Volume 27, Issue 1 (Winter 2020)                   Intern Med Today 2020, 27(1): 18-33 | Back to browse issues page

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Azadi R, Ahadi H, Hatami H R. The Relationship of Psychological Wellbeing and Psychological Hardiness With the Mediating Role of Social Support in Women With Breast Cancer. Intern Med Today 2020; 27 (1) :18-33
URL: http://imtj.gmu.ac.ir/article-1-3353-en.html
1- Department of Psychology, Kish Branch, Islamic Azad University, Kish, Iran.
2- Department of Psychology, Research Branch, Islamic Azad University, Tehran, Iran. , royaazad@gmail.com
3- Department of Psychology, Imam Hossein University, Tehran, Iran.
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1. Introduction
espite many advances in medical sciences, cancer is still a severe disease and, in many cases, is incurable. Also, a significant part of human society is at risk of contracting it [1]. Cancer is one of the health problems worldwide, and more than ten million new cancer patients are diagnosed each year, and approximately seven million cancer patients die [2]. 
Cancers refer to a wide range of diseases, each with its unique etiology, treatment, and prognosis. Most people with cancer experience a period of stress. In some patients, this stress resolves spontaneously and does not lead to long-term mental health problems and can be considered a normal adjustment response. However, some patients experience more severe mental health problems, which reduce their quality of life and daily functioning [3].
 After cardiovascular diseases and accidents, cancer is the third leading cause of death in Iran. Every year, more than 30000 Iranians die of cancer. It is estimated that more than 70000 new cases of cancer occur annually in the country. With the increase in life expectancy and aging in the country’s population, the incidence of cancer is expected to double in the next two decades. Among these cancers, breast cancer is the most common cancer and the most common cause of cancer death in Iranian women. It mostly presents in the form of invasive ductal and lobular adenocarcinomas [4]. Breast cancer is the second deadliest cancer after lung cancer in women, affecting 1 in 9 women. It is also a major stressor for several reasons; for example, surgical interventions often make the body ugly [5].
 Fortunately, this cancer is one of the most preventable and early-detectable cancers, and taking special measures can reduce late referrals. With effective treatment, we can increase survival, reduce mortality, and improve patients’ quality of life. The high prevalence of this cancer is due to its formation in several stages, classified as a multifactorial disease. The cause of cancer comprises infectious, environmental, and genetic factors in people [6]. Cancer endangers various aspects of mental health. It affects the person’s mental image of her own body and aggravates mental stress. These issues can affect the psychological wellbeing of these people [7]. Lower psychological wellbeing is the consequence of cancer. Disappointment can threaten the physical health and psychological wellbeing of patients and affect the process of recovery and rehabilitation [8].
 Based on extensive research, people with better psychological wellbeing are happy, enjoy their lives, communicate well, and generally have higher life satisfaction. Also, their quality of life is better than people with low psychological wellbeing [9]. Another study has shown that unpleasant life events can disrupt psychological wellbeing and lead to psychological problems such as depression and anxiety [10]. In general, the consequences of cancer are self-image threat; losing self-esteem; loss of freedom, physical comfort, denial, anger, depression, insecurity, loneliness, and consequently reduced psychological wellbeing [11].
 One of the factors that can affect the process of adaptation and its levels is psychological hardiness. Researchers have suggested the concept of hardy personality to explain the association between stress and disease in some people. They have hypothesized that hardiness prevents the harmful effects of stress, and thus having a hardy personality protects a person from stress-related diseases [12]. 
Using existential theories in personality, researchers define hardiness as a set of beliefs about oneself and the world, consisting of three components: commitment, control, and struggle. People with high commitment believe in the importance, value, and meaning of who they are and what they do, and consequently, they can find meaning in everything they do and arouse their curiosity. People who are in strong control find life events predictable and controllable and believe that they can influence what is happening around them. Fighters believe that change is a feature of the natural routine of life and that expectation of transformation is an incentive for growth rather than a threat to real security [2]. 
