The influence of coping types on post-traumatic growth in patients with primary breast cancer

概要

論 文

全

文

要

約

The influence of coping types on post-traumatic growth in
patients with primary breast cancer
（原発性乳がん患者の心的外傷後成長に対するコーピ
ングタイプの影響）

主指導教員：岡村
（医系科学研究科

仁

教授

精神機能制御科学）

藤本

智美

（医歯薬保健学研究科

1

保健学専攻）

Abstract

Background: The physical and mental impacts of breast cancer diagnosis in women are
substantial. Several studies have investigated the negative mental health effects of breast
cancer. However, in recent years, there has also been growing interest in posttraumatic
growth, a positive response to stressful events. Considering positive psychology focuses
on such virtues, proactive coping theory was chosen as a theoretical guide. This study
investigates how breast cancer patients’ posttraumatic growth is associated with proactive
coping and mental well-being.
Methods: A self-administered questionnaire survey was conducted with 80 breast cancer
patients aged 20 to 70 years attending an outpatient clinic. The survey was conducted
using the Posttraumatic Growth Inventory-Japanese version (PTGI-J), Proactive Coping
Inventory-Japanese version (PCI-J), and the Japanese version of the General Health
Questionnaire (GHQ). Single regression and a multiple regression analysis with PTGI-J as
the dependent variable were performed.
Results: The multiple regression analysis extracted proactive coping (P=0.006), emotional
support seeking (P=0.004), and avoidance coping (P=0.001) as factors associated with
posttraumatic growth in breast cancer patients.
Conclusions: These results suggest that using proactive coping for conflicts caused by a
breast cancer diagnosis and temporary avoidant coping for daily stresses during the
treatment process may enhance posttraumatic growth while preventing deterioration in
mental well-being. Additionally, seeking emotional support is important for posttraumatic
growth.

Key words: breast cancer; posttraumatic growth; proactive coping; mental well-being
2

Introduction

Although advances in medicine have improved the survival rate of cancer patients,
receiving a cancer diagnosis can still be traumatic. The reason for this is that is that cancer
patients experience a variety of issues, including fears and uncertainties about the future,
invasive medical procedures and their side effects, pain and malaise, as well as changes in
social roles and interpersonal relationships (1). Previous studies have reported that
approximately 18% to 20% of cancer survivors aged 40 and older experience anxiety
symptoms, that women are at twice the risk of anxiety than men, and that their fears and
distress about anxiety, depression, and cancer may persist for 10 years after treatment (2).
Additionally, a cancer diagnosis can also lead to posttraumatic stress disorder (PTSD) (3).
The physical and mental impact of breast cancer on women is substantial, with 25–30%
of them reporting depression 1–2 years after mastectomy (4). There are many reports on
the effects of such stressful events, which include both negative as well as positive
outcomes. For example, regarding the stress experiences of individuals and their resulting
growth, Park et al. (5) indicated that individuals can acquire positive self-concepts from
stress-related growth (SRG) as well as from routine stress, leading to personal growth.
Posttraumatic growth (PTG) (6) and benefit finding (7), defined as positive psychological
changes resulting from mental struggles with crisis events and difficult experiences, have
also been considered as positive aspects of stressful events. These concepts capture
people’s experiences of finding benefits in challenging events, such as their own strengths
and greater bonding with others (3).
Other useful concepts such as stress-coping behavior, problem-focused coping, and
emotion-focused coping, which coordinates unpleasant emotions generated under stressful
situations (8), are well studied in the literature. In recent years, the Proactive Coping
3

Theory (9) has been proposed in the field of positive psychology. This theory, which
captures cognitive appraisal and coping with changing events after facing stress, includes
four types of coping: reactive, anticipatory, preventive, and proactive. Based on this theory,
the Proactive Coping Inventory (PCI) scale was developed by Greenglass (10).
Regarding the differences between conventional and proactive coping, Usami (11)
pointed out the following three points: 1) while conventional coping is an effort to deal
with stressors that have already occurred, proactive coping is directed to the future, and
includes efforts to promote challenges and personal growth; 2) while traditional coping
mainly involves risk management when a negative appraisal of threats and harms is made
on stress, proactive coping involves goal management with stress as an opportunity for
challenges and growth; and 3) while conventional coping is triggered by negative
appraisals on requests from the environment, proactive coping is triggered by more
positive motives. However, research on proactive coping is currently scarce (12–15), and
to our knowledge, there is no research available on proactive coping in subjects with
cancer (16).
It is presumed that many cancer patients undergo personal growth while confronting the
disease. However, the characteristics of PTG and proactive coping in cancer patients are
not well characterized; it is important to examine these aspects because cancer patients not
only face the impact of being diagnosed with cancer, but also the subsequent treatment and
side effects, relationships and economic issues, and uncertainties surrounding a potential
recurrence. Therefore, this study aimed to determine how PTG in breast cancer patients is
associated with proactive coping and mental well-being. Exploring these relations can
help in the development of educational intervention methods that promote coping
competence as stress management. Furthermore, internal growth can be expected through
educational interventions on stress management, which can contribute to the improvement
4

of breast cancer patients’ quality of life (QOL).

