for
participants to have membership in more than a single category. Thus, this assumption
was met because observations within groups were independent of each other.
among the groups; this is determined by examining the non-significance of Levene’s test
for each ANOVA performed. The Levene’s test was found to be significant in the
this assumption for homogeneity of variance was not met in those two cases. The Welch
F-ratio and the Brown-Forsythe F-ratio, more robust tests of equality of means, were used
The purpose of this study was to examine the relationships between demographic
resourcefulness, and sexuality among the study participants. Three major research
questions were addressed, the first two questions had 1 to 4 sub-questions related to the
180
Research Question 1. What are the differences in or relationships of major study
demographic characteristics (i.e. age (A), gender (B), education (C), and religion (D) in
1A: What is the relationship between age and perceived stress in rectal cancer patients?
2A: What is the relationship between age and spirituality in rectal cancer patients?
3A: What is the relationship between age and resourcefulness in rectal cancer patients?
4A: What is the relationship between age and sexuality in rectal cancer patients?
was used to determine if significant relationships existed between the age and each of the
major study variables. A bivariate correlation matrix is presented in Table 4.11. Age was
found to be negatively and significantly correlated with perceived global stress, (r = -.20,
p<.05) and the measures of sexual function in both males and females (r = -.24 and r = -
.36, p<.05, respectively). There were no significant correlations between age and
sexuality. In summary, age had a negative relationship with perceived global stress,
indicating that older study participants reported lower global stress and younger
participants reported greater global stress. Age was not associated with cognitive
negatively related with sexual function in both males and females, indicating older study
participants reported lower sexual function while younger participants reported better
sexual function.
181
Table. 4.11. Pearson’s correlation coefficients between Age and Study Variables (Q1A-4A)
Cognitive Perceived Spirituality Resource- Sexual Satisfaction Male Male Female Female
Appraisal stress fulness Commun- Sexual sexual sexual sexual sexual
of stress (global) ication relationship self- function function self-
concept concept
1B: Is there a significant gender difference in the perceived stress in rectal cancer patients?
2B: Is there a significant gender difference in the spirituality in rectal cancer patients?
3B: Is there a significant gender difference in the resourcefulness in rectal cancer patients?
4B: Is there a significant gender difference in the sexuality in rectal cancer patients?
sexual satisfaction).
was found between males and females (t(1,118) = 2.30, p=.023). The mean scores on
perceived global stress for female participants was significantly higher (M=11.88,
SD=5.82) than the mean score for male participants (M=8.93, SD=6.34). Moreover, there
was a significant gender difference between the mean scores on resourcefulness (t(1,118)
=2.87, p=.005). More specifically, the mean score on the measure of resourcefulness in
females (M=106.25, SD=18.61) was higher than the mean score obtained for the males
appraisal of stress, spirituality, or sexuality. In summary, the findings indicated that the
women perceived greater global stress but were more resourceful than the men.
183
Table 4.12. Comparison of Genders on Major Study Variables
Male Female Mean P
n = 88 n = 32 t
difference (2tailed)
Variable Mean SD Mean SD
Cognitive 54.89 10.00 55.62 9.46 .74 .36 .717
appraisal of
stress
Perceived stress 8.93 6.34 11.88 5.82 2.94 2.30* .023
(global)
Spirituality 86.45 12.11 83.09 13.91 -3.36 -1.29 .199
1C: Are there significant differences in perceived stress by level of education in rectal
cancer patients?
2C: Are there significant differences in spirituality by level of education in rectal cancer
patients?
cancer patients?
4C: Are there significant differences in sexuality by level of education in rectal cancer
patients?
(cognitive appraisal of stress, F(4,115)= .83, p= .51; global stress, F(4,115)=2.45, p= .05,
184
respectively). There were no significant mean differences by educational level found on
spirituality (F(4,115)=1.47, p= .22). However, the findings indicated that there was a
p=.001). The Scheffé and Bonferroni post hoc analyses showed that the study participants
who completed elementary school scored significantly lower than those who completed
middle school (mean difference = -22.33, p=.010) and those who completed high school
(mean difference = -18.15, p=.001). In other words, the study participants who completed
middle school (mean difference = 22.328, p=.010) and those who completed high school
(mean difference =18.146, p=.001) had significantly greater resourcefulness than those
sexual relationship (F(4,115)=4.53, p=.002). Scheffé and Bonferroni post hoc tests were
conducted to determine where the differences in mean values were. Post hoc analysis of
the Bonferroni test revealed that the study participants who completed elementary school
scored significantly lower than those completing high school (mean difference= -5.40,
p=.004) and those with graduate education (mean difference = - 10.83, p=.022). These
findings were consistent with the mean plots presented in the study (Table 4.13). The
results of the Scheffé test showed that those who completed high school scored
significantly lower than those who completed elementary school (mean difference = -5.40,
p=.015). In other words, study participants who completed high school or completed a
graduate degree had significantly higher scores on sexual relationship than those who
completed elementary school. In summary, more highly educated rectal cancer patients
185
The findings showed no significant differences by educational level on
educational level was found on male sexual self-concept (F(4,83)=3.07, p= .021). The
Bonferroni test in the post hoc analysis showed that male participants who completed an
elementary school education had significantly lower scores on male sexual self-concept
than those who completed graduate degrees (mean difference = -23.70, p= .030) and
those who completed an undergraduate degree (mean difference = -22.98, p= .043). The
results were consistent with the mean plots presented. In other words, male participants
who completed an elementary school education had a lower sexual self-concept than
those who completed higher education, such as an undergraduate degree and graduate
degree, respectively.
As for the differences by educational level on male sexual function, the Levene
test was significant, indicating that the assumption of homogeneity of variance was not
met (p=.000). Thus, the Welch and Brown-Forsythe tests, which reflect the F-ratio for
robust equality of means, were performed (Fields, 2005). Both the Welch (F=.000) and
the Brown-Forsythe tests were significant (F=.014) indicating that there were significant
self-concept (p=.021), and male sexual function (p=.000/.014). The study participants
who were more highly educated, were more resourceful and reported better sexual
186
Table 4.13. Comparison of Educational Levels on Major Study Variables
Welch/
School/Degree Elementary Middle High Undergrad Graduate
F Sig Brown-
N = 120 n = 36 n = 11 n = 44 n = 25 n=4 Forsythe
Variables M M M M M
(SD) (SD) (SD) (SD) (SD)
Cognitive 55.47 51.09 55.66 56.08 50.00 .83 .51
appraisal of (8.71) (10.36) (11.10) (8.14) (13.64)
stress
Perceived stress 11.67 9.27 8.18 10.64 4.50 2.45 .05
(global) (5.57) (6.60) (5.89) (7.18) (6.46)
Spirituality 82.25 82.64 88.59 85.84 88.25 1.47 .22
(10.64) (16.97) (11.28) (14.70) (14.06)
Resourcefulness 85.94 108.27 104.09 97.32 100.75 5.36 .001
(18.07) (20.74) (21.25) (17.66) (12.12)
Communication 32.83 38.09 36.84 34.28 41.25 2.21 .07
(7.74) (6.20) (8.96) (7.89) (4.99)
Sexual 34.92 38.45 40.32 38.32 45.75 4.53 .002
relationship (5.91) (6.86) (7.33) (6.76) (4.72)
N = 32
n=9 n=4 n = 13 n=5 n=1
Female sexual 50.33 54.25 58.62 50.40 55.00 .67 .62
self-concept (10.83) (16.40) (13.13) (14.59)
Female sexual 15.58 17.65 19.64 22.16 30.90 .68 .61
function (9.81) (13.40) (10.64) (9.86)
N = 88 n = 27 n = 7 n = 31 n = 20 n=3
1D: Are there significant differences by religion on perceived stress in rectal cancer
patients?
2D: Are there significant differences by religion on spirituality in rectal cancer patients?
patients?
4D: Are there significant differences by religion on sexuality in rectal cancer patients?
187
Because the identification of religion was put into four categories, one-way
ANOVAs were used to determine if there were differences by religion reported by the
study participants on 1) perceived stress (global stress and cognitive appraisal of stress), 2)
p=.52), male sexual function (F(4,83)= 1.30, p=.28), female sexual function (F(4,27)=.66,
major study variables, perceived stress (global stress and cognitive appraisal of stress),
spirituality, resourcefulness, and sexuality (sexual function - male and female, sexual
self-concept - male and female, sexual satisfaction, i.e. relationship and communication)
(Table 4.14).
188
Table 4.14. Comparison of Religion on Major Study Variables
Taoism & Catholicism
Groups Atheism Buddhism other &
F Sig
N = 120 n = 12 n = 63 beliefs Christianity
n = 36 n=9
M M M M
(SD) (SD) (SD) (SD)
Cognitive 52.83 55.06 55.42 56.89 .32 .81
appraisal of (8.83) (10.29) (10.67) (7.29)
stress
Perceived stress 9.75 9.35 10.22 10.22 .16 .92
(global) (6.63) (6.60) (5.76) (6.87)
Spirituality 88.33 85.44 84.17 88.22 .47 .71
(13.32) (13.28) (12.38) (8.23)
Resourcefulness 102.00 100.11 91.69 96.56 1.49 .22
(15.76) (21.19) (22.03) (14.55)
Communication 35.33 34.86 36.50 34.44 .34 .80
(8.75) (8.53) (7.86) (7.80)
Sexual 39.75 38.13 38.22 37.78 .19 .90
relationship (6.98) (6.72) (7.63) (8.45)
N = 32
n=0 n = 22 n=8 n=2
Female sexual 53.14 58.75 50.00 .67 .52
-
self-concept (11.21) (14.81) (26.87)
Female sexual - 18.20 22.35 14.35 .66 .52
function (10.93) (8.73) (12.94)
N = 88 n = 12 n = 41 n = 28 n=7
cancer-related variables (i.e. stage of disease (E), type of treatment (F), time since
operation (G), and comorbid conditions (H)) in rectal cancer patients? (Q1E - Q4H)
1E: What is the relationship between stage of disease and perceived stress in rectal cancer
patients?
189
2E: What is the relationship between stage of disease and spirituality in rectal cancer
patients?
3E: What is the relationship between stage of disease and resourcefulness in rectal cancer
patients?
4E: What is the relationship between stage of disease and sexuality in rectal cancer
patients?
