Self-Efficacy Training Improved
The Quality of Life
for
Cancer Patients Undergoing Chemotherapy
Abstract
The
survival of cancer patients is often short despite receiving therapy, but it really depends on various things including those that
play an important role
is
the
ability
of
patients to improve
their
life status in dealing with illnesses and therapy through increased self-efficacy because self-efficacy of cancer patients often experience reduction due to cancer and the therapy it undergoes. The
pre–test and
the first
post -test and also the
second
post-test
research design in the form of self-efficacy training of
cancer patients
undergoing
chemotherapy
used
a quasi-experimental
design without
a
control group. Data analysis used dependent t test and repeat ANOVA test. There were significant effects and differences in
self-efficacy training on the quality of life of
cancer
patients
undergoing chemotherapy
with
the p value dependent test was 0,000 and the repeat ANOVA test was p value 0,000. The uses of structured self-efficacy training be one of the considerations of nursing interventions
to improve the quality of life of cancer patients undergoing chemotherapy.
Keywords:
self-efficacy training, quality of life
1. Introduction Cancer is a problem that is of concern to
the world
because
it is the second leading cause of
death.
Cancer
is estimated to be responsible for 9,6 million deaths in the world in 2018, where cancer causes 1 in 6 deaths worldwide. (WHO, 2018). The percentage of patient survival after being diagnosed with cancer is usually within 5 years. The proportion of patients recovering from cancer deaths also occurs after 5 years after the diagnosis is established. However, this depends on how the individual interprets the cause of cancer because each patient will experience sophistication in the detection and treatment of different, factors that cause a patient to survive from cancer such as treatment itself, comorbidities, behavioral differences, and biological differences and screening earlier than cancer is experienced (American Cancer Society,2017). Cancer therapy with chemotherapy used in some affected patients is the first alternative as a therapy to overcome the cancer that is experienced. Chemotherapy as a therapy in treating cancer has the goal of therapy to eradicate cancer cells, control the enlargement of the cancer so that it does not spread and to reduce the symptoms caused by cancer. Chemotherapy has the nature of working throughout the body, which differs in the way it works with radiation therapy or surgery (Junaidi, 2007). Patients who have just been diagnosed with cancer will ask about how long they will live, how they can be cured, hair loss. Cancer patients who, without being given training, must make medical decisions in a state of being experiencing fear, pressure and high vulnerability (Leigh&Stovall,2012). After the patient faces chemotherapy, he will ask about whether there is still a chance to be cured, if it cannot be cured, how long will it live, will it be better or worse, is there any benefit in taking chemotherapy treatment, can it live long with chemotherapy, is there anything other things that can be done (Harrington&Smith,2008). Patients will pay attention to the body’s symptoms that occur and must learn in dealing with unknown situations by asking about how many times I have to check myself, are there any symptoms that arise, is this normal, why do I feel fatigue or fear and faces hopes for a future that is not clear. In this condition,
the quality of life of cancer patients
is an important concern (Leigh&Stovall,2012).