Patients and Methods

Study participants and eligibility criteria
Subjects were outpatients at University X Medical School Hospital and met the
following criteria: 1) aged 20 to 70 years with a first diagnosis of breast cancer between
April 1, 2010, and March 31, 2018 (this time period was selected because, in consultation
with a physician, the recommended duration of hormone therapy after surgery for breast
cancer was 5 to 10 years); 2) undergoing initial treatment for breast cancer and adjuvant
treatment such as radiotherapy, chemotherapy, and hormone therapy on an outpatient basis,
or having completed initial treatment and being followed-up on an outpatient basis; and 3)
the treatment content during hospitalization and the stage at the diagnosis were not
regarded. Patients with advanced cancer who were in a physically and mentally difficult
condition to answer a questionnaire survey were not included. Sampling was performed
continuously from December 2017 to July 2018.

Ethical considerations
This study was conducted with approval from the Institutional Review Board of Shiga
University of Medical Science (approval number: 29-007). The researchers informed the
subjects of the purpose and method of the study, explained the consent form, and that they
could withdraw both verbal and written consent at any point. Envelopes containing a
questionnaire, the consent form, and the withdrawal of consent form were distributed.
Consent to participate in the study was obtained by returning the signed consent form and
the questionnaire.
5

Survey items
1) Basic attributes
Data about patients’ gender, age, marital status, form of residence, number of close
friends, time since diagnosis, and stage at diagnosis were collected.

2) PTG
The Posttraumatic Growth Inventory-Japanese version (PTGI-J), which has been
verified for reliability and validity by Taku et al. (17), was used. This scale assesses the
positive psychological changes that arise as a result of mental struggle with crisis events
and difficult experiences. It consists of 18 items comprising 4 subscales relating to others,
new possibilities, personal strength, spiritual change, and appreciation of life. Scoring is
based on a 6-point Likert scale (0–5 points) ranging from “never experienced at all” to
“very strongly experienced,” with total points calculated for each of the four subscales.

3) Stress coping
The Proactive Coping Inventory, Japanese version (PCI-J) was used (18). It consists of
7 subscales comprising 55 items of proactive coping, reflective coping, strategic planning,
preventive coping, instrumental support seeking, emotional support seeking, and
avoidance coping. Scoring is based on a 4-point Likert scale (1–4 points) ranging from
“not at all applicable” to “highly applicable” and a total score is calculated for each
subscale. The scale has been verified for reliability and validity by Kawashima (19).

4) Mental well-being
A shortened Japanese version (21) of the General Health Questionnaire (GHQ)
produced by Goldberg et al. (20) was used. The shortened version consists of 28 items
6

comprising 4 factors, namely physical symptoms, anxiety and insomnia, social activity
impairment, and depressive tendencies. Two types of scoring forms were available (0-3
points) and the GHQ method (0-0-1-1 points) with four options ranging from “good” to
“very bad.” The GHQ method was adopted in this study. The cut-off point of the score of
the GHQ28 is 5/6 points, and those scoring five or less are considered healthy while
scoring six or more is indicative of problems.

Statistical analysis
The normality of the data was checked. The basic attributes of the subjects, the mean
and standard deviations of each variable, and Cronbach’s alpha coefficients were
calculated through descriptive statistics. Each basic attribute was divided into two groups,
and a t-test was performed to assess its association with PTGI-J scores. Pearson
correlation coefficients between PTGI-J, GHQ and PCI-J were calculated. In addition,
Pearson correlation coefficients between “time since diagnosis,” “stages at diagnosis,”
PTGI-J scores, GHQ, and PCI-J subscales were calculated. Associations between PTGI-J
and basic attributes, time since diagnosis, stages at diagnosis, PCI-J, and GHQ were
examined using a single regression analysis, followed by a multiple regression analysis
using the forced input method with PTGI-J total score and each subscale score as the
dependent variable and variables found to be associated in single regression analysis as the
independent variable.
The statistical analysis software SPSS Ver. 25 was used, and the significance level was
less than 0.05.

