Self-Efficacy Affects Cancer Patients in Solving Problems, Seeking Support and Avoiding Problems as Coping Mechanisms

Background: Cancer is a disease that causes various physical and mental problems. Being diagnosed with cancer affects the self-efficacy and behavior of individuals to choose a coping mechanism in facing the problem. Purpose: This study aimed to determine the effect of self-efficacy on solving problems, seeking support, and avoiding problems as coping mechanisms in cancer patients. Methods: A cross-sectional study was conducted on 45 cancer patients selected using a total sampling technique from two public health centers in Surabaya, Indonesia. Data were collected using the General Self-Efficacy Scale and Coping Strategy Indicator, and analyzed using the Shapiro Wilk for data normality, and linear regression to determine the effects of self-efficacy on solving problems, seeking support, and avoiding problems with p< 0.05. Results: The results showed the participants’ rate of self-efficacy levels (M=3.26), and coping mechanism levels in solving problems (M=3.46), seeking support (M=2.88), and avoiding problems (M=3.27), as well as mean scores of self-efficacy (32.6±3.8), solving problems (34.6±3.8), seeking support (31.8±3.7), and avoiding problems (32.7±3.2). Based on the linear regression test, there was a significant effect self-efficacy on solving problems (p<0.001; R=0.97), seeking support (p<0.001; R=0.98), and avoiding problems (p<0.001; R=0.98) as coping mechanisms. Conclusion: Cancer patients who had high self-efficacy scores would choose solving problems and seeking support as the coping mechanisms, but those with lower scores on self-efficacy prefer to avoid the problems.


Design and samples
The present research was a cross-sectional study, involving simultaneous data collection on independent and dependent variables. The samples were 45 cancer patients were conscious and aged more than 17 years old in two public health centers in Surabaya, Indonesia. A total sampling technique was used to recruit the samples.

Instruments and data collection
This study used the General Self-Efficacy Scale (GSE) adopted from a previous study by De las Cuevas and Peñate (2015) to measure self-efficacy's scores, and the Coping Strategy Indicator (CSI) adopted from Togas and Alexias (2018) to measure the scores of solving problems, seeking support, and avoiding problems. The GSE consists of 10 closed-ended questions using a 4-point Likert scale (1=not at all true, 2=hardly true, 3=moderately true, 4=exactly true). Meanwhile, the CSI is composed of three parts. The first part consists of 11 closed-ended questions that describe solving problems, while the second and third part consists of 10 closed-ended questions each that describe seeking support and avoiding problems, respectively. The section of solving problems and seeking support uses a 4-point Likert scale (1=never, 2=occasionally, 3=sometimes, 4=always), while the section of avoiding problems applies reversed Likert scales (1=always, 2=sometimes, 3=occasionally, 4=never). The questionnaires had been backto-back translated into the Indonesian version by reliable translators, and tested for their validity and reliability by the researchers. The general self-efficacy scale showed the R of 0.831-0.948 with a Cronbach's alpha of 0.921, while the coping strategy indicator showed the R of 0.890-0.932, with a Cronbach's alpha of 0.931. After consented for participation, respondents completed the demographic data and the questionnaires. The data were collected in April 2019.

Data analysis
The collected data were entered into SPSS 25.0 and tested for normality using the Shapiro Wilk test (p>0.05). The results showed that the data were normally distributed (p=0.314 for self-efficacy; p=0.60 for solving problems; p=0.195 for seeking support, and p=0.165 for avoiding problems). A further analysis was performed using the step linear regression test to examine effects of self-efficacy on solving problems, seeking support, and avoiding problems.