Because stage of disease is considered as ordinal data and the major study
variables are continuous variables, Spearman’s rho was conducted to determine if there
were significant relationships between the stage of disease (A, B1, B2, C1, and C2) of the
study participants and each of the major study variables. A bivariate correlation matrix is
displayed in Table 4.15. The stage of disease (tumor stage) was found to be negatively
and significantly correlated with male sexual function (rho= -.24, p=.023) while no
significant correlations were found between stage of disease and perceived global stress
(rho= -.02, p=.87) and cognitive appraisal of stress (rho=.09, p=.35), spirituality
(rho= .07, p=.47), resourcefulness (rho= .09, p=.34), female sexual function (rho= -.31,
p=.09), sexual self-concept (males, rho= -.02, p=.88 and females, rho=.31, p=.09), and
communication (rho= .04, p=.69), and sexual relationship (rho= -.04, p=.65). In summary,
the findings indicated that in these rectal cancer participants, the stage of disease
diagnosed was negatively associated with male sexual function such that the higher tumor
1F: What is the relationship between type of treatment and perceived stress in rectal
cancer patients?
190
2F: What is the relationship between type of treatment and spirituality in rectal cancer
patients?
3F: What is the relationship between type of treatment and resourcefulness in rectal
cancer patients?
4F: What is the relationship between type of treatment and sexuality in rectal cancer
patients?
Because the type number of treatments received was viewed as ordinal data and
the major study variables as continuous data, Spearman’s rho was performed to answer
treatment and each of the major study variables. Receiving surgery was coded as one type
of the treatment; receiving postoperative chemotherapy was coded as two types of the
three types of the treatment to make it ordinal data. A bivariate correlation matrix is
presented in Table 4.16. Type of treatment was found to be negatively and significantly
correlated with male sexual function (rho= -.30, p=.005). There were no significant
correlations between cancer treatment and the other major study variables, namely
resourcefulness, female sexual function, sexual self-concept (males and females), and
findings indicated that in these rectal cancer participants, cancer treatment was negatively
associated with male sexual function, such that the more treatment received, the worse
191
Table 4.15. Intercorrelation Between Stage of Disease and Major Study Variables (Q1E-4E)
Cognitive Perceive Spirituality Resource- Sexual Satisfaction Male Male Female Female
appraisal d stress fulness Commun- Sexual sexual sexual sexual sexual
of stress (global) ication relationship self- function function self-
concept concept
N = 120 n = 88 n = 32
Stage of
Disease .09 -.02 .07 .09 .04 -.04 -.02 -.24* -.31 .31
Table 4.16. Intercorrelations Between Type of Treatment and Major Study Variables (Q1F-4F)
Cognitive Perceived Spirituality Resource- Sexual Satisfaction Male Male Female Female
appraisal stress fulness Commun- Sexual sexual sexual sexual Sexual
of stress (global) ication relationship self- function function self-
concept concept
N = 120 n = 88 n = 32
Type of
.17 .12 -.10 .00 -.02 -.07 -.11 -.30** -.26 .20
Treatment
Spearman’s rho was used, * p <.05 **p<.01
Q1G – 4G: (Pearson’s correlations)
1G: What is the relationship between time since operation and perceived stress in rectal
cancer patients?
2G: What is the relationship between time since operation and spirituality in rectal cancer
patients?
3G: What is the relationship between time since operation and resourcefulness in rectal
cancer patients?
4G: What is the relationship between time since operation and sexuality in rectal cancer
patients?
were used to determine whether relationships existed between time since operation and
the major study variables (Table 4.17). Time since operation was found to be negatively
correlated with perceived global stress (r= -.21, p=.023). However, no significant
correlations were found between time since operation and cognitive appraisal of stress
sexual relationship), sexual self-concept (males and females), and sexual function (males
In summary, the findings indicated that in these rectal cancer patients, the time
since their operation was associated with perceived global stress such that the longer it
was since their operation, the lower was their perceived global stress.
1H: What is the relationship between comorbid conditions and perceived stress in rectal
cancer patients?
193
2H: What is the relationship between comorbid conditions and spirituality in rectal cancer
patients?
3H: What is the relationship between comorbid conditions and resourcefulness in rectal
cancer patients?
4H: What is the relationship between comorbid conditions and sexuality in rectal cancer
patients?
moment correlation analysis was conducted to determine whether there were significant
relationships between the number of comorbid conditions and each of the major study
significantly correlated with resourcefulness (r= -.19, p=.04). There were no significant
correlations between the number of comorbid conditions and perceived stress (global
stress and cognitive appraisal of stress), spirituality, sexual satisfaction, sexual function
(males and females), and sexual self-concept (males and females). In summary, the
findings revealed that the number of comorbid conditions was negatively associated with
194
Table. 4.17. Correlations between Time since Operation and Study Variables (Q1G - 4G)
Cognitive Perceived Spirituality Resource- Sexual Satisfaction Male Male Female Female
appraisal stress fulness Communi- Sexual Sexual sexual Sexual sexual
(global) cation relationship self- function self- function
concept concept
(N = 120) (n = 88) (n = 32)
Time
since
-.17 -.21* .11 .18 .12 .08 .14 .04 -.16 .10
operation
* p <.05
195
Table 4.18. Correlations between Comorbid Conditions and Study Variables (Q1H-4H)
Cognitive Perceived Spirituality Resource- Sexual Satisfaction Male Male Female Female
appraisal stress fulness Commun- Sexual Sexual sexual Sexual sexual
(global) ication relationship self- function self- function
concept concept
N = 120 n = 88 n = 32
Number of
cormobid .05 .18 -.10 -.19* -.13 -.13 .04 .10 -.26 -.21
condition
* p <.05
1
Research Question 3. What are the relationships between perceived stress and sexuality
(Q5), spirituality and sexuality (Q6), resourcefulness and sexuality (Q7), perceived stress
and spirituality (Q8), spirituality and resourcefulness (Q9), and perceived stress and
conducted to determine if significant relationships among all the major study variables.
Q5. What are the relationships between perceived stress and sexuality?
study: perceived global stress and cognitive appraisal of stress. Perceived global stress
was moderately but negatively correlated with the indicators of sexuality, including
communication (r= -.40, p<.001), sexual relationship (r= -.46, p<.001), male sexual self-
concept (r= -.35, p=.001), female sexual self-concept (r= -.54, p=.001) and male sexual
function (r= -.21, p=.048). Cognitive appraisal of stress was found to be negatively and
significantly correlated with communication (r= -.26, p=.004) (Table 4.19). The findings
communication, sexual relationship (n=120), male sexual self concept (n=88), female
sexual self concept (n=32) and lower scored on male sexual function (n=88) (i.e., sexual
dysfunction). In addition, it was found that the higher the study participants scored on
cognitive appraisal of stress, the lower was their scores on communication with their
partners. In other words, male participants who perceived greater global stress had lower
sexual function, and both male and female participants who perceived greater global
stress reported lower sexual self-concepts and lower sexual satisfaction (Q5).
196
Q6. What are the relationships between sexuality and spirituality?
The findings indicated that spirituality was positively and significantly correlated
with communication (r= .47, p<.001), sexual relationship (r=.48, p<.001), male sexual
self-concept (r=.44, p=.000), and female sexual self-concept (r=.47, p=.007), indicating
that study participants who reported higher scores on the measure of spirituality had
higher scores on measures of sexual satisfaction and sexual self-concept (Q6)(Table 4.19).
p=.001), and sexual self-concept in males (r=.36, p=.001) and females (r=.50, p=.004).
The findings indicated that greater resourcefulness had higher scores on measures of
Q8. What are the relationships between perceived stress and spirituality?
the two indicators of perceived stress (global stress and cognitive appraisal of stress) and
correlated with spirituality (r= -.54, p=.000). The findings showed that cognitive
appraisal of stress also had a significant and negative correlation with spirituality (r= -.37,
p=.000) (Table 4.19). The findings indicated that greater perceived stress, in terms of its
cognitive appraisal and global nature, was associated with lower spirituality in the study
participants. In other words, patients who perceived greater stress scored lower
spirituality.
Q9. What are the relationships between perceived stress and resourcefulness?
197
Pearson’s correlational analyses were conducted to examine relationships between
the two indicators of perceived stress (global stress and cognitive appraisal of stress) and
resourcefulness. The results showed that perceived global stress was negatively and
significantly correlated with resourcefulness (r= -.32, p=.000); however, there was no
association between cognitive appraisal of stress and resourcefulness (r= -.10, p=.291)
(Table 4.19). The findings showed that study participants who reported lower perceived
global stress also reported greater resourcefulness, however their resourcefulness was
Pearson’s correlational analysis was conducted and the findings showed that
spirituality was positively and significantly correlated with resourcefulness (r= .32,
p=.000) (Table 4.19), indicating that the study participants who reported greater
direction of the correlation between the two indicators of perceived stress: cognitive
appraisal of stress and perceived global stress (Table 4.19). The findings showed that
study participants with greater cognitive appraisal of stress also reported greater feelings
associated with sexual self-concept in males (r= .38, p=.000) and females (r= .48,
p=.000), while sexual relationship was found to be positively correlated with male sexual
self-concept (r= .44, p=.000) and female sexual self-concept (r= .63, p=.000) (Table
198
4.19). Moreover, there was a significant correlation between communication and sexual
relationship (r= .68, p=.000). This indicated that higher scores on the measures of
communication and sexual relationship were strongly associated with sexual self-
concepts. In summary, having a more positive sexual self-concepts was associated with
199
Additional Analyses of Cancer-related Variables and Major Study Variables
dichotomous variable (present or not present) was examined in relation to the other major
difference existed between patients with colostomy and those without a colostomy
difference on perceived global stress between patients with a colostomy and those
without a colostomy (t(1,118)= -2.58, p= .011). The mean score on perceived global
stress for persons who had colostomy was significantly higher (M= 12.23, SD =5.20)
than those who did not have a colostomy. Also, a significant mean difference was found
between those with and those without a colostomy on cognitive appraisal of stress
(t(1,118)= -2.44, p= .016). The mean score on the measure of cognitive appraisal of
stress in those with a colostomy (M=58.80, SD=8.54) was higher than those who had no
colostomy. In addition, a significant mean difference was found between those with and
those without a colostomy was found on female sexual function (t(1,30) = 2.394,
p= .023). The mean score on female sexual function in women with a colostomy was
lower (M= 8.13, SD=10.27) than women without a colostomy (M= 20.55, SD=9.64).
Similarly, there was a significant mean score difference on male sexual function (IIEF)
(t(1,86)= 2.76, p= .007) between men with a colostomy and those without a colostomy.
