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Figure 2.: Overview of study sample. Detailed descriptives of the study sample will be given in the ‘Results’ section
NOTE: 1: physiological and psychological measures not included in the present dissertation (blood count, NK cell number and activity, nausea/vomiting, emotional and physical well-being scales, PSDS and Life Event List, Structured Psychological Interviews),
2: the questionnaire was asking hypothetical questions about the willingness of patients of participating in a study that involves alternative adjuvant interventions eg.: hypnosis and music among 8 other possibilities.
4.5 Measures and data collection (relevant to the dissertation)
68 The measuring points were the following:
• T1: after diagnosis and surgery, before starting chemotherapy treatment and psychological interventions. This point served as a baseline,
• T2: after 12 weeks of AC treatment, on the first PAC treatment,
• T3: after 12 week of PAC treatment, at the end of chemotherapy treatment and psychological intervention period,
• T4: 12 months after diagnosis, early survivorship, in the past few months most probably re-entering previous life, field of work and duty,
• T5: 24 months after diagnosis, medium-term survivorship,
• T6:36 month after diagnosis medium-term survivorship.
4.5.2 Quantitative measures 4.5.2.1 PICI
Psychological immune competence was measured by the Psychological Immune Competence Inventory (PICI), which is an 80-item inventory containing 16 scales and 3 subordinate systems. PICI was conceptualised and operationalized to evaluate individual mental resistance and coping capacity. The test explores those personality resources that grant effective coping strategies to endure stressful events in a way that the integrity, effective functioning, and developmental potential of the personality remain uninjured.
The validity of PICI was tested with the Big Five dimensions, with the Three Giants (Neuroticism, Psychoticism, Extroversion), and with prominent indicators of healthy personality ( learned resourcefulness, dispositional optimism, constructive thinking, hardiness, psychological well-being and ego-resiliency, and with effective functioning in life (mental/somatic healthy, flow, burnout) (Oláh, 2005a). The 16 scales are: (1) Positive Thinking, (2) Sense of Control, (3) Sense of Coherence, (4) Creative Self-Concept, (5) Sense of Self-Growth, (6) Change and Challenge Orientation, (7) Social Monitoring Capacity, (8) Problem Solving Capacity, (9) Self-Efficacy, (10) Social Mobilizing Capacity, (11) Social Creation Capacity, (12) Synchronicity, (13) Goal-Orientation, (14) Impulse Control, (15) Emotional Control, and (16) Irritability Control. The three subordinate systems are: Approach-Belief Subsystem, Monitoring-Creating-Executing Subsystem, Self-Regulating Subsystem. The items of PICI consist of a Likert scale, ranging from 1 to 4, where 1 means “does not describe me at all” and 4 means “describes me completely”. (Oláh, 2005b, 2005a) General immune competence can be described by
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the cumulative PICI score (i.e., by adding up the scores of all the scales) (Perczel Forintos, Kiss, & Ajtay, 2007). PICI was registered six times; T1: after the diagnosis and surgical resection, before the chemotherapeutic treatment as baseline, T2: after 12 weeks of AC treatment, T3: at the end of the 24 weeks of chemotherapeutic treatment, T4–T5–T6:
follow-up period, 1–2–3 years after diagnosis.
4.5.2.2 WHOQOL-100
Quality of life was assessed by the WHOQOL-100 questionnaire that measures
“individuals’ perceptions of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns” (The WHOQOL Group, 1998 p. 1405). WHOQOL-100 proved to be reliable and valid on a sample of breast cancer patients and survivors (Den Oudsten, Van Heck, Van der Steeg, Roukema, & De Vries, 2009). 100 questions cover 24 facets, creating six domains: physical health, psychological domain, level of independence, social relations, environment and spirituality/religion/personal beliefs. Each facet consists of four questions (4–20 points). The 25th facet, overall QOL and general health, is not among the domains. WHOQOL-100 was registered six times, as was PICI.