Characteristics of participants
The result showed that more than half of the participants were old, ranging from early older adults to the elderly. The stages of cancer varied from stage I-IV, and most of the participants have been diagnosed with cancer for 1-3 years. Almost all participants had a support system from their nuclear families, such as their parents, daughter, or son.  Table 2 showed that in the level of self-efficacy in cancer patients, there were three top components of self-efficacy, comprised of managing to solve the difficult problems (M=3.47), ability to adapt to all situations (M=3.38), and finding a way out of the problems (M=3.33).  Table 3 showed that there were three top components in solving problems (M=3.46), comprising of enthusiasm and effort in solving the problems (M=3.84), full attention to solve the problem (M=3.80), and planning an action carefully before doing something (M=3.60). For seeking support as a coping mechanism (M=2.88), there were two top components, comprising of the hope that the family will continue to help in solving a problem (M=3.49), and receiving help and support from friends and family in solving the problem (M=3.29). For avoiding problems as a coping mechanism (M=3.27), there were three top components in avoiding problems, comprising of staying away from others (M=3.73), avoiding others (M=3.64), and relieving stress by imagination (M=3.64). Effects of self-efficacy on solving problems, seeking support and avoiding problems Table 4 showed that the mean score of all variables was high, meaning that most participants had high self-efficacy and positive problem-solving and positive support seeking, and less problem avoidance as a coping mechanism. While based on the linear regression, it is shown that there was a significant effect of self-efficacy on these three forms of coping mechanisms. Self-efficacy had an effect of 97.7% on solving problems, 98.3% on seeking support and 98.4% on avoiding problems.