Men who had a colostomy had lower mean scores on male sexual function (M= 36.31,
SD= 24.24) than those without a colostomy (M= 50.11, SD=20.20). No mean score
200
satisfaction (i.e., communication and sexual relationship) in males and females between
n = 26 n = 62
Male sexual self- 98.62 12.44 104.10 13.89 86 1.74 .086
concept
Male sexual function 36.31 24.24 50.11 20.19 86 2.75 .007**
n=4 n = 28
Female sexual 61.00 10.95 53.39 12.99 30 -1.11 .275
self-concept
Female sexual 8.13 10.27 20.55 9.64 30 2.39 .023*
function
*p<.05; **p<.01
For the analysis between length of time since cancer diagnosis and the major
study variables, three categories were created: <12 months (<1year), 13-60 months (1-5
years), > 61 months (>5 years)). One-way ANOVAs were performed to determine if
there were differences by the three categories of time since cancer diagnosis on 1)
sexuality indicators. The findings indicated that there were no significant differences by
time since cancer diagnosis for any of the major study variables as shown in Table 4.21.
201
Table 4.21. Comparison by Length of Time since Diagnosis of Major Study Variables
Groups < 1 year 1 – 5 years > 5 years
N = 120 n = 40 n = 62 n = 18
df F Sig
M M M
(SD) (SD) (SD)
Cognitive appraisal of 55.00 55.89 52.50 2,117 .83 .44
stress (9.32) (9.52) (11.93)
Perceived stress (global) 9.33 10.74 7.06 2,117 2.56 .08
(6.15) (6.14) (6.74)
Spirituality 88.13 83.06 88.44 2,117 2.57 .08
(11.84) (13.17) (11.32)
Resourcefulness 98.60 94.60 105.11 2,117 1.91 .15
(23.02) (19.84) (16.90)
Communication 36.88 34.11 36.33 2,117 1.53 .22
(7.02) (8.06) (10.78)
Sexual relationship 39.67 36.97 39.78 2,117 2.29 .11
(6.65) (7.36) (6.53)
N = 32 n = 15 n = 15 n=2
Female sexual self- 59.80 49.93 46.50 2,29 2.93 .07
concept (11.05) (13.12) (12.02)
Female sexual function 16.61 21.95 14.70 2,29 1.18 .32
(11.89) (8.51) (10.89)
N = 88 n = 25 n = 47 n = 16
Male sexual self- 102.24 102.66 102.31 2,85 .01 .99
concept (12.83) (14.64) (12.64)
Male sexual function 48.64 45.57 43.31 2,85 .30 .74
(22.65) (21.82) (22.25)
*p<.05, **p<.01
men and women to determine the relationships on perceived stress (global and cognitive
appraisal stress), spirituality, and resourcefulness and dependent variable (sexuality). The
results indicated that perceived global stress was negatively correlated with male sexual
function (r= -.21, p=.048), sexual self-concept in males (r = -.35, p=.001) and females
(r= -.54, p=.001), communication (males, r = -.35, p=.001; females, r=-.50, p=.001), and
sexual relationship in males (r= -.44, p=.000) and in females (r=-.50, p=.004), and
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communication in both sexes (r=-.39, p=.000) and sexual self-concept (r= -.46, p=.000)
The findings also indicated that cognitive appraisal of stress (an indicator of stress)
was negatively associated with sexual function in males (r= -.22, p=.036) and in females
(r= -.45, p=.01), communication in males (r= -.30, p=.004), and in both sexes (r= -.26,
and sexuality for men and women separately, Pearson’s product moment correlation
analysis was conducted. Spirituality had a significant positive correlation with sexual
both sexes (r=.47, p=.000), sexual relationship in males (r= .47, p=.000), sexual
relationship in females (r= .48, p=.005) and sexual relationship in both genders (r =.48,
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Table. 4.23. Gender Differences on Spirituality and Sexuality
Variables Total (N =120) Men (n = 88) Women (n =32)
r (p) r (p) r (p)
Spirituality & Sexuality
Sexual function (M/F) .13 (.219) .02 (.896)
Sexual self-concept (M/F) .44***(.000) .47**(.007)
Communication .47***(.000) .46***(.000) .47**(.007)
Sexual relationship .48***(.000) .47***(.000) .48**(.005)
* p <.05, **p <.01, ***p<.001
Pearson’s product moment correlation analysis was used to determine the strength
and direction between resourcefulness and sexuality in males and females. The findings
revealed that resourcefulness was positively correlated with sexual self-concept in males
p=.015) and in both sexes (r=.02, p=.01), sexual relationship in males (r =.49, p=.000), in
females (r=.42, p=.017), and in both genders (r=.04, p=.000). However, resourcefulness
was not associated with communication in males (r=.20, p=.066) as shown in Table 4.24.
one-way ANOVAs, key findings for each of the research questions are highlighted below:
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Demographic Data Findings
Age. Age had a negative correlation with perceived global stress (r=-.20, p< .05),
and sexual function in both men and women. Gender differences were found on
perceived global stress and on resourcefulness (t(1,118 ) = 2.30, p < .05) and t(1,118)
=2.87, p < .01, respectively. Significant difference by educational level were found on
4.53, p= .002), male sexual self-concept (F(4,83) = 3.07, p=.021), and male sexual
function (Welch (F= .000) and Brown-Forsythe tests (F= .014)), while the level of
significance was set at p = .05. The findings indicated the highly educated rectal cancer
patients reported more resourcefulness and greater sexual relationship, and male sexual
self-concept and sexual function. There were no significant differences by religion on the
Stage of disease. Stage of disease (tumor stage) was found to be negatively and
correlated with sexual function in the male rectal cancer patients (rho= -.24, p=.023),
indicating higher it was the tumor stage, the worse was the male sexual function.
Significant difference was found by cancer treatment on the measure of male sexual
function (rho= -.29, p=.006), indicating the more treatment the male patients received,
the worse sexual function they had. In these rectal cancer patients, the time since their
operation was significantly associated with perceived global stress (r= -.21, p< .05) such
that the longer it was since their operation, the lower was their perceived stress. No
significant correlation was found between the number of comorbid conditions and
sexuality, perceived global stress, cognitive appraisal of stress, and spirituality. There
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was a negative correlation between the number of comorbid conditions and
resourcefulness (r= -.19, p=.04). The findings indicated that study participants who had a
With respect to the relationships among study variables, the research findings
showed that rectal cancer patients had lower sexual self-concepts and lower sexual
satisfaction while they perceived higher global stress (r= -.35, p=.001 (male); r= -.54,
p=.001 (female), and r= -.40, p< .001 (communication); r= -.46, p< .001 (sexual
relationship), respectively). In the male rectal cancer patients, lower sexual function was
associated with greater perceived global stress (r= -.21, p=.048) (Q5). The findings also
showed that greater spirituality in both men and women was associated with greater
respectively) and more positive sexual self-concept (r=.44, p=.000 (male); r=.47, p=.007
(female)) (Q6). Further, the findings indicated that greater resourcefulness was related to
relationship)) and more positive sexual self-concept (r= .36, p=.001 (male); r= .50,
p=.004 (female), respectively) (Q7). The findings indicated that greater cognitive
appraisal of stress and perceived global stress were associated with lower spirituality (r=
-.37, p=.000 and r= -.54, p=.000, respectively) (Q8). Moreover, lower resourcefulness
was associated with greater perceived global stress (r= -.32, p=.000) (Q9). In addition, in
the rectal cancer patients, greater spirituality was associated with greater resourcefulness
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Additional Findings
correlations indicated that greater cognitive appraisal of stress was associated with
greater perceived global stress (r= .46, p=.000). Moreover, communication between
partners had a positive and association with sexual self-concept in males (r= .38, p=.000)
and females (r= .48, p=.000), while sexual relationship was found to have a positive
correlation with male sexual-self concept (r= .44, p=.000) and female sexual-self concept
(r= .63, p=.000). Moreover, there was a positive correlation between communication and
sexual relationship (r= .68, p=.000). The findings thus indicated that the rectal cancer
patients who reported better communication or sexual relationship had more positive
sexual self-concepts. In summary, the findings showed that better sexual self-concept was
between age and type of treatment received (p=.03) and a positive correlation between
age and time since operation (p=.006) (Table 4.3), indicating young age patients received
more types of treatment and had a shorter length of time since their operation, while older
patients likely received less types of treatment and had a longer length of time since their
operation. In addition, the number of types of cancer treatments received was positively
correlated with patient’s stage of disease (p=.000), indicating that patients with a higher
stage of disease received more types of cancer treatment. However, age was not related to
the number of comorbid conditions (Table 4.3). With respect to the time since operation,
the findings showed that there were significant differences by length of time since
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operation between genders (p=.03), with the men reporting a longer time since their
Gender differences on major study variables. In men, perceived global stress was
perceived global stress was negatively associated with sexual self-concept (p=.001),
communication (p=.004), and sexual relationship (p=.004). The findings revealed that
men who had low scores on sexual function, sexual self-concept, communication, or
sexual relationship, were found to have high scores on perceived global stress. In addition,
relationship, were found to have high scores on perceived global stress (Table 4.23, 4.25).
Cognitive appraisal of stress had a negative correlation with male sexual function
(p=.036) and female sexual function (p=.01), communication (total, p=.001) and
communication (males, p=.004), indicating that low sexual function in both men and
women and low scores on communication for the total sample and the men, were
associated with higher scores on cognitive appraisal of stress (Table 4.23, 4.25).
p=.000; and females, p=.007), sexual relationship (total sample, p=.000; males, p=.000;
females, p=.005). These results showed that persons with a lower sexual self-concept,
low communication, and less satisfactory sexual relationship in both genders were low in
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Resourcefulness was also positively related with male sexual self-concept
(p=.001), female sexual self-concept (p=.004), communication (total sample, p=.01 and
in females, p=.015), sexual relationship (total sample, p=.000; males, p=.000; females,
p=.017). These results showed that persons with a lower sexual self-concept, low
(Table 4. 25).
between persons with and persons without a colostomy on perceived stress (global,
p=.011; cognitive appraisal nature, p=.016). The mean scores (i.e., global and cognitive
appraisal of stress) for the persons with a colostomy were higher than the mean scores of
the men and the women who had a colostomy versus those who did not (males, p=.007;
females, p=.023). In the men and the women, mean scores on sexual function were lower
for those with a colostomy in comparison with those who had no colostomy (Table 4.20,
Table 4.25).
between concerning scores on the major study variables and respondent characteristics
In this descriptive study, there is a need to interpret all of the findings with
caution because of the number of statistical tests that were required for examining the
relationships between the demographic and cancer-related variables and the four major
209
Considering the chance of type I error that may occur when conducting multiple
statistical tests, a Bonferroni correction may be applied, which involves dividing the
desired level of significance (p = .05) by the total number of statistical tests that were
performed (n = 139). Applying this formula (.05 divided by 139 tests), the new level of
showing trends toward significance and worthy of further examination in future studies.