Patients who have been diagnosed with cancer
will face unequal adaptations in dealing with chemotherapy and the side effects obtained when using chemotherapy. The side effects vary including physical side effects and psychological side effects.(Lavdaniti,2015). Eventually, patients who face chemotherapy will experience a decrease in quality of life.(Perwitasari,2009). Chemotherapy has a close relationship in shaping the quality of one’s life (Massoni et al,2015). Quality of life is a state of individual life which is confronted with several aspects which as a whole are in a prosperous condition. Quality of life has a meaning that is in line with the notion of health (Juczynki,2006). According to WHO, quality of life or health consists of welfare in the physical, psychological and social fields where it is not just the absence of disease or weakness.(WHO,2008). Self-efficacy in cancer patients following the therapy they undergo will experience varying levels of carrying out their duties in controlling the problems that occur (Foster et al, 2015). Self-efficacy is a belief that determines how a person thinks, motivates himself and how finally he decides to do a behavior to achieve the desired goal (Bandura (1997) in Snyder&Lopez,2002). From a study it was found that low self-efficacy often occurs in women, experiencing higher pain and depression, lack of quality of life scores, low socioeconomic status, lack of social support and have more negative perceptions about cancer (Foster et al,2015). Self-efficacy in dealing with cancer is an ability that is done to overcome the stress experienced by cancer patients who have good self-efficacy will be easier to deal with life lived and the lack of negative psychological impacts that occur and improve quality of life. (Chirico et al,2017). The positive or negative moods of individuals who will shape their efficacy in several studies are influenced by several neurotransmitters that exist in the brain’s limbic system. One of them is endorphins. The endorphin hormone is a neurotransmitter that will be released into the body when individuals are in a state of excitement with laughter, love, when listening to music or in a calm state such as during meditation. When endorphins are released into the body a lot, then the individual will have a high positive mood with him self. (Dfarhud et al,2014). The low
self-efficacy of cancer patients undergoing
chemotherapy causes a decrease in the quality of life. For this reason, efforts are needed to improve self-efficacy through training in the form of group intervention support. Supporting short-term group interventions in cancer patients such as providing information, such as providing information, emotional and social support, stress management, relaxation techniques will improve psychological well-being, reduce anxiety and depression, increase self-confidence in overcoming problems and quality of life. (Weis, 2003). One’s self-efficacy is developed through four main sources, namely the esperience of success, the experience of others, social persuasion and physical and emotional conditions. Experience of success is gained through direct experience and achievements in the past. While the experience of others is gained through the use of social models by means of observation. Social persuasion is obtained through suggestion or acceptance of suggestions to be able to overcome problems, as well as physiological and emotional states obtained through situations created to influence physiologically and emotionally (Bandura in Snyder & Lopez, 2002). 1.1 Aim
The aim of
the
study was to
analyze
the effect of self-efficacy
training
on the quality of life of
cancer
patients
undergoing chemotherapy.
In this study,
only
the experimental group received self-
efficacy training. Before
intervention,
a pre-test was done then the next day followed by self-efficacy training for 2 days plus a
post-test, and
at
4 weeks later
a
post test
was conducted again. 1.2 Research Question and Hypotheses The problem can be formulated :”How was the effect of self-efficacy training
on the quality of life of cancer patients
undergoing chemotherapy”.
The
hypothesis
of
this
study was
that there was an
effect of self-efficacy training on the quality of life of
cancer
patients
undergoing chemotherapy. 2. Research Method A quantitative study using
a quasi-experimental
design without
a control group
was
conducted
at
the
dr. Pirngadi General Hospital Medan, Indonesia from July to October 2019. The population were all cancer patients undergoing chemotherapy. Sample size was measured using the hypothesis test formula for the proportion of a single population of 48 respondents. The sampling technique was consecutive sampling with sample were as follows, adult patients with minimal cancer are undergoing second chemotherapy, ECOG Performance Status <4, have full awareness and did not experience disorientation in place, time and people, can communicate using good Indonesian, are willing to be respondents and follow the research procedures until the final stage. Respondents were divided into 10 groups, where 1 group consisted 4-5 respondents (8 groups of 5 respondents, 2 group of 4 respondents). On the second day to the third day, each group will experience self-efficacy training within 2 days assisted with a training module where day 1 was 2 hours long, and day 2 is 2,5 hours, 2 hours exercise and the first post test 0,5 hours. After 4 weeks, in the fifth week, respondents in each group received a second post-test with the same questionnaire The research variable was self-efficacy, namely the patient’s belief in thinking, in motivating himself and deciding the role, emotional function, cognitive function, and social function as well as the symptoms that occur were measured by the Cancer Behavior Inventory-B self-efficacy questionnaire with interval measuring scale 12 -108, Quality of life which was a condition of the individual’s life conditions which is confronted with several aspects of the individual’s personal life as a whole in a prosperous condition
measured by the FACT-G
Version-4
quality of life
questionnaire with interval measuring scale 0-108. Data anayzed using paired t test and repeated ANOVA test.