7

Results

Questionnaires were distributed to 120 individuals diagnosed with breast cancer within
the recruitment period who met the inclusion criteria and provided consent to participate
in the study; 80 participants returned their questionnaires (66.7% recovery rate). All
returned questionnaires were included in the analysis (100% effective response rate).

Basic attributes of the subjects and descriptive statistics for each variable
The basic attributes of the subjects are shown in Table 1. The score ranges, mean values,
standard deviations, Cronbach’s alpha coefficients of PTGI-J, PCI-J, and GHQ items are
shown in Table 2.
Most subjects were older than 40, except for one subject in their 30s. Less than 5 years
accounted for 95% of the time since breast cancer was diagnosed, and approximately 80%
was Stage 0-II (Table 1).
The mean PTGI-J and GHQ total scores were 38.60±20.14 and 5.15±4.68, respectively.
The Cronbach’s alpha coefficients for each scale item were all greater than or equal to
0.70 (Table 2).

Correlation between PTG and GHQ, PCI-J
In the association between PTGI-J and GHQ scores, there were significant negative
correlations between PTGI-J total score and impaired social activity and depressive
tendency (Table 3). Moreover, there were significant positive correlations between the
PTGI-J total score and all subscales of the PCI-J in the association between PTGI-J and
PCI-J (Table 4).

8

Associations between time since diagnosis, stage at diagnosis, PTGI-J, GHQ, and PCI-J
subscales
There were no significant correlations between time since diagnosis and other subscales.
Significant negative correlations were found between stages at diagnosis and proactive
coping, reflective coping, and strategic planning. There were no significant correlations
between time since diagnosis, stages at diagnosis, PTGI-J, and GHQ subscales (Table 5).

Factors associated with PTG (single regression analysis)
When PTGI-J was compared by dividing each basic attribute into two groups, no
significant differences were found for any of the items (Table 6). In relation to PTGI-J and
PCI-J, significant positive correlations were found between the PTGI-J total score and the
PCI-J proactive coping, reflective coping, strategic planning, preventive coping,
instrumental support seeking, emotional support seeking, and avoidance coping. In
relation to the PTGI-J and GHQ, there were significant negative correlations between
PTGI-J scores and GHQ social activity impairment and depressive tendency. There were
no significant correlations between PTGI-J and stages at diagnosis and time since
diagnosis (Table 6).

Factors associated with PTG (multiple regression analysis)
The multiple regression analysis using the forced input method was performed using the
PTGI-J total score and each subscale score as the dependent variables, and the variables
found to be associated with the PTGI-J total score in the single regression analysis as the
independent variables. In addition, among the items with significant associations in the
single regression analysis, reflective coping showed a correlation coefficient of 0.60 or
higher with proactive and strategic planning, so eight items that excluded reflective coping
9

were placed as independent variables for the multiple regression analysis to avoid multiple
collinearity. The results extracted proactive coping (P=0.006), emotional support seeking
(P=0.004), and avoidance coping (P=0.001) as factors affecting PTG in breast cancer
patients, explaining 37.8% of the variance (Table 7). Further, multiple regressions using
each subscale of the PTGI-J as the dependent variable extracted emotional support seeking
and avoidance coping, explaining 29.9% of the variance. In the new possibilities,
proactive coping of the PCI-J was extracted, explaining 19.4% of the variance. In both the
personal strength and spiritual change and appreciation of life, proactive coping,
emotional support seeking, and avoidance coping were extracted, the former explaining
29.8% of the variance and the latter 22.9% of the variance.

Discussion

The correlation between PTGI-J and GHQ was calculated using Pearson correlation
coefficient; the results showed negative linear relationships between PTG and impaired
social activity and depressive tendency. An analysis using cross-sectional data from three
months after diagnosis for the association between PTG and QOL in cancer patients
suggests that there is a negative linear correlation between PTG and QOL. However, there
is a curvilinear relationship between depressive symptoms and PTG at the same time point,
with patients with low and high PTG reporting weaker depressive symptoms and those
with medium PTG reporting stronger depressive symptoms (22). The results of a
meta-analysis of studies addressing the relationship between PTG and PTSD also reported
a positive linear correlation between PTG and PTSD, but an even stronger inverted
U-shaped curve relationship as significant (23). The present research yielded different
results regarding the curvilinear relationships, similar to those of previous studies. This
10