This is especially true for the analysis conducted for the demographic and cancer-related
variables.
However, highly significant relationships (i.e. p < .0003) were found among
demographic and cancer-related variables and some of the major study variables. For
example, greater perceived global stress was correlated with lower spirituality (r= -.54,
p=.000), lower resourcefulness (r= -.32, p=.000) and less communication (r= -.39,
p=.000) and greater cognitive appraisal of stress was correlated with lower spirituality (r=
-.37, p=.000). However, lower spirituality was correlated with less positive male sexual
self-concept (r= .44, p=.000), lower resourcefulness (r= .32, p=.000), less communication
in males (p=.000) and in the total sample (p=.000), and less satisfying sexual relationship
in males (p=.000) and in the total sample (p=.000). Lower resourcefulness was correlated
with less satisfying sexual relationship in males (p=.000) and in the total sample (p=.000).
In addition, the higher stage of disease was correlated with a greater number of cancer
treatments.
210
As for the additional analysis, cognitive appraisal of stress was significantly
correlated with perceived global stress (r= .39, p=.000), communication and sexual
relationship were correlated (r= .68, p=.000) and both communication and sexual
relationship were associated with sexual self-concept in the women (r= .48, p=.000 and
r= .63, p=.000, respectively) and the men (r= .38, p=.000 and r= .44, p=.000,
respectively).
211
Table 4.25. Associations Between Concerning Scores on Major Study Variables and
Respondent Characteristics
Scores on Major Study Variables Respondent Characteristics
High Perceived Global Stress Young age
Women
Colostomy performed
Shorter length of time since operation
Low male sexual function
Low sexual self-concept (men/women)
Low communication (men/women/both)
Low sexual relationship (men/women/both)
High Cognitive Appraisal Stress Colostomy performed
Low communication (men/both)
Low sexual function (men/women)
Low Resourcefulness Men
More comorbid conditions
High global stress
Low education
Low spirituality
Low communication (women/both)
Low sexual relationship (men/women/both)
Low sexual self-concept (men/women)
Low Spirituality High perceived stress (global & cognitive)
Low resourcefulness
Low communication (men/women/both)
Low sexual relationship (men/women/both)
Low sexual self-concept (men/women)
Low Communication High perceived stress (global & cognitive)
Low sexual self-concept
Low Sexual relationship High perceived stress (global)
Low education
Low sexual self-concept
Low communication
Low Sexual self-concept High perceived stress (global)
Low communication
Low sexual relationship
Low education (men)
Low Sexual function Old age
Low education (men)
Colostomy performed
Higher stage of disease
More types of treatment (men)
High perceived stress (global) (men)
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Stage of
Disease
rho= -.24
rho= .81
rho= -.29
Type of Male sexual function
r= -.24
Treatme r= -.36 Female sexual function
r=.22 Communication
r= -.19 Sexual relationship
Resource- r=.43
Comorbid Male sexual self-concept
fulness
condition r=.36
r=.50 Female sexual self-concept
r=.38 Male sexual self-concept
Commun-
ication r=.48
Female sexual self-concept
r=.68
r=.63 Female Sexual self-concept
Sexual r=.44
relationship
Male sexual self-concept
Education
Male sexual function
Figure 4.2. Relationships among Demographic and Cancer-related and Study Variables
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CHAPTER V: SUMMARY and DISCUSSION
Introduction
and empirical literature. In addition, study limitations and the influence of cultural issues
and impact of instrument translation are addressed. The implications for theory
development, future research, clinical practice, health policy, and nursing education, and
Summary
This descriptive and exploratory study was the first step to examine relationships
among major study variables that included perceived stress, spirituality, resourcefulness,
and sexuality in Taiwanese adults with rectal cancer who were undergoing cancer
(Neuman, 1995), Lazarus’s (1984) stress and coping theory, and Zauszniewski’s (2006)
degrees of harmony, stability, and balance. The goal of nursing in Neuman’s Model is to
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(treatment of symptoms following stress reaction), or tertiary prevention (adapting,
Stress appraisal, through the process of cognitive appraisal for the situation
significance of the stressful event to the person (appraisal) is a key component in the
somatic health is attained. Two coping resources, self-help and help-seeking strategies,
which have been identified in the mid-range theory of resourcefulness, have been found
This study involved a sample of 120 rectal cancer adults ranging from 29 to 85
years of age, who were recruited through physician’s referral in a Medical Center in
southern Taiwan. This sample included 32 women and 88 men. The sample size was
determined by power analysis for statistical tests needed for the study: Pearson’s product
samples t test.
Sexuality, a major focus of the study, is a sensitive area for all persons. Structured
following order to broach the topic gradually: Perceived Stress Scale (PSS-10), Cognitive
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F)/ Sexual Self-Schema Scale-male(SSSS-M), Enriching, Nurturing Relationship,
Index of Erectile Function (IIEF)/ Female Sexual Function Index (FSFI). Demographic
Pertinent findings
Analyses of sample characteristics showed that about 27% (n=32) were women
and 73% (n=88) were men, with a mean age of 61 years. Ninety-six percent of the study
participants were married and had an average of three children, while 4% were not
levels. Ninety percent of the rectal cancer patients had religious beliefs. About 55% were
improve their sexual function during sexual activities, while women (13%) were more
Statistical analyses of cancer-related data revealed that the average length of time
since cancer diagnosis was 36 months, which was nearly the same as the length of time
since their operation. Thirty-two percent of the patients were diagnosed with cancer in
Duke A, 24% were in Duke B1, 3% were in Duke B2, 5% were in Duke C1, and 36%
were in Duke C2. Over half (52%) of the rectal cancer patients had surgery treatment
only, 37% received surgery plus postoperative chemotherapy, and 11% received surgery
plus postoperative chemotherapy and radiotherapy. The majority of the patients (84%)
underwent a low anterior resection (LAR) and 25% of the patients had a colostomy
performed.
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Discussion
demographic characteristics (i.e. age (A), gender (B), education (C), and religion (D)) in
Relationships between age and perceived global stress. As expected, age was
found to be negatively correlated with perceived global stress (1A), indicating that older
participants reported lower global stress and younger patients reported greater perceived
global stress. The findings were consistent with Rong (2000) who reported that elderly
subjects tended to have low stress, high resourcefulness, and high adaptive functioning.
The results of this correlational analysis also support Neuman’s systems model (1995),
which says that age-related developmental processes interact with the person’s
stressors (i.e, time since diagnosis), throughout the adjustment process. According to
Lazarus and Folkman’s (1981) transaction model, cognitive appraisal depends on the
person affects the environment) and therefore influences his/her perception of the
stressors. This, in turn, affects the degrees of harmony and stability in the person -
environment interaction.
Relationships between age and cognitive appraisal of stress. The second indicator
of perceived stress was cognitive appraisal of stress. No correlation was found between
217
age and cognitive appraisal of stress. This was unexpected, however, similar findings
that showed no correlation between age and cognitive appraisal of stress were found in
two studies (Herzer, Zakowski, Flanigan, & Johnson, 2006; Laubmeier et al. 2004).
Those studies differed from the current study in that they focused on threat appraisal
rather than the cognitive appraisal of stress that includes threat, challenge, and harm/loss
the samples in those two studies involved cancer survivors, but did not focus specifically
on rectal cancer patients. Accordingly, the current findings are only partially consistent
The results from this study reported here were not consistent with Bowman and
colleagues’ (2003) study, which reported that age was negatively correlated with stress
appraisal, indicating that younger cancer survivors, including 30% of colorectal cancer
patients, reported more stressful appraisal. This study showed no association between age
and cognitive appraisal of stress. The discrepancy between the findings from the
Bowman et al’s (2003) study and the study reported here may be related to differences in
The incongruent results that were found between the two indicators of perceived
stress may have been related to measurement error. Although the Chinese translation of
the PSS has been used in Taiwanese people and does appear to measure the perceived
degree to which environmental demands exceed one’s ability to cope, the measure of the
second indicator, cognitive appraisal of stress, was translated into Chinese for the first
time for this study; it is used to measure the threat, challenge, and harm/loss dimensions
of stress appraisal.
218
During the data collection on the measure of cognitive appraisal of stress, the
research assistant/researcher consistently used the term “this health condition” instead of
using the word “cancer.” Participants could have different interpretations concerning
what was meant by “this health condition.” Thus, it is very possible that the measure
may have captured perceived response to a specific stressor (this health condition) other
than cancer. Alternative explanations may be the homogeneity or size of the sample,
both of which may affect the significance of the findings. Future studies of larger
samples and consistent use of phrasing on study questionnaires, i.e. specific referral to
Relationships between age and resourcefulness. Age was not associated with
resourcefulness in the present study. This finding is consistent with the study by
Zauszniewski and colleagues (2005), which found that age was not a significant predictor
may influence the process regulating cognition (process regulator), and then, in turn,
affect resourcefulness (personal and social). The sample in the study reported here was
recruited from a single medical center and may have been too homogeneous in terms of
age to obtain significant results. Future studies should focus on recruitment of rectal
Relationships between age and spirituality. Age was not associated with
spirituality in the present study. According to Neuman’s (1995) model, age is related to
219
influences and is also influenced by all other variables. Because age was associated with
are seen as a means for strengthening the spiritual nature of the person. The mean score
from 51 to 100, indicating that the majority of the participants had a high level of
spirituality (i.e., meaning in life). One explanation for this finding may be related to the
length of time since their diagnosis or operation (mean=36 months). Perhaps over time,
the participants were better able to adopt a positive attitude in relation to their stressful
Relationships between age and sexuality. The correlation matrix indicated that
age was negatively related with sexual function in both males and females (4A),
indicating older rectal cancer study participants reported lower sexual function while
younger participants reported better sexual function. The negative relationship found
between age and sexual function in both gender groups was partially consistent with
Lindau and colleagues (2007) and Brecher’s (1984) studies, which found that sexuality or
sexual activity declined with advancing age and illness. However, Lindau and colleagues
al. 2007), whereas the age ranges of the sample in the study reported here were from 29
to 85 years. In contrast with the study reported here, Schmidt and colleagues (2005b)
found that for male rectal cancer patients, impaired sexuality was independent of age.