This study was approved by the ethics
commission
of the
Health Ministry
of
Health Polytechnic,Medan,number 261/KEPK POLTEKKES KEMENKES MEDAN/2019. 105 3.Results 106 Univariate Analysis 107 Characteristics of Respondents 108 109 Characteristics of respondents in this study include age, sex, marital status, income, occupation, education, cancer diagnosis, duration of cancer and ECOG can
be seen in table 1.
110
Table 1 Distribution of
Respondent
Characteristics
Variable Frequency Total (%) Age 20 - 34 3 6,3 % 35 - 44 10 20,8 % 45 - 59 30 62,5 % 60 - 74 4 8,3 % 75 - 90 1 2,1 % Total 48 100,0 %
Gender Male 14 29,2 % Female 34 70,8
% Total 48 100,0 % Marital Status Single 1 2,1 % Married 44 91,7 % Widower/widow 3 6,3 % Total 48 100,0 % Income ˃ Rp. 4.500.000 6 12,5 % ≥ Rp. 2.132.188 – 4.500.000 17 35,4 % < Rp. 2.132.188 25 52,1 % Total 48 100,0 % Type of Work Housewife 18 37,5 % Private Employees 2 4,2 % Civil Servants/State-Owned Enterprises 4 8,2 % Entrepreneur 3 6,3 % Retired 3 6,3 % Etc 18 37,5 % Total 48 100,0 % Education Elementary School Middle School 12 25,0 % 5 10,4 % 111 112 113 114 115 116 117 118 119 120 121 122 High School 25 College 6 52,1 % 12,5 % Total 48 100,0 % Cancer Diagnosis
Breast Cancer Lung Cancer Ovarian Cancer Uterine Cancer
Penile
Cancer
Rectal
Cancer
Testicular
Cancer
Colon
Cancer
Lymph Node
Cancer
Cervical Cancer 22 3 5 2 3 3 2 5 2 1 45,8 % 6,3 % 10,4 % 4,2 % 6,3 % 6,3 % 4,2 % 10,4 % 4,2 % 2,1 % Total 48 100,0 % Long Suffered From Cancer < 1 Year 26 ≥ 1 – < 5 Year 20 ≥ 5 – < 10 Year 2 54,2 % 41,7 % 4,2 % Total 48 100,0 % ECOG 1 16 2 27 3 5 33,3 % 56,3 % 10,4 % Total 48 100,0 % Self Efficacy The results of this study have described the minimum score, maximum, mean and standar deviation of self-efficacy, can be seen in table 2.
Table 2 Minimum
Score,
Maximum, Mean
and
Standard Deviation of
Self-Efficacy Type N Min Max Mean SD Pre
self-efficacy score Post
self-efficacy
Score
1
Post
self-efficacy
Score
2 48 33 48 40 48 43 96 54,75 100 64,73 103 73,60 13,73 12,98 12,36
Quality of Life The results of this study
have described
the
minimum score, maximum, mean and standard deviation of quality of life, can be seen in table 3. Table 3 Minimum Score, Maximum, Mean and Standar Deviation of Quality of Life Type N Min Max Mean SD Pre Quality of Life Score 48 29 93 59,62 14,53 Post Quality of Life Score 1 48 53 94 70,17 10,51 Post Quality of Life Score 2 48 56 98 76,52 11,26 123 124 125 126 127 128 129 130 131 132 133 134 Bivariate Analysis Bivariate analysis in
this study was
about
the effect of self-efficacy
training
on the quality of life of
cancer
patients
undergoing chemotherapy. To analyze the effect
before and after the training
was given,
a t
dependent
test
was performed with a
significance level
(α) =
0,05
if
the data
was
normally distributed,
or wilcoxon test with
significance level
(α) =
0,05
if
the data were not normally distributed.