4.5.2.3 Post-traumatic Growth Inventory
The post-traumatic growth of patients was measured by the Post-Traumatic Growth Inventory (PTGI) (Tedeschi & Calhoun, 2004), an instrument developed to assess positive changes and outcomes after a traumatic event. It is a 21-item questionnaire with five sub-scales: Relating to Others, New Possibilities, Personal Strength, Spiritual Change and Appreciation of Life. The five-factor structure of the questionnaire was proved to be valid on a sample of physically active breast cancer survivors.(Brunet, McDonough, Hadd, Crocker, & Sabiston, 2010). The PTGI is registered once in the follow-up period, three years after the diagnosis (T6).
All questionnaires were filled out on occasions when the patient visited the institution for examination or treatment, i.e. it did not represent an extra trip. They were filled out in the research room, ensuring calm conditions or occasionally patients could fill it in the waiting area adjusted to their needs. A member of the research team who was present at that time presented the questionnaire to the patient in paper form. No one refused to fill
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in the questionnaires, but since the participants on the study were seriously ill, errors could have occurred.
4.5.2.4 Hypnotic susceptibility
Hypnotic susceptibility was measured by the Stanford Hypnotic Clinical Scale for Adults (Morgan & Hilgard, 1978) before and after chemotherapy treatment only in the case of music and hypnosis group. The standard hypnosis was carried out by the hypnotists participating in the study (mainly by the principal investigator of the study), in the room reserved for the research, under undisturbed conditions at the National Institute of Oncology.
4.5.3 Qualitative data
4.5.3.1 Patients’ subjective experience of interventions
Besides quantitative data, qualitative information was also gathered from patients.
Relevant to this work was the subjective experience of patients while either receiving hypnosis/music or being accompanied throughout an actual chemotherapy infusion treatment. Patients’ subjective experience was registered by research assistants via face-to-face interviews following each session. Assistants asked patients to report on their thoughts and feelings after each hypnosis or music session, or in the case of the special attention group, after receiving the chemotherapy infusion, or while waiting for their blood test results. The first standardised question asked of the hypnosis/music group was:
“Please tell us, in your own words, everything you have felt and experienced since listening to the hypnosis/music” and for the group with special attention: “Please tell us, in your own words, everything you have felt and experienced since receiving the chemotherapy.” However, assistants were allowed to raise further questions to clarify patients’ statements, to facilitate more detailed explanations, or to reflect on their emotions in a non-directive way. All assistants were trained in the above-described process. The patients’ answers were recorded on an mp3 player and later transcribed verbatim for further analysis. The verbatim texts serve as the basis for content analysis.
The lengths of the answers given varied from 5 to 2279 words, with the mean 203.
Figure 3 below gives an overview of the study protocol, frequency of interventions, measuring times and data collection.
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Figure 3.: Study protocol: frequency of interventions, measuring times and data collection.
T1-T6: measuring points,
H/M/SpA: Hypnosis, Music, Special Attention, PICI: Psychological Immune Competence Inventory, QOL: WHOQOL quality of life questionnaire, PTGI: Post-Traumatic Growth Inventory,
Other physiological and psychological indicies not included in the present dissertation were measured, details see below.
4.5.4 Data measured in the study but not used in the dissertation
The study measured a number of other variables that are beyond the scope of this dissertation. At the same time, it is important to mention these outcome measurements for a full insight.
Several physiological indicators were measured in the study:
• Full blood count was measured before the initiation of treatment, during each chemotherapy treatment, (in case of AC treatment also one week after chemotherapy as a check-up), and at the end of the chemotherapy phase, altogether 21 times.
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• Natural Killer (NK) cell activity was measured six times as PICI and WHOQOL100 was measured: at the beginning of chemotherapy treatment before the first AC, 12 weeks later before the first PAC treatments, and at the end of the chemotherapy protocol, then every 12 months for three years follow-up.
• Nausea/ vomiting as side-effects were registered at each chemotherapy treatment, 17 times altogether.
Psychosocial measures which were not included:
• Analogous emotional and physical wellbeing scales were registered each time when meeting with the patients, during chemotherapy and also in the follow up period, 25 times altogether. Patients were asked to choose a face or a body image closest to their actual emotional and physical feelings, and afterwards to explain their choice.
• Structured interviews (the first psychological interviews and the interviews after the termination of the chemotherapy treatment, and at the end of a three-year follow-up period) were conducted to gain a better insight into patients’ attitudes toward the chemotherapy treatment and to our interventions before and after.
• PSDS and Life Event List were registered at T6, three years after the diagnosis