Gender differences on perceived global stress. The findings from the present
study indicated there was a significant gender difference on perceived global stress (1B);
female patients reported higher perceived global stress than male patients. This finding is
220
consistent with conclusions drawn by Graupe and colleagues (1997), who concluded that
female colorectal cancer patients are special risk group with a high level of psychological
strain. This finding is also consistent with a study conducted by Northouse and colleagues
(2000), which found that female colon cancer and their spouses reported high emotional
distress or concurrent stress. Perceived stress depends a great extent upon how the person
conceptualizes stress. There are wide individual differences in the perception of what is
than the male study participants (3B). A gender difference on resourcefulness was also
found in the study by Zauszniewski and Chung (2001), which showed a gender difference
another study contradicts this finding and reported no difference between elderly men and
reported here, the sample characteristics in Zauszniewski and Chung’s (2001) study (i.e,
women with diabetes) and Bekhet and Zauszniewski’s (2008) study (relocated elders)
differed from those in the present study (rectal cancer adults). In addition, both previous
studies measured only personal resourcefulness, while the study reported here measured
suggests that gender is an intrinsic factor that may influence process regulators, which
may include cognitions (i.e. cognitive appraisal) and the person’s self-control skills and
221
Educational level and major study variables. The findings showed there were
relationship (p=.002), male sexual self-concept (p=.21), and male sexual function
(F=.000/F=.014) (4C), indicating that more highly educated rectal cancer patients
reported greater sexual relationship (satisfaction), better sexual self-concept in men, and
better sexual function. The study participants who were more highly educated, were more
resourceful (4C).
findings of this study are consistent with the findings reported by previous studies where
persons with higher educational levels were more highly resourceful than those with less
education (Bekhet & Zauszniewski, 2008). However, the sample characteristics in Bekhet
and Zauszniewski’s (2008) study differed from the sample in the present study. In the
study reported here, the participants were Taiwanese rectal cancer adults (aged 29 to 85),
while in Bekhet and Zauszniewski’s (2008) study, they were American elders (aged 65 to
95), many of whom had chronic conditions, and who recently relocated to retirement
communities.
men. A similar significant difference by education level was also reported in other studies,
which showed that increasing education was associated with better relocation adjustment
(Bekhet & Zauszniewski, 2008) and better adaptation (Rong, 2000); both relocation
This finding is also partially consistent with a study conducted by Ustundag and
colleagues (2007), which showed a significant difference between self-esteem scores and
222
educational status (p< .05) and highly educated patients had higher scores on self-esteem.
results from the study reported here highlighted sexual self-concept in both genders.
These findings may also reflect the ancient Chinese belief “Knowledge is extremely
important above everything else.” Since ancient times, sex discrimination has been an
existing phenomenon in the Chinese society; men have had more opportunities than
honor for the person and also for his family, which in turn, elevates one’s self esteem,
and, therefore contribute to increasing one’s sexual self-concept. Thus, the cultural effect
may provide an explanation for the relationship between educational level and sexual
educational level, no studies were found to support this finding. However, the association
between sexual relationship and education may be related to the association found
higher education is believed to elevate one’s self-esteem, and therefore, one’s self-
With regard to the educational difference on male sexual function, very few
empirical studies were found in support of this finding. One explanation could be that in
traditional Chinese society, men have more opportunities for receiving education, which
provides them more available resources for problem-solving, such as sexual problems;
knowledge concerning how to manage sexual problems may positively affect their sexual
function.
223
Research Question 2. What are the differences in or relationships of major study
satisfaction) in relation to the cancer-related variables (i.e. stage of disease (E), type of
treatment (F), time since operation (G), and comorbid condition (H)) in rectal cancer
Relationships between stage of disease and sexuality. The findings indicated that
the stage of disease was negatively associated with male sexual function such that higher
tumor stage (i.e., advanced cancer) was associated with greater male sexual dysfunction
(Q4E). Very few empirical studies have reported differences in sexuality at the various
stages of disease in rectal cancer patients. The findings are consistent with a study
conducted by Morino and colleagues (2009), who reported that the advancement of
tumors significantly predicted impaired sexual function in male rectal cancer patients
Relationships between type of cancer treatment and sexuality. The findings from
the study reported here indicated that type of treatment (i.e., surgery, surgery plus
associated with males’ sexual function in that the more treatment received, the worse was
their sexual function (Q4F). These findings were similar to the studies conducted by
Ameda and colleagues (2005) and by Morino and colleagues (2009), who found that two
factors - types of surgery (i.e., APR or LAR) and adjuvant or neoadjuvant treatment were
2005; Morino et al. 2009). Other studies, however, had findings that were inconsistent
224
with these findings that suggested that the type of surgery had an effect on sexual
function of both genders (Ness et al. 1998; Chatwin et al. 2002; Camilleri-Brennan &
Steele, 2001; Hendren et al. 2005; Schmidt, Bestmann, Küchler, Longo, et al. 2005b;
Schmidt, Bestmann, Küchler, & Kremer, 2005a; Asoglu et al. 2009) or that radiation was
negatively associated with sexual function in both men and women (Temple et al. 2003).
Basically, these studies focused on the effects of cancer treatment (i.e., surgery or
adjuvant therapy or neoadjuvant) on sexual function rather than on the types of cancer
treatment as in the study reported here. Future research may focus on the relationship or
Relationships between time since operation and perceived global stress. The
findings indicated that time since the study participant’s operation was associated with
perceived global stress such that the shorter it was since their operation, the higher was
their perceived global stress (1G). This may indicate that over time, the patients may have
developed cope strategies and may have adapted to having had the operation.
The positive correlation between time since operation and perceived global stress
is consistent with the study conducted by Bekhet & Zauszniewski (2008), which reported
that time since relocation had a positive association with relocation adjustment (Bekhet,
2007). Both studies illustrate the effects of coping with stress over time. However, in
studies that specifically examined time since diagnosis in cancer patients, Laubmeier and
colleagues (2004) and Herzer and colleagues (2006) found no significant correlation
between time since diagnosis and threat appraisal in cancer patients. Since the length of
time since operation was similar to the length of time since diagnosis in the present study,
the findings were consistent with those reported by Laubmeier and colleagues (2004) and
225
Herzer and colleagues (2006). However, the study by Herzer and colleagues (2006)
focused on persons with multiple types of cancer rather than rectal cancer as in this study
(1G).
indicating that greater comorbidity was associated with lower resourcefulness (3H).
These findings are consistent with the study conducted by Tithiphontumrong’s (2005)
study, which found that elders with fewer chronic conditions had greater personal
resourcefulness. However, the sample characteristics of the study reported here were
different from those of the other study (Tithiphontumrong, 2005). The Resourcefulness
scale scores for this sample ranged from 39 to 138 with a mean of 97.51 and a standard
deviation of 20.73, which reflected high levels of resourcefulness. The participants in this
study scored above the average score on the resourcefulness scale, especially personal
indicate that the participants did not tend to seek help from others. One possible
explanation for why a greater number of chronic conditions were associated with lower
resourcefulness may be that the study participants did not seek help for treatment
illnesses, which then became chronic over time. This may be especially true in this study,
intrinsic factors that may affect self-control behavior and help-seeking ability, that
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Relationship among the Main Study Variables
Research Question 3. What are the relationships between perceived stress and sexuality
(Q5), spirituality and sexuality (Q6), resourcefulness and sexuality (Q7), perceived stress
and spirituality (Q8), spirituality and resourcefulness (Q9), and perceived stress and
In the study reported here, perceived global stress was negatively associated with
relationship), sexual self-concept (male and female), and male sexual function. These
findings from the present study are consistent with those of Kreitler and colleagues (2007)
who reported a significant main effect of perceived stress on quality of life, which was
self-image, sense of control, sense of coping, and meaningfulness in cancer patients with
mixed diagnoses (Kreitler, Peleg, & Ehrenfield, 2007). Their sample age (ranging 18 to
78 years) is similar to the sample in the current study, however, only about 30% and 12%
One of the indicators of perceived stress in the present study, cognitive appraisal
The results of the present study are partially consistent with the other studies, which have
reported that greater harm/loss appraisal was related to or explained lower body pain and
role limitations (Ahmad, 2000), lower self-assessed health and increased depressive
cognitive appraisal and social constraints (Herzer et al. 2006). Herzer and colleagues
227
(2006) indicated that the cancer patients’ threat appraisal predicted their perception of
social constraints (i.e., perceived inadequacy of social support from spouse resulting in
Cognitive appraisal of stress in the current study did not specifically measure
either harm/loss or threat appraisal; it also measured challenge appraisal. If the study
reported here involved measures of harm/loss, threat, and challenge appraisal individually,
the sample size would be insufficient to detect significant results. Increasing the sample
size should be considered in designing future studies to examine the three types of
The present findings also support Neuman’s systems model (1995), which states
that an open client system actively interacts with environmental stressors, so that while
the person is invaded by particular stressors (i.e., cancer and its treatment), the stability
factors (defense lines), such as coping abilities, problem-solving abilities defend against
the stressors to retain the system’s stability, and a reaction to stressors takes place (i.e.,
The findings from this study showed that spirituality was positively and
relationship), and sexual self-concept (males and females) (Q6), which indicated that
spirituality and sexuality are closely related (Helminiak, 1998). No other studies were
found that specifically examined the relationship between spirituality and sexuality in
persons with rectal cancer. Anderson and Cole (1978) found that sexual activity enhanced
handicapped people’s self-esteem, which fostered their spiritual growth and development.
228
However, because the two samples are very different and the measures were dissimilar,
colleagues (2003) reported that 83% of cancer patients who had a religious faith in
general were less reliant on health professionals, had less need for information, and had
less need for help (possibly reflecting less social resourcefulness) with their sexuality
than those who said they had no religious faith (Mclllmurray et al. 2003). This study
definition for spirituality in the present study reflected meaning in life rather than
religious faith.
In another study, Kim and Seidlitz (2002) reported that the spirituality was not
associated with stress in college students. But spirituality moderated / buffered the effect
of stress on negative affect and physical adjustment and was directly related to
adjustment and negative affect (Kim & Seidlitz, 2002). Although the findings may not
directly support the present study, several studies were found that describe spirituality
viewed as coping mechanism (Feher & Maly, 1999; Lamdan et al. 1997).