From
the
results of the normality test with Shapiro-Wilk obtained
pre, post-1 and post-2
self efficacy
variables
were not normally distributed, while the
pre, post-1, post-2
quality of life
variables
were normally distributed. After the normality test was carried out, the correlation test was carried out and followed by a test of the effect before and after the self-efficacy training on
the quality of life of cancer patients undergoing chemotherapy
according to
the
results of the normality test. The result can be seen in table 4 and table 5. Table 4 Correlation of
Self Efficacy
With
Quality of Life In Cancer
Patients
Undergoing Chemotherapy
Correlation P R Correlation of pre self-efficacy with pre 0,000 0,491 quality of life Correlation of post-1 self-efficacy with 0,000 0,600 post-1 quality of life Correlation of post-2 self-efficacy with 0,000 0,624 post-2 quality of life 135 136 137 Table 5
The Effect of Self-Efficacy
Training
on The Quality of Life of
Cancer
Patients
Undergoing Chemotherapy Influence Mean Standard p Differences Deviation
The effect of self efficacy
before the
intervention
and after
the
9,98 0,69 0,000 intervention The effect of self-efficacy after the intervention and after 4 weeks 8,88 5,54 0,000 Influence of
quality of life before the intervention
and
after the
10,54 8,30 0,000 intervention Influence of
quality of life
after
the intervention and after
4 weeks 6,35 5,43 0,000 138 139 140 141 142 143 144 145 To carry out the comparative hypothesis of numerical variables of more than two groups, was there a difference between the three
measures of self-efficacy
and
quality of life
both before training, after training and 4 weeks after training, then Repeated Anova
test if the data
was
normally distributed and
Friedman
test
if
the
data was not normally distributed. The results ofvariables showed
that there were significant differences in self-efficacy
score before, after and 4 weeks after self efficacy training using the Friedman test with p 0,000,
there were significant differences in the quality of life
score before, after and 4 weeks after self-efficacy training using repeated anova test with p 0,000. 146 147 4. Discussion 148 149 150 151 152 153 The purpose
of this study was to
analyze
the effect of self-efficacy
training
on the quality of life of
cancer
patients
undergoing chemotherapy. In this study, self-efficacy training
in cancer patients undergoing chemotherapy
was designed as
an
effort
to improve quality of life. The
findings can be summarized in the statistical test data of this study showing that self-efficacy training in cancer patients undergoing chemotherapy can improve
quality of life.
From
the
results
of the study
showed
the
majority
of
cancer respondents undergoing chemotherapy aged 45-59 years, female, married, low income, housewive and other occupations or non-permanent jobs, having a high school education, the diagnosis of breast cancer, length of suffer < 1 year, and ECOG 2. The patients included in this study partially experienced a decrease in self-efficacy which displayed an efficacy score before self-efficacy training of (54,75±13,73). Several
studies have shown that self-efficacy in
cancer
patients
was low.(Lev,1999; Curtis et al,2014). After an attempt was made on the patient, self-efficacy increased (64,73±12,98). Four weeks after efforts were made to the patient, the patient’s self-efficacy increased by (73,60±12,36). Cancer patients will experience high fear, pressure and vulnerability without training or information (Leigh&Stovall,2012). Without efforts to increase the self-efficacy given to cancer patients, the patient’s self-efficacy will decrease. (Lev et al,1999).