might be due to the limited sample size used in this study. When examining the
relationship between PTG and mental well-being, it is necessary not to assume a linear
relationship only, but to take into account the possibility of a curvilinear relationship.
Multiple regression analysis revealed proactive coping, emotional support seeking, and
avoidance coping as factors influencing PTG in patients with primary breast cancer.
Previous studies of cancer patients have suggested that higher PTG is experienced when
they actively address their disease. It has also been reported that social support is a
necessary condition for cancer patients to actively cope with their diagnosis (24).
Proactive coping was the most influencing factor in PTG, which is based on voluntary
goals and links cognition and action. Schwarzer (9) states that proactive individuals strive
to improve their lives and environments, rather than responding to previous or anticipated
adversities. Improvement of one’s own life and the environment is not considered to be a
negative understanding of breast cancer by being diagnosed and confronted with the
disease, but rather as a flexible change in the way the condition made the person grasp
their surroundings to establish a new life. Individuals cannot control whether they are
diagnosed with breast cancer; however, (10) taking responsibility for the consequences of
the events that occurred to oneself may enhance proactive coping and consequently
influence PTG. In a study by Lisica et al. (25), proactive coping and optimism have been
reported to be associated with PTGI, strength as a human, and gratitude for life (25). Our
results showed that proactive coping was associated with three of the PTGI-J subscales
other than relationships to others, consistent with the results of previous studies. In other
words, in the context of cancer diagnosis and treatment, actively addressing problems with
high self-esteem, flexibility to change one’s priorities, and focusing on the new
possibilities of the self, seems to enhance PTG (25).
Previous studies revealed that women report higher emotional support seeking than men
11

(10). This suggests that women are more likely to use social support as a coping strategy
when dealing with stress. In addition, an association between social support and PTG has
been shown (5, 26–28). In this study, emotional support seeking was also a factor affecting
PTG, and the results of multiple regressions using PTGI subscales as dependent variables
also showed that emotional support seeking was associated with relationships to others,
consistent with previous studies (29). The idea of a growth model that assumes the
position of reinforcing factors for becoming healthy suggests that it is also meaningful for
the person to make distressing ruminations, indicating that the presence of a person who
hears the person's narrative warmly becomes a major force (30). From these facts, we can
infer that it is important for people to talk about their worries with confidantes when
dealing with stress and that increased PTG can be expected by seeking support in such
emotional aspects. In supporting individuals in challenging situations, Tedeschi et al. (31)
suggest that supporters need to believe in the coping abilities and resilience that humans
have when facing difficulties, without overlooking the signs that survivors show when
trying to grow; developing such sensitivities is critical for supporters.
Avoidance coping, which involves not performing any specific action, was shown to be
a factor affecting PTG. It is often captured negatively and has been reported to increase
stress responses or negative emotions (32-34). Meanwhile, there are reports that avoidance
coping reduces stress and can be adaptive, depending on how it is used (35, 36). As a
mechanism by which PTG occurs, people experience events in which their core beliefs are
shaken, often associated with emotional distress. Immediately after the event, there is a
process of automatic, intrusive thinking and rumination. In an attempt to alleviate the
distress, PTG is said to arise through self-disclosure and self-analysis as a result of a
variety of coping strategies, distraction, talking to people, and changing the intrusive
mindset to a more positive one (37). Given this, the process of PTG may also require
12

temporary avoidance coping. In previous studies, avoidance coping has been reported to
have aspects of attenuating psychological stress responses through mood relief (38). In
other words, while moderately alleviating emotional distress such as anxiety through
avoidance coping, PTG needs to be coupled with challenges to be solved, which should be
addressed fundamentally by proactive coping. In light of these findings, it is necessary to
ensure reassurance that short-term stress, such as daily anxiety, arising during a long
treatment process after a breast cancer diagnosis, should be relieved by using temporary
avoidance coping. In addition, it is suggested that the introduction of support, mainly
during proactive coping, preserves mental well-being. Additionally, preparing the
environment in which the support can be obtained in relation to the reliable
person/supporter is important in order to utilize emotional support seeking.
This study has some limitations. First, the subjects of this study were patients with
primary breast cancer at a single institution. Consequently, results cannot be applied to all
breast cancer patients and should be interpreted with caution. Second, the PTGI-J, used in
this study, is focused on “cognition,” and thus we did not investigate how PTG in breast
cancer patients are changing as “behaviors” or at the behavioral level. Third, this is a
cross-sectional study focused on how patients themselves changed at the time of the
survey, looking back at the time of the diagnosis of breast cancer, and comparing their
status before and at the time of the survey. Therefore, a possible recall bias cannot be
denied. Longitudinal studies are needed to assess objective changes at the behavioral level,
including interventions such as stress management, to promote PTG, and surveys
administered before and after the interventions. However, it cannot be said that the
changes in individual growth that result from mental struggle are accompanied by changes
at the behavioral level. Therefore, it is important to focus on studying changes at a given
moment through cross-sectional studies to accumulate knowledge, emphasizing on
13