When people’s psychological hardiness is weak, they lack the components of commitment, control, and struggle and are at risk of disease and stressful events, so that the person considers stress a disaster. People with low psychological hardiness assess life-changing events as negative and uncontrollable compared to high-hardy people. A general and internal citation approach for side effects external events and documents have positive events. Also, they prefer to use a reversible adaptation strategy such as abandoning and denying behavior, and such a cognition neither changes the situation nor solves the problem [13]. 
Various studies have shown the positive role of social contacts in psychological adjustment and health. Doctors believe that social connections are useful in a person’s wellbeing and recovery. In general, adaptation and coping with chronic diseases such as cancer occurs more rapidly in people who have many good traits such as flexibility, problem-solving ability, hope, courage, religious spirit, and social support [14].
Ryff presented a model based on a study of mental health and stated that his model’s components are positive mental health criteria. These dimensions help measure a person’s level of wellbeing and positive functioning [15]. Psychological wellbeing requires an understanding of the existential challenges of life. The psychological wellbeing approach examines the observed growth and development in the face of life’s existential challenges and emphasizes human development. For example, pursuing meaningful goals, transforming and progressing as an individual, and establishing quality relationships with others are very important. A wealth of research literature in the 1950s and 1960s has analyzed the fundamental challenges and problems of life [16].
Cancer is a threatening disease and can affect a person’s life in various ways [17]. The patient and family are experiencing profound challenges [18]. Multiple studies have shown that these patients have different needs after being diagnosed with the disease. These needs include a close and intimate relationship, respect, and contact with support groups. They also need to have hope, talk about new social identities, know how to deal with death, be accepted by family and friends despite disease, and receive more attention and care from family [19].
Despite several kinds of research on women with cancer, no Structural Equation Modeling (SEM) studies have been conducted on the relationship between wellbeing and psychological hardiness, especially with the mediating role of social support. Therefore, due to the diversity of needs and concerns of cancer patients, an accurate understanding of their needs and concerns is essential. This information helps professional staff, especially nurses, provide appropriate counseling services to patients and families [20]. In this regard, this study aimed to determine the relationship between psychological wellbeing and psychological hardiness with the mediating role of social support in women with breast cancer.
2. Materials and Methods
The research method is applied and correlational based on SEM. The study population included women with breast cancer living in Mazandaran Province, Iran, in 2018. To determine the sample size, we employed the ratio of sample volume to independent parameters. 
Due to the ratio of more than the sample size to the number From the observed variables and independent parameters, the model Complexity, a free parameter estimation method (estimation) From the maximum probability) (need to measure the sample above), is missing Data volume (less than 5%), and the relationship between Normality of sample multivariate with sample size 246 people are required for effective SEM implementation.
Sample size, according to components The model included 246 patients with breast cancer. They were elected With a simple random sampling method. After identification Cancer patients based on their medical records In Imam Khomeini Hospital in Sari, the first 246 Women who agreed to participate in this study, Were registered.
The research was conducted as follows: at first, the preliminary explanations about the study’s purpose and how to complete the study tools and keep the information confidential were given to patients. Then, their informed consent was obtained to participate in the research and complete the questionnaires. Next, the Psychological Wellbeing Welfare Questionnaire (RSPWB), Ahvaz Hardiness Inventory (AHI), and Berlin social support were administered. Then invalid questionnaires were removed, and a total of 236 questionnaires were analyzed. 
The inclusion criteria were women with breast cancer and willingness to cooperate in the research. The exclusion criteria included an unwillingness to continue cooperation by the patient and failure to complete questionnaires. The ethical code (ID: IR283269) was issued by the National Research Ethics Committee of the Islamic Azad University, Kish Branch. The license for conducting questionnaires was issued in Imam Khomeini Hospital in Sari City with the necessary coordination. In this study, SEM was used to analyze the obtained information. The study analysis was done in SPSS v. 24 and Amos v. 23.
Study tools 
Ryff Scales of Psychological Wellbeing (RSPWB)