The findings reported here indicated that resourcefulness was positively and
relationship), and sexual self-concept (males and females) (Q7). No studies were found
rectal cancer patients. However, the results from this study may be consistent with a
study conducted by Pedro (2001) that showed an inverse correlation between learned
229
resourcefulness and health-related quality of life (HRQL) in long-term cancer survivors
(Pedro, 2001) and a study by Lai (2005) that persons with greater positive beliefs, which
included a positive view of oneself, has greater resourcefulness and better adaptive
functioning. However, the studies by Pedro (2001) and Lai (2005) only measured
partially consistent with Zauszniewski’s (2007) study, which showed that teaching
life.
in that resourcefulness is viewed as intervening factor for coping with stressful situation
(i.e., cancer and treatment) between process regulators (i.e., primary and secondary
The findings of the present study indicated that perceived stress, conceptualized
as cognitive appraisal and global stress, was negatively associated with spirituality (Q8).
The findings in the present study were opposite to other studies done on spirituality and
health perception and health impairment in the older adults with rheumatoid arthritis
(Potter & Zauszniewski, 2000). Spirituality was found to have a significant impact on the
health perception of the older adults with rheumatoid arthritis (Potter & Zauszniewski,
2000). However, in the study reported here, spirituality was not conceptualized as both
religiosity and existential well-being (sense of life purpose and satisfaction) as it was in
230
Spirituality can be viewed as an emotion-focused coping strategy. The findings
from the present study support the interrelationships of the person’s spirituality, stressors
(cancer and cancer treatment), and reactions to stressors (i.e., indicators of sexuality) in
the Neuman Systems Model (1995), but not in the negative direction, as found in this
developed in Hong Kong (Chinese), but this study was the first time it was used in the
Taiwanese population. Even though the pilot test showed there was no problem in
understanding the items, the items are scored on a 10-point scale with response ranks
from 0 (not at all) to 10 (very much),which makes it possible for patient’s to tend to use
extreme scores or scores all in the middle of the scale for all items. Such response biases
can produce scores that may distort the data. Another explanation involves cultural
differences in the interpretation of items on the scale; the scale was developed in Hong
Kong and may not reflect the meaning in life for Taiwanese people.
and other factors, such as time of stressor occurrence (e.g., time since their diagnosis/
operation, past and present condition of the patient, nature and intensity of the stressor)
may affect the person’s coping, and therefore, influence their perceptions. Future research
could consider examination of the relationship between perceived stress and spirituality
The results from this study showed that perceived global stress was negatively
and significantly associated with resourcefulness (Q9). Rong’s (2005) study showed that
231
there was an association found between learned resourcefulness and perceived stress,
which was similar to the findings from the study reported here. However, Rong’s study
only focused on learned resourcefulness, whereas the current study focused on both
sample recruited in the present study was also Taiwanese, however the ages of
participants in the current study had a wider distribution. Rong (2005) also found learned
However, the study reported here was the first attempt to examine the relationships
among these variables in persons with rectal cancer. Thus, future research might test the
stress and sexuality. In addition, the findings reported here indicated that cognitive
appraisal of stress was not associated with resourcefulness (Q9). These findings are
partially consistent with Neuman’s systems model (1995), in which an open client system
actively interacts with his/her environmental stressors (i.e., intra- inter-, or extrapersonal
and social resourcefulness). Thus, the relationship between global stress and
resourcefulness theory, but the lack of association between cognitive appraisal and
resourcefulness is not.
232
The findings of the present study also reflect a Chinese idiom, which suggests that
“Relying upon oneself is better than relying upon others.” This may explicitly indicate
the characteristics of Taiwanese persons who tend to be self-reliant, which may have
been reflected in their low to moderate scores on the social resourcefulness items of the
Resourcefulness Scale.
Vey little empirical evidence was found to support the findings of the present
study in regard to the positive association between spirituality and resourcefulness (Q10).
Potter and Zauszniewski (2000) reported that spirituality and resourcefulness were
the Potter and Zauszniewski (2000) study was measured only as personal and not social
that study was not the same as in the present study, which also captured the social (help-
seeking) dimension of resourcefulness. In addition, the two studies differed in the way
that spirituality was conceptualized. In the Potter and Zauszniewski (2000) study, it was
conceptualized as religiosity, which was not true for the study reported here. Finally, the
samples in the two studies differed. Whereas the Potter and Zauszniewski (2000) study
included persons with rheumatoid arthritis, this study focused on persons with colorectal
cancer. Since spirituality of often considered a dimension of quality of life, the study
theory, which suggests a positive association between resourcefulness and quality of life.
Additional Analyses
233
Major study variables. The findings from the current study showed that cognitive
appraisal of stress was positively associated with perceived global stress. Similarly,
Golden-Kreutz and colleagues’ (2005) study showed that cancer-related traumatic stress
symptoms were significantly associated with perceived global stress (r= .62, p< .001) in
breast cancer patients. This association reflects the positive association between intrinsic
factors (i.e. perceived global stress) and process regulators (i.e. cognitive appraisal)
In addition, the communication that takes place between partners was positively
related with the sexual self-concept of both the men and women who participated in the
study, while their satisfaction with their sexual relationship was positively associated
with their sexual self-concepts. This showed that sexual satisfaction was positively
1999). The finding from the present study showed that sexual satisfaction (i.e.,
communication and sexual relationship) was positively associated with the sexual self-
concept, which is consistent with findings from a study by Menard and Offman (2009)
that found strong correlations among sexual self-esteem, sexual assertiveness, and sexual
satisfaction (Menard & Offman, 2009). The findings from the present study are partially
consistent with other research in which the body image, sexual self-esteem, sexual
satisfaction and life satisfaction of women with physical disabilities were found to be
significantly lower than those in women without disabilities (Victor, Ilana, & Daniela,
234
2009). In addition, Victor and colleagues (2009) found that sexual satisfaction was a
major factor in explaining the variance in life satisfaction in both groups of women
(disabled and non-disabled), and the relationships between sexual satisfaction and life
The findings reported here are partially consistent with the study conducted by
Holmes (2003), which reported that women who received transplants had poorer sexual
health, poorer body image, loss of sexual interest, decreased sexual satisfaction and more
ongoing sexual problems than those in a group of healthy women (Holmes, 2003). The
findings of the present study are also consistent with Beckham and Godding’s (1990)
study, which found that a patient’s perceptions of sexual satisfaction may depend on
factors other than frequency of intercourse and the definitions of satisfaction may differ
between and within individuals over time (Beckham & Godding, 1990). Although the
findings from these two studies involved women who were not rectal cancer patients, the
findings were similar to the present study in terms of various indicators of sexuality. The
similarity of the findings across studies may be related to the seriousness or chronicity of
the illness. Therefore, a longitudinal study may be helpful for exploring/ determining
focusing on the exploration of lived experiences on their sexual problems including views
Sexual self-concept, including body image and one’s role performance, may change over
235
time. Therefore, prospective longitudinal studies to examine the effects of role function
Illness can induce a threat to one’s self-concept (such as loss of control and
autonomy, one’s self-image changes), threat to one’s emotional equilibrium, and threat to
permanent physical changes (Cohen & Lazarus, 1979). Anderson and Cole (1978)
indicated that frank discussion of sexuality was important for the self-esteem and
between communication with their partners and sexual self-concept in the study reported
here. Kralik and colleagues (2001) study showed that changes in body image,
communicating sexuality, and meeting the needs of others were three concerns of women
who live with chronic illness. The findings from this study are partially consistent with
the study conducted by Weber (2001), which reported that most dyadic logs for the
longer term survivors of prostate cancer (support partners) revealed that the most frequent
topics of discussions were about incontinence and erectile dysfunction. This reflects the
relationship. However, these two samples can not be comparable since the participants in
was that of an employed female participant in the present study who was accompanied by
her husband to the data collection interview. She honestly revealed that in order to meet
236
her husband’s needs, she has been using the lubricant during sexual activities for a while.
“It works well.” She added. However, before she was leaving the room, she turned to the
researcher and spoke softly, “Please do not let my husband know the substance, I don’t
want him feel bad.” She gave a kindly reminder. Obviously, there was no communication
between the couple regarding this sexual issue from this woman’s confession. It is not
difficult to imagine that she must be experiencing considerable stress in using the
The results of the study reported here showed there was a positive correlation
relationship was associated with a more positive sexual self-concept. These findings
were partially consistent with a study of survivors of mixed cancers conducted by Schag
and colleagues (1994), which found that patients with colon and prostate cancer had
fewer problems with communication with their partner than did those with lung cancer
(Schag, Ganz, Wing, Sim, & Lee, 1994). Badr and Taylor’s (2006) found that persons
with lung cancer talked with their partners about their relationships and reported fewer
constraints and better communication about cancer. These findings indicated the
importance of communication within the couple’s relationship (Badr & Taylor, 2006). In
addition, in a qualitative study of palliative cancer patients that included colon cancer
patients who underwent cancer treatment (i.e., surgery and chemotherapy / and radiation),
the major themes included expression of sexuality, discussing sexuality, and quality of
life (Lemieux, 2004). Takahashi and Kai (2005) identified long-term outcomes of the
relationship with breast cancer women’s partners as an emerging theme. They also
reported that one of the factors influencing the women after treatment for breast cancer
237
was the importance of the sexual relationship with her partner (Takahashi & Kai, 2005).
These themes from previous studies reflected the association of the communication
The findings from the present study were not consistent with the findings from a
study conducted by Molassiotis and colleagues (2000) that found that the sexual
relationship among women with gynecological cancer was moderately influenced by low
sexual function. Sexuality, defined as the frequency of sexual activity, followed by sexual
pleasure and satisfaction with or interest in sex, was most impaired (Molassiotis et al.,
2000). However, the age range in the present study was greater than the age range in the
study by Malassiotis and colleagues (2000), which was from 29 to 75. In addition, the
while the study reported here focused on both men and women with rectal cancer.
Therefore, the two study samples differed and may not be comparable.
is a male participant who indicated that a discouraging word from one’s spouse is enough
to destroy the other’s self-esteem, and, in turn, it destroys the sexual relationships
between the partners. In fact, in Chinese culture, using a negative word such as “useless”
function.
communication is one man who came alone to the data collection interview. He was able
communication between partners. The researcher noticed that tears were running in his
238
eyes, and immediately passed tissue papers to him and kindly reminded that he may
them. The man refused the request and responded to the researcher “It has nothing to do
with the questionnaire items, it is between me and my wife that I need to deal with.”