changes in individual growth.
This study revealed that proactive coping, emotional support seeking, and avoidance
coping influenced PTG in primary breast cancer patients. These results suggest that
proactive coping can be used for conflicts caused by a diagnosis of breast cancer and that
temporary avoidance coping for daily stresses during the course of treatment can enhance
PTG while preventing deterioration in mental well-being. Additionally, it was shown that
emotional support seeking was important.

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Table 1. Basic attributes
Item

Category

N (%)

Sex

Female

80 (100)

Age

30s

1 (1.3)

40s

25 (31.3)

50s

21 (26.3)

60 or more

33 (41.3)

Married

63 (78.8)

Marital status

Form of residence

Number of close friends

Time since diagnosis

Unmarried

7 (8.8)

Bereavement

4 (5.0)

Divorced

6 (7.5)

Cohabitation

73 (91.3)

Living alone

7 (8.8)

Few

6 (7.5)

1

13 (16.3)

2–3

35 (43.8)

4–5

23 (28.7)

6–10

2 (2.5)

11 or more

1 (1.3)

6 months to less than 1 year

5 (6.3)

1 year or more and less than 3 years

37 (46.3)

3 years and less than 5 years

34 (42.5)

Greater than 5 years
Stage

4(5.0)

Stage0

11 (13.8)

StageI

30 (37.5)

StageII

24 (30.0)

StageIII

5 (6.3)

StageIV

2 (2.5)

Do not know

8 (10.0)

18

Table 2. Descriptive statistics for each variable of the subjects
Variable

Score range

Mean (SD)

SE

alpha

0–90

38.60 (20.14)

2.253

0.786

Relating to others

0–30

14.15 (7.27)

0.813

0.776

New possibilities

0–20

7.40 (5.80)

0.649

0.784

Personal strength

0–20

7.99 (5.51)

0.617

0.785

Spiritual change and

0–20

9.06 (5.43)

0.607

0.784

Proactive coping

1–56

36.00 (6.11)

0.683

0.789

Reflective coping

1–44

30.90 (4.80)

0.537

0.792

Strategic planning

1–16

10.70 (1.91)

0.215

0.802

Preventive coping

1–40

27.45 (4.91)

0.549

0.792

Instrumental support seeking

1–32

21.61 (4.20)

0.470

0.798

Emotional support seeking

1–20

14.50 (2.56)

0.287

0.799

Avoidance coping

1–12

8.01 (1.53)

0.172

0.804

GHQ28 total

0–28

5.15 (4.68)

0.524

0.817

Physical symptoms

0–7

1.83 (1.71)

0.192

0.809

Anxiety and insomnia

0–7

2.18 (1.88)

0.210

0.810

Impaired social activity

0–7

0.60 (1.28)

0.144

0.811

Depressive tendency

0–7

0.55 (1.32)

0.148

0.811

PTGI-J total

appreciation of life

SD: standard deviation, SE: standard error of the global mean, alpha: Cronbach's alpha
coefficient

19

Table 3. Correlation between PTGI-J and GHQ

1. PTGI-J
2. Physical symptoms

1

2

－

0.021
－

3. Impaired social activity

3

5. Depressive tendency

5

0.011

-0.231*

0.444**

0.174

0.188

0.541**

0.547**

－

0.651**

－

4. Impaired social activity

4

-0.239*

－

Pearson correlation coefficient, *: P < 0.05, **: P < 0.01

20

Table 4. Correlation between PTGI-J and PCI-J

1. PTGI-J
2. Proactive coping

1

2

3

4

5

6

7

8

－

0.396**

0.317**

0.278**

0.344**

0.302**

0.472**

0.399*

－

0.627**

0.376**

0.387**

0.145

0.230*

-0.059

－

0.657**

0.475**

0.202

0.251*

0.230*

－

0.435**

0.403**

0.262*

0.310**

－

0.381**

0.356**

0.232*

－

0.605**

0.353**

－

0.303**

3. Reflective coping
4. Strategic planning
5. Preventive coping
6. Instrumental support seeking
7. Emotional support seeking
8. Avoidance coping