This scale was created in 1989 by Carol Ryff. The original form has 120 questions, but in subsequent studies, short forms of 84 questions, 40 questions, and 18 questions were prepared. In this study, the 84-question form was used. This scale has subscales of environmental control, purposeful living, and personal growth. The validity and reliability of the scale have been reported as appropriate in numerous studies. Ryff reported the internal consistency coefficient of this questionnaire’s subscales as follows: mastery of the environment=0.90, purposeful life=0.90, and personal growth=0.87. The reliability of this scale was obtained by the Cronbach alpha method as 0.89, 0.92, and 0.91 for the components of mastery of the environment, purposeful living, and personal growth, respectively [21]. 
In Iran, this scale was translated and standardized. The reliability coefficients calculated by the Cronbach alpha method for subscales of environmental mastery, purposeful life, and personal growth were 0.78, 0.77, 0.70, and 0.78, respectively. To validate this test’s structure, we evaluated the correlation between its scales and its overall correlation, which yielded good results [22]. 
In this study, the scale’s reliability was obtained by calculating the Cronbach alpha coefficient for the whole scale as 0.82 and the subscales of environmental mastery, purposeful life, and personal growth as 0.91, 0.77, and 0.80, respectively.
Ahwaz Hardiness Inventory (AHI)
This questionnaire was prepared and validated by Kiamarsi (1998) and is a 27-item self-report scale. To assess this questionnaire’s validity, we used four criteria tests: the questionnaire of anxiety, depression, self-fulfillment, and the structural definition of psychological hardiness. Psychological hardiness questionnaire with anxiety questionnaire (r=0.55), depression questionnaire (r=0.62), self-fulfillment questionnaire (r=0.55), and with the structural definition of psychological hardiness (r=0.51) has a significant relationship that indicates its desired and satisfactory validity. The reliability of this scale was also obtained as 0.90 by calculating the Cronbach alpha [23]. In this study, the scale’s reliability was obtained by calculating the Cronbach alpha coefficient for the whole scale of 0.84.
Berlin Social Support Questionnaire
The questionnaire was developed by Schwarzer and Schulz (2000) as a self-report scale designed to assess social support in cancer patients who have undergone surgery and has 52 items with 5 components: perceived existing support, the need for support, seeking support, actual support received, and support. This questionnaire was translated into Persian and then corrected and reviewed by three English language teachers and reviewed and finalized by 6 professors of surgery and psychiatry. To evaluate the questionnaire’s reliability, we used the retest method, and the reliability of the questionnaire was confirmed as 0.90. The Cronbach alpha coefficient for the components of perceived support and the need for support, search for support, supporter, and actual support were obtained as 0.78, 0.75, 0.79, 0.75, and 0. 77, respectively [24]. 
In this study, the reliability of the scale using the calculation of the Cronbach alpha coefficient for the whole scale was 0.88, and for the subscales of perceived existing support, the need for support, support search, actual support received, and support were obtained as 0.78, 0.75, 0.89, and 0.85, respectively.
3. Results
A total of 246 patients with breast cancer participated in the study. Their mean±SD age was 75±35 years ranging from 35 to 75 years. Also, 72% of patients were married, and 28% were single.
According to Table 1, the correlation of research variables is significant (P<0.01). 