The results of the
study
showed that there was a
relationship
between self-efficacy and
the quality of life of cancer patients
who underwent
chemotherapy
before self-efficacy training with p 0,000 having moderate relationship strength (r=0,491), after training with p 0,000 having strong relationship strength (r=0,600), after 4 weeks training with p 0,000 has the strength of strong relationship (r=0,624). Several studies have suggested that there was a strong
relationship between self-efficacy and quality of life in cancer patients and
the therapy they undergo (Chirico,2017; Omran&Mcmillan,2018). The
results of the study
also
showed that the
mean difference in
self-
efficacy scores before the intervention and after the intervention was (9,98±0,69) and there was an
effect of self-
efficacy
training on the
self-efficacy
of
cancer
patients
undergoing chemotherapy
with
a p value of 0
,000 < 0,05. The mean difference in
self-efficacy
score
after intervention and after 4 weeks of intervention was (8,88±5,54) and there was an
effect of self-efficacy
training
on the
self-efficacy
of cancer patients
undergoing chemotherapy after 4 weeks of self-efficacy training with p value 0,000 < 0,05. The
study results
also
showed
a
significant difference between the
three measurements of
self-efficacy
both pre,post-1,post-2 with a p value of 0,000 <0,05. Self-efficacy is an essensial essence for a human beingh in living his life, in forming proper behavior, healthy and prosperous. It’s role is also very important in controlling the conditions of life that must be faced. Self-efficacy doest not come suddenly, but must continue to be built and developed. Development through four ways includes the experience of success, the experience of others, social persuasion and the creation of physical and emotional conditions. (Bandura in Snyder&Lopez,2002;Hoffman,2013). Self-efficacy is an important component in cancer patients. Based on that the condition can be a trigger factor or a factor that reduces the occurrence of cancer (Lev,1997;Cunningham,1991;Chirico et al,2017). Patients who are diagnosed with cancer will be faced with the actions they will receive and this will have an effect on their self-efficacy (Mystakidou et al,2012; Akin,2008). Patients in this study partially experienced a decrease in quality of life with an average score of (59,63±14,53), and when viewed from each dimension also partially decreased as physical dimensions with an average score (15,81±5,50), dimensions of socail/family relationships with an average score (16,75±4,41), dimensions of feeling conditions with an average score (14,27±4,84), and dimensions of functional conditions with an average score (13,21±4,19). Several studies have shown that
quality of life in cancer patients
was low.(Nayak
et al,
2017; Driessen
et al,
2012). Low quality of life will be displayed by a decrease in physical conditions, poor social/family relationships, unstable mood conditions, and functional conditions in living everyday life and at work becomes low. After efforts were made to the patient, the quality of life of the patient increased with an average score of (70,17±10,51), and also increased if described from each dimension also increased.
Cancer patients who undergo chemotherapy
will
experience
changes in their life status.(Iconomou et al,2004). Efforts
to improve the quality of life
in
cancer patients undergoing chemotherapy
are efforts that must be done continuously. Cancer will have a decreased impact on immune power, while chemotherapy undertaken as a treatment can also damage normal cells in the patient’s body. Self-efficacy
is one of the factors related to quality of life.
(Meifen et al,2015
;Foster et al,2015). The
results of the
study
showed
the
difference in mean
quality of life
scores
before the intervention
and
after the intervention
was (10,54±8,30) and there was an
effect of self- efficacy
training
on the quality of life of
cancer
patients
undergoing chemotherapy
with a
p value of 0,000<0,05. Structured self-efficacy training can build self-efficacy slowly and thoroughly in improving aspects of quality of life (Tsay,2003). Self-efficacy training for cancer patients undergoing chemotherapy will provide an opportunity for the individual to build and increase his confidence to deal with things in the future that must be endured. A strong self-confidence will be able to change the overall quality of life of a person both physical condition, social/family relationship, feeling condition and functional condition. The results of the study illustrated the
difference in mean quality of life
scores after
the
intervention and after 4 weeks of intervention by (6,35±5,43) and there was an
effect of self-efficacy training on the quality of life of
cancer
patients
undergoing chemotherapy after 4 weeks of intervention with p value 0,000 < 0,05. The study results showed
a significant difference
between
the
three measurements
of quality of life
both before, after and 4 weeks after the intervention with p value 0,000 < 0,05. Training in the form of short-term interventional group support in cancer patients can increase self-confidence in overcoming problems and quality of life.(Weis,2003;Ko&Park,2011). When health workers assess and implement efficacy based patient health improvement programs are important concepts in shaping
the quality of life of patients.(
Church,2004). In this study, it can be concluded that structured self-efficacy training in a short time can be an effort to improve
self-efficacy and quality of life in cancer
patients
undergoing chemotherapy.
Acknowledgments
The
research was
sponsored
by Polytechnic of Health,Medan, North Sumatera, Indonesia. We would like to thank to health officers at
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