DISCUSSION
The present study aimed to determine the effects of self-efficacy on solving problems, seeking support, and avoiding problems as coping mechanisms in cancer patients. Results showed that cancer patients had a high score of self-efficacy, in which they managed and found a way out to solve difficult problems and could adapt to situations. Self-efficacy helps overcome the problems that vary greatly from the consequences of cancer and the effects of treatment (Foster et al., 2015). A similar result also reported that 112 patients undergoing adjuvant endocrine therapy showed that those with higher self-efficacy were able to overcome physical symptoms of cancer and had a significant relationship related to greater functional, emotional, and social well-being (Shelby et al., 2014). Another study stated there was a positive relationship between self-efficacy and quality of life, the ability to adapt to cancer diagnosis, and reduce the distress of cancer patients (Wang, Liu, Shi, & Wang, 2016). Someone with self-efficacy is more likely to be adaptable and has a high desire to live. The adaptation process of adult cancer patients starts from facing an unknown situation, followed by patients looking for relevant information and decision-making considerations, and also listening to healthcare professionals' suggestions so that the patients get a chance to extend their life and the desire to survive (Chao, Wang, Hsu, & Wang, 2015). Patients who have good self-efficacy will achieve a good quality of life. This was also reported by a study of 100 breast cancer patients that there was a significant relationship between self-efficacy and the quality of life of patients, including physical health, mental health, social relationships and satisfaction with the environment (Moradi et al., 2017).
Another finding of this study showed a significant effect of self-efficacy on solving problems, which means that the participants who are eager to choose solving problems as a coping mechanism to respond to the stressors have an adaptive coping mechanism. This has been seen from the component of solving problems, that the participants were enthusiastic, full of attention, and could plan their actions to solve a problem. This result is supported by another study where patients who have high expectations resulted in the improvement of self-confidence, self-efficacy, and high welfare, and caused patients to have strong support for using strategies to achieve their goals in solving problems (Bahryni, Bermas, & Tashvighi, 2016). A similar result declared that among 121 breast cancer patients undergoing surgery, those who had less emotional distress also had more positive problem-solving (Heppner, Armer, & Mallinckrodt, 2009). Based on the findings of this study, the majority of participants were in the old age (54.1 years), had cancer stage of II and III, and had also been diagnosed with cancer for more than 1 year. All of these participants chose to solve problems with adaptive and positive coping mechanisms. This result is supported by another study where 281 participants with gynecologic cancer having the mean age of 54.8 and in stage II and III of cancer predominantly also had resilience in psychologically adapting, and expressed three types of coping strategies, namely positive emotions, reframing cancer experiences positively, and fostering a sense of peace and meaning in life. This causes a good quality of life (Manne et al., 2015). Another research stated that positive coping was found in women cancer patients undergoing cancer treatment and were diagnosed for cancer for more than 6 months (Kvillemo & Bränström, 2014).
Our findings also showed that self-efficacy affected seeking support. The participants hoped for and received help and support from friends and family in solving the problem. Seeking support is an effort made to seek help from those who are relevant to others to help to solve problems (Zartaloudi & Madianos, 2010). A study reported that patients who had problems were more likely to seek support from parents, friends, partners (Chow & Glaman, 2013). A study conducted for individuals who were depressed and anxious found that 47% sought support from professional experts to help solve their problems (Wallerblad, Möller, & Forsell, 2012). This study found that the majority of participants had been diagnosed with cancer for more than 1 year and the nuclear family lived with patients to provide support. A study stated that cancer patients who were diagnosed in the first 1-3 years experienced shock disorders such as physical, emotional, social, work, and financial stress, which made them in dire need of support from others (Stanton, 2012). Another study also explained that cancer survivors decided to seek support, especially from family members such as children, parents, siblings and more distant relatives to help them making treatment decisions, emotional support, inspiration, motivation, informational support, and spiritual support, and provide facilities (Muhamad, Afshari, & Kazilan, 2011). A qualitative descriptive study of 14 breast cancer patients stated that family support could increase individual involvement in the fight against cancer (Chung & Hwang, 2012). Seeking support, which is a finding of this research, is also caused by the active involvement of cancer survivors in community activities. The findings in this study are supported by the results of another study, which stated that the majority of cancer patients who were more than 50 years old and were active in online community groups had a better atmosphere and quality of life (van Eenbergen, van de Poll-Franse, Heine, & Mols, 2017). The same results were also presented by a study which stated that the involvement of cancer patients in a support group in online communities could improve the ability to express emotions properly, and was beneficial for improving the health condition of patients (Han et al., 2011). A study explained that breast cancer patients had a high awareness to know more about the disease and its treatment, therefore, the majority of patients visited health professionals to consult their problems (Agbokey et al., 2019).
Participants in this study having low scores on self-efficacy are more likely to choose to avoid problems as an alternative coping mechanism. Avoiding as coping is a form of individual behavior that seeks to avoid, deny, ignore and not solve problems properly which causes the individual to be in a stressful situation (Holahan, Moos, Holahan, Brennan, & Schutte, 2005). A study of 97 gynecological cancer stated that patients who lacked self-confidence and were pessimistic had a significant association with the onset of anxiety and depression (Zenger, Glaesmer, Hockel, & Hinz, 2011). Older people who are diagnosed with cancer are more anxious. It is supported by a study reporting that for patients diagnosed with cancer in late adulthood, 20% of them tend to report prolonged anxiety (Mitchell, Ferguson, Gill, Paul, & Symonds, 2013). Prolonged anxiety can cause an individual to feel hopeless; the hopelessness is related to cancer-related concerns, such as feeling different from others and feelings of alienation. Together, this can affect a patient's subjective responses, such as helpless responses, difficulty in resolving problems and affective disorders, and also poor general well-being (Grassi et al., 2010). Breast cancer patients experiencing a recurrence in four months after diagnosis reported feeling hopeless, feeling alone, and are very vulnerable to depression (Brothers & Andersen, 2009). Cancer patients experiencing anxiety and depression at moderate levels are more likely to have coping strategies to avoid problems (Karabulutlu, Bilici, Çayır, Tekin, & Kantarcı, 2010). Avoiding problems is one of the maladaptive coping mechanisms. Cancer patients experiencing excessive stress will perform maladaptive coping mechanisms, and use of maladaptive coping will further increase their psychological pressure and reduce their quality of life (Ravindran, Shankar, & Murthy, 2019). A study of 346 patients undergoing palliative care with complex physical symptoms found that they had major coping strategies that focused on emotions, such as cognitive avoidance and fatalism; this selection of coping was influenced by socio-demographic variables and disease (Pereira & de Brito Santos, 2016). The similarity in results was also reported in study where 22 patients of breast cancer that received adjuvant therapy felt emotional encounters, isolationism, fatalism, feeling guilt and blaming others, and also avoided the problems, such as avoided threatening and unpleasant thoughts (Hajian, Mehrabi, Simbar, & Houshyari, 2017).
This study has limitations. The participants in this study were cancer patients with all stages and types of cancer, and therefore, which might influence the patients' responses to their condition. This study was also conducted with small sample size. Despite the limitations, this study could describe the self-efficacy and coping mechanisms of cancer patients.

CONCLUSION
The results of the study showed that self-efficacy affects the coping mechanism, where individuals who have positive self-efficacy will choose to solve problems and seek support as their coping mechanisms, while individuals with negative self-efficacy tend to choose to avoid the problem. The findings of this study are important to provide positive support to patients to increase self-efficacy, to be able to choose adaptive coping. Based on the finding of this study, it is recommended to explore the internal and external motivation of cancer patients to choose coping mechanisms in future studies.