－

Pearson correlation coefficient, *: P < 0.05, **: P < 0.01

21

Table 5. Associations between time since diagnosis, stage at diagnosis, PTGI-J, GHQ, and PCI-J subscales
1. Time since

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

－

0.246*

-0.009

-0.091

-0.124

-0.152

-0.186

-0.141

-0.031

-0.033

0.021

0.166

0.049

-0.062

-0.077

-0.096

0.018

－

-0.044

-0.116

-0.171

0-.150

-0.070

0.030

0.157

0.181

-0.225*

-0.286*

-0.249*

-0.075

0.001

0.005

-0.157

－

0.607**

0.607**

0.579**

0.056

0.028

-0.206

-0.166

0.264*

0.283*

0.272**

0.337**

0.380**

0.494**

0.404**

－

0.669**

.588**

-0.016

-0.052

-0.226*

-0.265*

0.375**

0.204

0.257*

0.248*

0.250*

0.333**

0.248*

－

.568**

0.000

0.019

-0.170

-0.169

0.341**

0.206

0.179

0.267*

0.133

0.347**

0.395**

－

0.022

0.041

-0.170

-0.211

0.370**

0.371**

0.211

0.287**

0.207

0.383**

0.273*

－

0.444**

0.174

0.188

0.025

0.019

-0.066

-0.012

-0.017

-0.083

0.106

－

0.541**

0.547**

-0.135

-0.184

-0.210

-0.174

-0.084

-0.039

0.039

－

0.651**

-0.138

-0.070

-0.208

-0.081

-0.165

-0.084

-0.208

－

-0.251*

-0.113

-0.209

-0.056

-0.176

-0.030

-0.016

－

0.627**

0.376**

0.387**

0.145

0.230*

-0.059

－

0.657**

0.475**

0.202

0.251*

0.230*

－

0.435**

0.403**

0.262*

0.310**

diagnosis
2. Stage
3. Relating to
others
4. New
possibilities
5. Personal
strength
6. Spiritual change
and appreciation
of life
7. Physical
symptoms
8. Impaired social
activity
9. Impaired social
activity
10. Depressive
tendency
11. Proactive
coping
12. Reflective
coping
13. Strategic
planning

22

14. Preventive

－

0.381**

0.356**

0.232*

－

0.605**

0.353**

－

0.303**

coping
15. Instrumental
support seeking
16. Emotional
support seeking
17. Avoidance

－

coping

Pearson correlation coefficient, *: P < 0.05, **: P < 0.01

23

Table 6. Factors associated with PTG -Single regression analysisFactors

Correlation

P Value*

coefficient
Time since diagnosis

-0.105

0.178

Stage at diagnosis

-0.136

0.114

Physical symptoms

0.021

0.425

Anxiety and insomnia

0.011

0.461

Impaired social activity

-0.231

0.019

Depressive tendency

-0.239

0.016

GHQ total

-0.119

0.147

Proactive coping

0.396

<0.001

Reflective coping

0.317

0.002

Strategic planning

0.278

0.006

Preventive coping

0.344

0.001

Instrumental support seeking

0.302

0.003

Emotional support seeking

0.472

<0.001

Avoidance coping

0.399

<0.001

Mean (SD)

P-value**

Factors

N

Age

0.570
20–49 years

26

40.46 (20.15)

50–70 years

54

37.70 (20.27)

Marital status

0.083
Married

63

36.57 (19.54)

Unmarried, bereaved, or

17

46.12 (21.14)

divorced
Form of residence

0.941
Cohabitation

73

38.55 (19.72)

Living alone

7

39.14 (26.02)

Number of close friends

0.209

Not more than 5

77

38.04 (19.85)

6 or more persons

3

53.00 (27.07)

*: Pearson correlation coefficient, **: t-test, SD: standard deviation

24

Table 7. Factors associated with PTG -multiple regression analysisIndependent variable

Standardized

P

T

VIF

0.004

0.976

0.030

1.870

-0.179

0.152

-1.446

1.940

Proactive coping

0.300

0.006

2.806

1.450

Strategic planning

-0.061

0.582

-0.553

1.551

Preventive coping

0.083

0.445

0.769

1.481

-0.114

0.357

-0.926

1.912

Emotional support seeking

0.348

0.004

2.985

1.727

Avoidance coping

0.349

0.001

3.378

1.355

coefficient (β)
Impaired social activity
Depressive tendency

Instrumental support seeking

Adjusted R2=0.378

25