In this study, we first investigated the association of demographic and clinical variables with resilience and we found that education, married/cohabitaton and distant cancer metastasis were the associated factors with resilience. We then did the correlation study and found that Chinese oral cancer patients had moderate level of resilience. Moreover, hope, optimism and perceived social support positively correlated with resilience while perceived stress was negatively correlated. Further study with hierarchical linear regression analysis showed that hope, optimism and education were predicative factors for resilience. Finally, we were able to reveal that resilience was associated with anxiety symptoms in oral cancer patients.
Factors associated with resilience
Many potential influencing factors of resilience were considered in this study. However, most of the demographic and clinical variables such as age, gender, BMI, job status, income, residence area, smoking, drinking alcohol, type of treatment and family history of cancer were not related to resilience in the univariate analyses, so these variables were not adjusted in the following hierarchical linear regression analyses. Regression analyses for marriage, education, distant metastasis as well as the psychosocial factors revealed hope, optimism and education as the main predictors of resilience. These three factors in combination explained 48.9% of the variance in resilience of oral cancer patients, with self-reported hope making the largest predictive contribution. To our knowledge, we are the first to report such findings in oral cancer patients. These results may have useful implications for clinical research and management of oral cancer.
The finding that hope had the strongest association with resilience (β = 0.386,
p < 0.01) was similar to the results in previous studies among other cancer patients. For example, in a longitudinal study, hopefulness was found capable of predicting resilience among hereditary colorectal cancer patients [
37]. Hope was also found positively related to the level of resilience among patients with breast cancer, metastatic colorectal cancer and adolescent or young adults with cancer in cross-sectional studies [
38‐
40]. A cancer diagnosis is a stressful event for most individuals. Besides the overload of physical stress caused by cancer and its treatment, many patients experience mental stress such as worries about the prognosis of treatments, disruption of ordinary life functions and the length of survival [
41]. Cancer diagnosis and its subsequent treatment decreased patients’ hope level and increase psychological distress [
42]. In this sense, our finding that hope was the strongest predictor for resilience in oral cancer patients is important, because hope is a positive psychological resource for people experiencing difficult situations. It was reported that hope could give cancer patients reasons for survival [
43]. Study also demonstrated that hope was negatively associated with negative affectivity and positively related to life satisfaction in newly diagnosed cancer patients [
44]. Therefore, enhancing the level of hope may become one of the important strategies to increase the level of resilience among oral cancer patients.
In addition to hope, we found that optimism was another positive psychological resource for resilience (β = 0.190,
p < 0.01). This result was also consistent with the previous findings by others. For instance, one study demonstrated that individuals with lower optimism were more adept to engaging cognitive and behavioral resources to promote resilience; optimism and resilience synergistically promoted adjustment to chronic pain, making patients feel less severe pain [
19]. Optimism is a mental attitude of positive expectation or belief on things that are about to happen. It is a positive and open-minded attitude towards life, which can improve patients’ life satisfaction, reduce negative emotions and behaviors, and improve their quality of life. All the features of optimism are favorable to person’s resilience. Importantly, a study found that, although optimism was a stable personality trait, cognitive behavioral therapy could convert pessimism to optimism through certain activities including encouraging individuals to take part in positive social activities, to feel positive living atmosphere, and reducing the intensity of stressors [
45]. Therefore, we suggest that optimism should be included in clinical psychological counseling, and clinicians should help patients develop optimism to adjust their psychological pressure and relieve the negative emotions.
In this study, we also found that education level made a limited predictive contribution as indicated by a modest positive relationship between education and resilience (β = 0.175,
p < 0.01). The influence of education on patients’ psychology had been confirmed in many studies. Some researchers even found educational level a direct predictor of resilience [
45,
46]. This should be easy to understand as higher level of education endows a person stronger ability to acquire knowledge on health and the awareness of methods to combat illness. In addition, people with higher level of education may obtain a better income that would make him or her feel more hopeful of completing the treatment.
On the other hand, the finding in this study that perceived social support and perceived stress were not statistically significant factors for resilience were not consistent with previous researches [
45,
47]. Although this phenomenon was somewhat surprising, it should not be so difficult to understand. Resilience may not be significantly affected by things of short duration or sudden, because it is the inner strength of a person himself or herself. This strength or positivity is formed from inherent quality as well as long term accommodation to the environment/atmosphere. In our sample population, all the three factors i.e. education, optimism and resilience are all internal factors or factors that had been developed before the disease was diagnosed. This phenomenon together with the new understanding of resilience reminds us that we should carry out further studies on the clinical use of the psychological resource scales or other scales to screen patients for lower education and psychological capitals so that interventions may be taken to better care patients with low level of resilience.
The relationship between level of resilience and level of anxiety
In the present study, we found that the levels of anxiety varied with different levels of resilience (X
2 = 39.216,
p = 0.000). Patients with higher resilience reported lower level of anxiety. The study also showed that there was a linear trend between resilience level and anxiety level among patients with oral cancer (X
2 = 35.624, p = 0.000). This finding indicated that the level of anxiety among oral cancer patients decreased as the resilience was improved. As one of the main forms of psychological disorders suffered by cancer patients, anxiety had been studied in many researches [
48‐
50], and it was all agreed that high prevalence of anxiety among the cancer patients necessitated an adequate management in addition to the traditional cancer therapy. In this sense, our study is important because it for the first time demonstrated the positive role of resilience in anxiety symptoms of oral cancer patients, which indicates that improving resilience may have the potential to alleviate anxiety in these patients as well. Therefore, methods should be sought to increase the level of resilience in order to improve the mental status of oral cancer patients.
An important value of this study is that we have identified the potential influencing factors associated with resilience in oral cancer patients for the first time. In this respect, our study has added to the evidence that hope, optimism and education are important factors for individuals with oral cancer, and may partially explain why individuals have different levels of resilience. Skinner’s reinforcement theory holds that behavior is a function of outcome, that is, the production of behavior is affected by certain results. If the result of a behavior is pleasant, it will increase the behavior, and this is called positive reinforcement. Psychological interventions that aim to increase patients’ social, spiritual and psychological well-being are important parts of the multidisciplinary approach to the treatment of oral cancers. Psychological interventions have been developed with a variety of modality that includes health education, psychotherapy, cognitive behavioral therapy, and supportive and group interventions. With the development of positive psychology, interventions based on positive psychology also have been reported in many studies. Our study further demonstrated the positive strengths for oral cancer patients to combat severe diseases and indicated that intervention strategies to improve level of resilience through rebuilding and enhancing the level of resilience should be considered for health care organizations. Up to now, psychological nursing or counseling strategies in clinical settings have not been enough. Therefore, it is necessary to explore the influencing factors of resilience in patients with oral cancer in order to develop strategies.
Nevertheless, there are some limitations in this study. First, because of the cross-sectional design, the causal relationship couldn’t be confirmed. Future researches should be carried out to assess whether interventions could improve the level of resilience among patients with oral cancer. Second, we only focused on the associations of resilience with hope, perceived stress, social support and optimism, while other factors which might be important to consider for resilience were not included. Moreover, a larger and multicenter sample is still needed to improve the representativeness of the findings. Despite of the limitations, our study does provide important new information on resilience in oral cancer patients and it has useful theoretical and clinical implications. It also suggests that an interventional strategy with positive factors may be beneficial to the patient care.