Effects Of Attribution Theory-based Psychological Adjustment On Health-related Quality Of Life In Women With Breast Cancer

Objective:This study aimed to analyze the mediating effects of attributional style on psychological factors and health-related quality of life（HRQo L）by clarifying the status quo and influencing factors of attributional style in women with breast cancer.On this basis,this study aimed to develop measures of psychological adjustment based on Attribution Theory and clarify its intervention effects on patients,so as to provide new evidence for the psychological rehabilitation mode of breast cancer patients and lay a foundation for the development of attribution-oriented psychological rehabilitation programs for cancer patients.Methods:This study was divided into two phases.The first phase of the study was designed as a cross-sectional study.The convenience sampling method was used to select 433 cases of breast cancer patients from four Tertiary Grade A hospitals in Xi’an（Shaanxi Provincial Cancer Hospital,The Second Affiliated Hospital of Xi’an Jiaotong University,Xi’an No.3 Hospital and Chang An Hospital）.The Attributional Style Questionnaire（ASQ）,Connor-Davidson Resilience Scale（CD-RISC-10）,Medical Coping Style Questionnaire（MCMQ）and Functional Assessment of Cancer Therapy-Breast（FACT-Bv4.0）were used to measure the attributional style,psychological resilience,coping style and HRQo L of breast cancer patients.Single sample t test was used to compare the attributional style score of breast cancer patients with norms.Pearson correlation analysis was used to analyze the correlations of attributional style with psychological factors（psychological resilience and coping style）and HRQo L.Univariate analysis and multivariate analysis were used to analyze the influencing factors of attributional style.Structural equation modeling（SEM）was used to analyze the mediating effects of attributional style on psychological factors and HRQo L.The second phase of the study was the intervention study.A total of 114 breast cancer patients（new cases）in Shaanxi Provincial Cancer Hospital were selected by convenient sampling and randomly divided into intervention group and control group,57 cases in each group.Patients in the control group received usual care,while patients in the intervention group received Attribution Theory-based psychological adjustment for 6 months on this basis.FACT-Bv4.0,ASQ,CD-RISC-10 and MCMQ were used to measure the HRQo L（major outcome）,attributional style,psychological resilience and coping style（secondary outcomes）of breast cancer patients before the intervention and 1,3,6 months after the intervention.Two independent sample t test andχ² test were used to compare the baseline data of the two groups.ANOVA for repeated measurement was used to determine the intervention effects of the Attribution Theory-based psychological adjustment on breast cancer patients.Results:1.The cross-sectional studyThe average ASQ score of breast cancer patients was 0.05±1.34,significantly lower than the score of norms[MD=-1.08,95%CI（-1.20,-0.95）,P<0.001].The highest score of dimension in ASQ was 0.42±1.30（stable dimension）,and the lowest score was-0.42±1.81（internal and external dimension）.The average score of CD-RISC-10 was 23.95±6.66.The coping style measured by MCMQ was divided into three dimensions,in which the average scores of coping style of confrontation,avoidance and resignation were 16.65±4.37,15.36±2.77,and9.62±3.06,respectively.The average score of FACT-Bv 4.0 was 87.49±17.35.Pearson correlation analysis showed that the attributional style score of breast cancer patients was positively correlated with the scores of psychological resilience（r=0.56）,coping style of confrontation（r=0.53）and HRQo L（r=0.56）significantly（P<0.01）,and negatively correlated with the score of coping style of resignation（r=-0.56,P<0.01）.But there was no significant correlation between the scores of attributional style and coping style of avoidance（P>0.05）.Analysis of influencing factors showed that the education level[B=0.15,95%CI（0.01,0.29）,P=0.040],marital status（married vs.others）[-0.54（-1.04,-0.05）,P=0.031],fertility status[-0.22（-0.38,-0.06）,P=0.009],chronic disease（with vs.without）[0.44（0.17,0.71）,P=0.001],psychological resilience[0.05（0.03,0.07）,P<0.001]and coping style of confrontation[0.06（0.03,0.09）,P<0.001]and resignation[-0.09（-0.13,-0.04）,P<0.001]were the main influencing factors of attributional style in breast cancer patients（R²=0.537）,embodied in patients with higher education level,married,few children,having chronic diseases,higher score of psychological resilience and coping style of confrontation and lower score of coping style of resignation had higher attributional style scores.Since coping style include confrontation,avoidance and resignation,psychological resilience and coping style were taken as psychological factors to establish three mediating effect models of psychological factors affecting HRQo L through attributional style.In model 1,attributional style had significant mediating effects on psychological resilience[0.10（0.06,0.15）,P=0.001],coping style of confrontation[0.09（0.06,0.14）,P=0.001]and HRQo L.Psychological resilience,coping style of confrontation and attributional style accounted for62%of the variation in HRQo L.In model 2,attributional style only had a significant mediating effect on psychological resilience and HRQo L[0.22（0.16,0.29）,P=0.001].Psychological resilience,coping style of avoidance and attributional style accounted for 60%of the variation in HRQo L.In model 3,attributional style had significant mediating effects on psychological resilience[0.11（0.07,0.17）,P=0.001],coping style of resignation[-0.12（-0.17,-0.70）,P=0.001]and HRQo L.Psychological resilience,coping style of resignation and attributional style accounted for 64%of the variation in HRQo L.The three structural equation modelings were all fit well.2.The intervention study6 months after the intervention,the HRQo L score of patients in the intervention group increased with time,and was higher than that in the control group at all follow-up points(F_time=378.640,P<0.001;F_intervention=21.640,P<0.001;F_interaction=141.908,P<0.001).The scores of attributional style(F_time=341.090,P<0.001;F_intervention=436.080,P<0.001;F_interaction=289.616,P<0.001)and psychological resilience(F_time=13.883,P<0.001;F_intervention=6.391,P=0.013;F_interaction=24.955,P<0.001)in the intervention group increased with time,and were significantly higher than those in the control group at all follow-up points.In coping style,patients’score of confrontation in the intervention group increased with time,and was significantly higher than that in the control group at all follow-up points(F_time=177.890,P<0.001;F_intervention=10.903,P=0.001;F_interaction=48.647,P<0.001),score of resignation in the intervention group decreased with time,and was significantly lower than that in the control group at all follow-up points(F_time=13.283,P<0.001;F_intervention=6.962,P=0.010;F_interaction=12.692,P<0.001).There were significant time effect(F_time=28.459,P<0.001)and interaction effect(F_interaction=15.205,P<0.001)on the avoidance scores of the two groups,but no significant statistical difference was found between the two groups（Fintervention=1.704,P>0.05）.Conclusions:（1）Breast cancer patients tend to have negative attributional style,which is closely correlated with psychological resilience,coping style and HRQo L.Its main influencing factors are education level,marital status,fertility status,chronic diseases,psychological resilience and coping style.（2）The attributional style of breast cancer patients has significant mediating effects on psychological resilience,coping style and HRQo L.（3）The Attribution Theory-based psychological adjustment can effectively improve the HRQo L,attributional style,psychological resilience and coping style of women with breast cancer.