Then he was looking down the table. The researcher offered a cup of water to the man
and suggested that maybe he needs a break. The men nodded his head. About 10 minutes
later, the man turned to the researcher and said that he is able to continue the
questionnaire items. Future research should include respondents’ feelings and thoughts
However, unexpectedly, the results from this study showed that sexual function in
males and females was not significantly correlated with either sexual self-concept in
males and females or sexual satisfaction (i.e., communication and sexual relationship).
These findings contradict the findings published by Bultler and colleagues (1998), who
reported that sexual satisfaction and intimate feelings were related to changes in female
sexual function with their partners (Bultler et al. 1998) and the findings published by
Anderson and colleagues (1997, 1999), who indicated that gynecological cancer patients’
sexual self-schema accounted for 34% of the variance in predicting current sexual
responsiveness and behavior after controlling the type of cancer and its treatment
(Anderson et al. 1997, 1999). Moreover, the findings from the present study are
inconsistent with those of Butler and colleagues (1998), who reported that sexual
gynecological cancer and findings from Yurek’s (1997) study that found that women with
breast cancer who had a negative sexual self-schema reported greater distress in sexually-
239
relevant situations than women without breast cancer. In addition, the findings from the
study by Yurek (1997) indicated that sexual self-schema contributed 55% in the
frequency of sexually intimate behaviors following breast cancer surgery. These three
studies focused on gynecological or breast cancer patients rather than rectal cancer
patients of both genders, as the study reported here has done. Moreover, sexual
satisfaction (communication and sexual relationship) in the present study did not reflect
sexual self-concept and sexual satisfaction can be attributed to several reasons: First,
although sexual problems may be substantial, for the sake of saving face, the study
participants were very likely not to honestly respond to the questionnaire items during the
people who live in the traditional conservative Chinese society, for whom it is possible to
choose not to face the problem honestly. Thirdly, they assume that sexuality is a personal
and private matter between their partners, so it should not be revealed to others.
These explanations can be supported by the information from the descriptive data
provided here. For example, approximately 21% (n =34) of the subjects who were
recruited did not meet the inclusion criteria due to sexually inactivity before surgery.
Eighty-eight percent of subjects including men and women responded “No sexual life”
“Nothing much to say about it.” It is likely that this topic made them uncomfortable to
speak of or to participate the study. ‘No sexual life’ does not necessarily reflect real
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problems for them. The descriptive data also demonstrated an increased percentage (12%
vs. 27%) for rating one’s sexual life before and after treatment as “not importance at all.”
About 26% reported their sexual relationship with partners at present as “not important at
all” which is consistent with their attitudes toward their sexual life after treatment. Over
27% of the men had severe erectile dysfunction and 31% of the women reported no
sexual activity in the last 4 weeks while they were interviewed. Over 37% of the women
participants indicated a low level of sexual satisfaction. Over 20% of the participants had
low or very low positive feelings about the quality and quantity of their communication
and about 9 % were somewhat dissatisfied with their expression of affection and had a
In fact, during the data collection interviews, about 30% of participants did not
hesitate to participate in this study. One male participant even indicated “This is an
important problem, however, people never discuss it with others even among cancer
patients.” A highly educated young woman who earned a master’s degree supported the
study and recommended that something like individual’s feelings, thoughts and
Demographic and cancer-related variables. The findings from the present study
showed that age was negatively associated with the type of treatment received; younger
patients received more types of treatment while older patients received less types of
treatment. Similarly, Cree and colleagues’ (2009) study of rectal cancer patients showed
that the decrease of adjuvant treatment associated with increasing age was marked
(p< .001), ranging from about 70 % in those aged < 65 years to about 30% in those aged
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> / = 75 years (Cree et al. 2009). However, although cancer treatment brings about
physiological and psychosocial changes in all age groups, elderly persons often
few of the more common problems faced by elders include: preexisting disease, sensory
changes, altered mobility, lack of social support, and alterations in cognitive function
(Robbins, 1989). Since receiving more types of treatment can place an increased burden
The results also revealed that age was positively associated with time since
operation; younger patients have shorter length of time since their operation, while older
patients had a longer time since their operation. Thus, the younger patients sampled in
this study had their surgery more recently than the elderly study participants. Surgery as
a form of cancer treatment is more commonly done in younger adults who may not be at
the same risk for complications that more elderly persons may experience because of
The findings also showed that the type of treatment received was positively
associated with the stage of the cancer that was diagnosed in the rectal cancer patients.
This finding was expected since cancer treatment is commonly dependent on the stage of
the disease process. The results from this study were consistent with those of Cree and
colleagues’ (2009), who reported that patients with stage III rectal cancer were more
likely to receive adjuvant treatment than stage II patients (Cree et al. 2009). In addition, a
significant gender difference was found in the length of time since operation with the
men reporting a longer time since their operation than the women patients. This may
242
suggest that the men were diagnosed with rectal cancer at an earlier age and therefore had
between persons with colostomy and without colostomy on perceived global stress, and
cognitive appraisal of stress. Also, there were significant differences on sexual function
in both genders.
Very few recent studies in regard to colostomy and perceived stress were found.
The results of the present study are consistent with the study conducted by Beckham and
Godding (1990), which provided empirical evidence that body image affects the sexual
functioning of cancer patients and by Monga (2002) who found that patients with a
colostomy face changes in body image in relation to their colostomy, which may affect
sexual enjoyment (Monga, 2002). The finding from the present study is partially
consistent with Ofman and Auchincloss’s (1992) study that showed that many persons
with a colostomy have difficulty adjusting to the odor and dealing with cleanliness, and
fear stool leakage, which may reflect the effect of colostomy on body image, and in turn,
The results of the study reported here focused on perceived stress, in terms of
cognitive appraisal and global stress, and sexual functioning of rectal cancer patients,
including persons with a colostomy and persons without a colostomy. Future research
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Limitations
The interpretation of the findings from the study is limited by sampling and
the use of a convenience sample. However, because this study was descriptive and
exploratory and the first to examine relationships among perceived stress, resourcefulness,
spirituality, and sexuality in Taiwanese rectal cancer patients who are difficult to identify
and recruit, study participants were enrolled in the study as they presented at the medical
centers that served as research sites. Recruiting the study participants in this way
provided a sample of rectal cancer patients who are currently being treated or monitored.
in this study. Thus, it was not possible to observe changes in perceived stress,
among the study variables. However, the purpose of this study was to examine
relationships among demographic and cancer-related variables and the major study
Third, the sample recruited from the medical center was mostly males (73%) and
the ratio of males to females was almost 3:1. This can be explained by the fact that the
medical center that served as a recruitment site was a veteran hospital in the past.
However, considering the challenges encountered in recruiting the study participants, the
length of time since cancer diagnosis ranged from one to ten years. Less than 7% (n=8) of
the study participants were diagnosed with cancer over nine years ago. Thus, the study
participants who had a longer time since being diagnosed with cancer may have adapted
244
Fourth, the data were collected during face-to-face interviews with the study
participants during which the study questionnaires were completed. Although the use of
possible that the data collector may have introduced a bias. It is possible that the data
training of the data collector, who was taught how to elicit item responses in a neutral and
consistent manner.
Finally, it is important to note that all the findings from this descriptive study
must be interpreted with caution because of the total number of statistical tests that were
needed (n = 139) to address the research questions and the possibility that some of the
findings may been significant by chance. The use of the Bonferroni correction procedure,
which would require applying a more stringent alpha level of significance (i.e. p < .0003)
would suggest that many of the findings may not be significant. However, the findings
obtained at p =.05 through p =.0003 are worthy of further examination in future research.
people’s sexual expressions and behaviors. Today, in sexual liberal societies, despite the
sexual beliefs still have an impact on contemporary Taiwanese societies. Heritage derived
Taiwanese persons.
245
In addition to the standard treatment regimens for cancer patients, alternative
forms of therapy, such as specific food therapy (e.g., high protein food, organic food) or
Chinese medicine, are also used for cancer patients. These alternative treatments are
believed to help Taiwanese persons with cancer to recuperate from their illness. For
sexual problems that may be encountered, certain specific Chinese herbs are
sexuality. Lieh-Mak and Ng (1981) described how men seek help for their sexual
problems (Lieh-Mak & Ng, 1981). However, among Taiwanese women, findings from
the present study indicated that the rate of using lubricant for women during their sexual
activity was higher than the rate of using Viagra for men with sexual problems (13% vs.
8%). Thus, the present study showed that women sought help more frequently for sexual
problems than did the men who participated in the study. However, besides the methods
mentioned in this study (i.e. lubricants for women and Viagra for men), other Chinese
traditional methods include the use of herbs, nutritious foods, and sex aids (Tang et al.
1996) were not found. The use of these methods should be investigated in future research
selection and judgment of instruments was used in designing the present study in order to
obtain reliable and valid data as well as to ensure cultural relevance. Among the eight
246
instruments used in this study (PSS, CAHS, RSS-10, BMSWBI-SP, SSSS-F/SSSS-M,
had been translated previously into Chinese (target language). Of these three measures,
the PSS-10 and IIEF were psychometrically tested in the Taiwanese population, however,
the BMSWBI-Sp was tested in Hong Kong, where the Chinese language is also spoken.
equivalence of the measure to ensure its cultural appropriateness (Brislin, 1970; Cause,
Coronado, & Watson, 1998). The translation method described by Brislin (1970) was
adopted for this study. The iterative process of translation-back translation and pilot
testing in the Taiwanese population were completed prior to the study (Werner &
Campbell, 1970). That is, item meanings for the Taiwanese version were similar to the
original English version and the items had cultural relevance for the Taiwanese culture.
As a result, the data collection interviews in the final study went fairly smoothly and
there was little difficulty in obtaining responses to the items from the study participants.
Very few of the questionnaire items needed clarification during the pilot testing.
For example, study participants asked for clarification on the resourcefulness scale item
that asked about borrowing money, because this is not acceptable in the Taiwanese
culture. During the interview, many of the patients responded to this item by saying that
it won’t never happen in their lives, because they spend money based on how much they
earn.