The strongest significance belongs to psychological hardiness and psychological wellbeing, respectively, as the observable variables of research. The highest values of correlation among the hidden variables belong to the variables of social support, quality of life, and motivation.
Table 2 indicate that social support individually has a significant effect on psychological hardiness (P<0.05). 

That is, social support can play a significant mediating role between psychological wellbeing and psychological hardiness. The impact of social support on psychological hardiness is significant and equal to 0.221, and the effect of social support on psychological wellbeing is significant and equal to 0.132 (P<0.05).
According to Table 3, among the indicators related to the paths of the model of psychological hardiness, social support, and psychological wellbeing of breast cancer patients, the strongest coefficients belong to psychological hardiness and social support (P≥0.05). 

In Table 4, the estimation of the indirect impact coefficients and the whole mediating model of the relationship between social support, psychological hardiness, and psychological wellbeing indicates the direct and indirect prediction of the relationships in this model. 

About 72% of hardiness can be explained by social support, and the mediating variable of social support can explain 33% of psychological wellbeing. Also, the coefficient of psychological hardiness based on psychological wellbeing mediated by social support is equal to 0.59 (P<0.05).
According to the values of the indicators in Table 5, the model has a good fit. 

The amount of Chi-square in degrees of freedom is less than three. Also, the value of RMSEA is equal to 0.077 and less than the value of 0.08, and the indices (GFI, AGFI, CFI), i.e. the values of variance and covariance of the model are all greater than the value of 0.90. Therefore, this model shows a good fit and is approved [25].
4. Discussion
This study aimed to explain psychological hardiness using social support and psychological wellbeing variables of breast cancer patients through structural equation modeling. According to the presented results, which indicated the model’s fitness, 59% of the variances of psychological hardiness can be explained by social support and 33% of the variances of psychological wellbeing by the mediation of social support (P<0.05). 
The results of this study are consistent with the results of the other studies [2, 7]. In addition to the positive role of spiritual wellbeing on social support, the results indicate that hardy people are more active and assertive in interpersonal relationships and tend to be close to people with high hardiness. In addition to the positive role of psychological wellbeing and social support, the results indicate that hardy people are more active and assertive in interpersonal relationships and tend to be close to people who have high hardiness [26]. Psychological hardiness based on social support increases positive thinking and interpretation based on the challenge rather than the threat of stressful situations. Therefore to find practical solutions, the individual more likely is drawn to the support of others, especially other hardy people. The significance of these results is that, according to research, receiving support from others for cancer patients acts as a shield against the negative consequences of the disease and treatment [27].
The results showed that psychological hardiness has a positive and significant relationship with psychological wellbeing and social support. Social support has a significant relationship with all components of hardiness and psychological wellbeing and is positive for all relationships (P<0.05). The results of this research are in line with other studies [6, 7, 8 ,10، 12]. The results also showed a significant and positive relationship between psychological hardiness and social support; that is, the components of social support, especially the support of family and friends, are predicted by the components of psychological hardiness in a direct and positive direction. 
The highest correlation between the components of social support and psychological hardiness belongs to family support and challenge (r=0.155) and perceived support (r=0.174). Social support is more effective in maintaining health when psychological hardiness is high, and psychological hardiness directly affects adaptation through social support. Previous cancer research has highlighted negative psychological experiences of cancer, including anxiety and depression [4, 5 , 6 ,8 , 9, 12]. Studies have also shown that a high proportion of cancer patients report positive changes in the disease, and most cancer patients describe some of the benefits of their disease experiences when they face death. 
People may re-evaluate goals and priorities and then experience more joy in life, relationships, and spirituality. In this regard, researchers brought up the term “post-traumatic growth” to indicate a positive psychological transformation in the post-experience life challenges [9]. Also, a study conducted on the quality of life of cancer patients showed that social support significantly improved the quality of life of patients [5]. This result is consistent with the present study results, which showed that the emotional dimension of social support affects psychological hardiness and life expectancy.
These results can be explained by the fact that people with a hardy personality can find meaning in everything they do and satisfy their curiosity. These people are entirely integrated with many aspects of their lives, such as job, family, and relationships. They consider life events predictable and controllable and believe in change, rather than stability, as a natural part of life. This personality trait gives the patient the ability to deal positively with life problems and stress caused by the disease and more readily accept adversity and hardships [28]. 
Diagnosis of breast cancer is an experience with high-stress levels that can have long-term adverse effects on self-esteem, family performance, marital affair, and quality of life. A human is a social being who needs the attention and social support of others. Therefore, patients cared for and supported by family, friends, and the community feels more psychological wellbeing. Support from others increases mental health and promotes personal growth and positive relationships in breast cancer patients [29]. 
One of the most important limitations of the research is the correlational design of the present study, and therefore the inference of causal relationships between variables is not certain. This condition means that in addition to the relationships obtained in this study, intervening variables such as social and cultural issues may affect the study results. Also, individual differences and the mental status of research samples affect their response to the questionnaire, entirely out of the researcher’s control. However, the researcher tried to control this issue by providing a calm environment and gaining people’s trust, and eliminating people who have apparent stress or anxiety.
5. Conclusion
In female patients with breast cancer, the positive effect of psychological hardiness along with psychological wellbeing can be explained through the mediating role of social support. Also, this research model can be recommended as an educational-therapeutic topic for physicians, psychologists, and nurses. This model is effective in promoting health and disease compatibility in breast cancer patients. In the treatment process, group therapy, especially health psychologists, is useful in supportive psychotherapy for breast cancer patients. Therefore, because of the importance of maintaining and improving the quality of life of patients with breast cancer, it is recommended that the degree of mental hardiness and social support with psychological wellbeing and intervention be evaluated to increase the mental health of these patients to improve and adapt to the disease.

Ethical Considerations
Compliance with ethical guidelines

All ethical principles are considered in this article. The participants were informed of the purpose of the research and its implementation stages. They signed a written and informed consent. The National Committee of Research Ethics of the Islamic Azad University, Kish Branch approved the study (Code: ID IR283269). The necessary coordination was done to conduct the questionnaires in Imam Khomeini Hospital in Sari City.

This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
All authors equally contributed to preparing this article.

Conflicts of interest
The authors declared no conflict of interest.

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Type of Study: Original | Subject: Diseases
Received: 2019/07/22 | Accepted: 2020/04/7 | Published: 2021/01/1

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