Most of the eight translated instruments had acceptable estimates of reliability and
validity. However, the scales measuring sexual self-schema for males and females had
lower internal consistency estimates -- .69 and .70, respectively. With regard to these
247
measures, 27 out of 45 terms in the male version and 26 out of 50 terms in the female
function), 6 of the 15 items reflect erectile function, while 19 items of scale measuring
sexual function in women (female sexual function) are evenly distributed across several
domains. Moreover, male and female versions of these scales are scored differently. For
example, items constituting the female version have assigned weights that are applied in
computing the total score; the items are not weighted in the male version of the sexual
function scale.
Implications
The findings from this study of perceived stress, resourcefulness, spirituality and
sexuality in Taiwanese persons with rectal cancer have implications for theory
Theory Development
The findings from this study support the three theories on which it was based. The
results from this study have important implications for holistic nursing theory
Taiwanese persons through the exploration of relationships among the major study
The findings support Neuman’s system model in the light of the four meta-
paradigm concepts of nursing. The findings of this study contribute to the expanding of
the nursing knowledge through filling the gaps that existed in the empirical literature. The
248
results specifically support the two major concepts, stress and the reaction to stressors,
which exist within the client (person) system in Neuman Systems Model.
other factors (e.g., time since their diagnosis/ operation, nature and intensity of the
stressor) may affect the person’s coping (flexible line of defense and resistance), and
therefore, it will influence the person’s stability/wellness. Neuman indicated that stressors
can have a positive or negative outcome, such as low sexual function or high sexual
satisfaction in this study. The findings from this study support the goal of nursing to
facilitate optimum wellness through primary (when stressor are identified), secondary
maintaining). The significant findings from this study support the interrelationships
The results also support Lazarus and Folkman’s (1984) stress and coping theory
in that when individuals encounter stressful situations, such as cancer and its treatment,
one’s cognitive processes determine both the perception of stress and one’s emotional
reaction through primary and seconday appraisal. The findings demonstrate that
perceived stress has its influences/associations on other major study variables (i.e.,
behaviors (e.g., social resourcefulness) were measured in this study and found to be
249
associated with intrinsic factors (i.e., perceived stress, number of comorbid conditions,
education), and quality of life (i.e. sexual satisfaction). Although the findings showed a
help from others in certain situations, this finding remaining consistent with
indicating that cognitive appraisal may not function as a process regulator in mediating or
Thus, this study extended the body of knowledge of the phenomena explicated
within the Neuman Systems Model, Lazarus’s Stress and Coping theory, and the mid-
Clinical Practice
determining whether or not cancer treatments were perceived as stressful. From the
findings, perceived stress (i.e., cancer treatment) was found to be associated with many
actively interact with environmental stressors (i.e., intra-, inter-, extrapersonal stressor)
that influence their reaction to stressors. Stressful events could eventually become
overwhelming. Thus, assessing stress and observing its impact on indicators of sexuality,
250
The results of the study showed that the patient’s perceptions of sexual
satisfaction may differ between and within individuals over time, it is important for
health care professionals to find out what the patient wants in terms of satisfaction. At the
same time, identifying variations due to the myths related to sexuality is needed, such as
1) participants fear that disease can be transmitted to the partner; 2) intercourse is the
only way to have sex; 3) sex without orgasm is not good sex; 4) intimacy is necessary
orgasm.
indirectly affect one’s sexual self-concept and sexual satisfaction for both men and
patterns must be rooted in an understanding of the relationship between the client and his
or her significant others. Communication barriers can create additional problem in couple
patterns between genders and enhancing the couple growth starts with/through
deals with sexually related issues for rectal cancer patients, nurses should listen and
associated and are also correlated with same outcome variables, that is, sexual
251
satisfaction (i.e., communication and sexual relationship) and sexual self-concept.
According to the findings, participants tend to rely on self-help skills (i.e., personal
resourcefulness) to deal with problems. Teaching patients include why, when and where
they may learn to rely on family/ friends, exchange ideas with others, and seek
indicators of sexuality (i.e., reaction of stress) were shown in the study’s findings. Thus,
sexuality (sexual satisfaction and sexual self-concept) should be tested to determine the
existence of moderating or mediating effect, which in turn, may lead to the development
of interventions that can enable rectal cancer patients to effectively use spiritual
incorporate significant findings from the study presented here, including those derived
assessment tool for screening persons at risk for high perceived stress, low spirituality,
low resourcefulness and low scores of indicators of sexuality satisfaction (i.e. low
252
communication and low sexual relationship), low sexual self-concept, and low sexual
function.
after operation for rectal cancer patients is essential for advanced nursing practice. In
addition to demographic data (i.e, age, gender, education, number of children, number of
comorbid conditions) and cancer-related data (i.e., time since operation/diagnosis, stage
might be included in an assessment as follows: 1) How important would you rate your
sexual function? 2) How would you rate yourself as sexual being? 3) How would you rate
your sexual relationship? 4) Have you taken/used medicine or substance to improve your
sexual function? 5) Have you taken Chinese medicine/hurb to improve sexual function? 6)
Have you talked about your problems with your partner? 7) Do you feel an inner need to
talk about your feelings? 8) When you are having problems, is talking about them
important to make things right again? 9) Do you like to keep problem with you?
A clinical pathway for screening the high risk rectal cancer patients and partners
for subjects at risk for experiencing sexual dysfunction, such as those with rectal cancer.
In addition, for the cancer patients to meet the goal of sexual health indicated by WHO
(1975), strategies should be established to help them successfully cope with anxiety and
Health Policy
According to the Taiwan government report (Taiwan Report, 2005) and supported
by the findings from this study, the prevalence of rectal cancer is increasing in younger
253
persons. Moreover, the survival rate is improving over time. As a result, the number of
younger aged survivors is expected to increase. For these individuals, sexual issues
following cancer treatments will become more prominent and significant, particularly for
those in the reproductive years of life. Future health policy should address the
establishment of a sperm or ovary bank for persons who are at risk of infertility after
and couples therapy should be provided as needed under the national medical insurance
system.
Nursing Education
for all health care professionals. Before dealing with sexual issues in their patients, health
sexuality for each individual. Health care professionals need to assess their own beliefs,
attitudes, and values toward sexuality through self-reflection and self-awareness. Thus, a
programs; these might include seminars on sexual issue as well as in-service program for
nurses in practice. Helminiak (1989) indicated that one who is uncomfortable with their
own sexuality may be uncomfortable with their own body, which may also influence their
self-esteem. However, one who is able to accept his or her own sexuality is better able to
accept the meaning and significance of their patient’s sexual problems. Therefore, he or
she will be better able to deal with their cancer patient’s sexual problems in a positive and
supportive manner.
254
The findings from this study will be disseminated through continuing education
programs to nurses working at the research sites where study participants were recruited.
The program will also address clarification of misconceptions concerning sexuality in the
Chinese culture and questions about preoperative concerns of cancer patients and how the
nurses might answer them. Such programs should also be expanded to include all health
Recommendations
Future Research
The present study was the first step to explore sexuality holistically. The findings
population. This study provided evidence for the reliability of translated measurements.
Future studies may further focus on experimental design, secondary analyses, model
testing, mediating or moderating effects testing, and qualitative research including both
Several recommendations for research can be made given the findings of this
First of all, for the future research and knowledge development, an adequate
sample size of women study participants is needed for making comparisons with men on
255
other demographic characteristics and cancer-related variables. To achieve this,
recruitment from additional medical centers that serve more women with rectal cancer in
Taiwan would be essential. Since men and women may differ on cancer-related and
that may suggest different interventions to promote sexual health for men and women.
integrated in and perhaps dependent upon one’s relationship with a sexual partner,
research that includes the rectal cancer patient and his or her partner would be
informative. Inclusion of the partner would provide another perspective and additional
information about the dyadic communication and relationship. The results from such a
study may inform future intervention research for persons with rectal cancer and their
partners.
Third, because the findings suggested that spirituality and resourcefulness were
associated with perceived stress and certain indicators of sexuality and that perceived
stress was related to indicators of sexuality, it is possible that the effects of perceived
resourcefulness. Therefore, future research should test for these effects. Such studies
variables, as identified within this study. However, a study of this kind would require a
sufficient sample of persons with rectal cancer would need to be obtained so that
sufficient power to detect significant effects would be attained. The findings from a
study of mediating and moderating effects would inform the future development and
256
testing of interventions that promote spirituality or resourcefulness in order to enhance
Fourth, the study presented here does not provide information about changes on
Fifth, a qualitative study of the sexuality among Taiwanese rectal cancer patients
and their partners might be conducted based on phenomenology theory to assess the
meaning of sexuality and the lived experience of having cancer and treatment relevant to
their culture.
Sixth, secondary analysis of the scoring of the measure used for male sexual
functioning to examine differences between the use of weighted and unweighted scores is
needed for evaluation of the usefulness of this measure for future research.
may be examined in relation to the other major study variables, demographics, and
resourcefulness are important for Taiwanese people facing stressful situations, such as a
Lastly, future research should examine the interrelationships among the major
study variables (perceived stress, spirituality, resourcefulness) and interpersonal (such as,
identified within the context of Neuman’s Model, and their effects on sexuality.
257
Plan for Dissemination
practice and nursing research, the results need to be disseminated not only to health care
professionals including researchers, faculty, student nurses, but also to people in clinical
practice, such as nurses, physicians, and patients. Dissemination of the findings can be
258
APPENDIX A
Data Collector Manual
5. Interpersonal relations
- To behave as a professional, not to communicate any judgments on
answers that respondents give
259
APPENDIX B
Data Collection Instrument
Study Title: Perceived stress, spirituality, resourcefulness and sexuality in patients with
rectal cancer undergoing cancer treatments
Investigator: Tsay-Yi Au, R.N., PhD candidate at Case Western Reserve University
SAMPLE SELECTION
260
APPENDIX C
DEMOGRAPHIC INFORMATION
Please take time to fill out the box of the following items to the best of your ability.
Thank you very much for providing related information.
261
8.2. How anxious are you when you think of sexual issue?
0 □ Not at all 1 □ A little bit
2 □ Somewhat 3 □ Quit a bit
4 □ Very much
8.6. How important would you rate your sexual aspect now?
0 □ Not at all 1 □ A little bit
2 □ Somewhat 3 □ Quit a bit
4 □ Very much
8.7. How important is your sexual relationship with your partner right now?
0 □ Not at all 1 □ A little bit
2 □ Somewhat 3 □ Quit a bit
4 □ Very much
262
12. Colostomy received? 0 □ No 1 □ Yes
263
APPENDIX D
264
APPENDIX E
265
266
267
268
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