Introduction
Family functioning is the social and structural properties of family interactions and relationships (e.g., cohesion and expressiveness). It is a crucial component of adjustment and well-being among Latinx patients coping with advanced cancer (Samuelsson et al. Reference Samuelsson, Wennick and Jakobsson2020). The family function includes levels of cohesion and expressiveness (Lewandowski et al. Reference Lewandowski, Palermo and Stinson2010). Expressiveness, for example, is being able to express one’s feelings and opinions adequately. Studies have identified 3 types of families among patients coping with cancer: low-expressive, detached, and supportive (Nissen et al. Reference Nissen, Trevino and Lange2016). Those with low-expressive and detached family types are associated with lower quality of life (QOL) levels (Fischer et al. Reference Fischer, Sauaia and Min2012; Nissen et al. Reference Nissen, Trevino and Lange2016).
Patients with advanced cancer and their families may experience significant distress in 4 domains: physical, psychological, social, and spiritual (Carlson et al. Reference Carlson, Angen and Cullum2004; Carlson and Bultz Reference Carlson and Bultz2003; Panzini et al. Reference Panzini, Mosqueiro and Zimpel2017). These domains are often the dimensions that define “QOL.” Improving the QOL is an important goal of cancer care (Panzini et al. Reference Panzini, Mosqueiro and Zimpel2017). Cancer patients report that QOL may be related to treatment and psychosocial factors like external stress and perceived support (Chirico et al. Reference Chirico, Serpentini and Merluzzi2017). A recent systematic review emphasized increased research on psychosocial factors to yield evidence-based to culturally diverse populations (Benish et al. Reference Benish, Quintana and Wampold2011; Griner and Smith Reference Griner and Smith2006). However, there is a gap in knowledge of how family function may impact Latinx patients coping with advanced cancer QOL.
This brief report aims to describe and determine the association of family functioning (e.g., cohesion and expressiveness) with psychosocial needs among Spanish Latinx patients coping with advanced cancers. To achieve these objectives, the study team conducted secondary data analysis of screened patients. The findings of this study provide information on the patient’s input on the perspective of integrating family members into therapy and will be used to refine a psychosocial intervention.
Methods
Participants and procedures
Secondary analyses were performed on data collected as part of a larger study whose purpose is to adapt and conduct a psychosocial intervention for advanced cancer patients (Costas-Muñiz et al. Reference Costas-Muñiz, Garduño-Ortega and Torres-Blasco2020a Reference Costas-Muñiz, Torres-Blasco and Castro-Figueroa2020b). Participants were patients with advanced cancer recruited from Memorial Sloan-Kettering Cancer Center (MSKCC), New York; Lincoln Medical Center, New York; and Ponce Health Sciences University, Puerto Rico. Research staff identified and approached patients between August 2015 and October 2018. A non-probability sampling technique was used, and 103 patients were recruited for the quantitative phase. All patients provided their written consent. This research was reviewed and approved by the 3 institutions’ review boards/privacy boards/ethical board.
Measures
Sociodemographic and clinical variables were assessed in the baseline questionnaire from the overall study and retrieved by the research team for this manuscript. They included age, marital status, income, education, employment status, language, birth country, place of residence, clinical diagnosis, stage, years since diagnosis, and treatments received (including cancer and psychiatric treatments). In addition, the baseline questionnaire included the following validated measures in Spanish: the Family Relationships Index (FRI) (Moos and Moos Reference Moos and Moos2002), the Hospital Anxiety and Depression Scale (HADS) (Hyland et al. Reference Hyland, Hoogland and Gonzalez2019), and the Functional Assessment of Cancer Therapy: General (FACT-G) (Cella et al. Reference Cella, Tulsky and Gray1993).
Family Relationships Index
The FRI is a 12-item, true–false response scale derived from the short form of the Family Environment Scale, a well-validated measure of an individual’s perception of their family’s functioning, including such constructs as interpersonal relationships and organizational structure (Moos and Moos, Reference Moos and Moos2002). The team included the overall scale of family function and the subscales of family cohesion and family expressiveness. The FRI’s total Cronbach’s alpha scale was .86; lower family functioning was equal to 9 or less on the scale.
Hospital Anxiety and Depression Scale
Anxiety and depression symptoms were assessed using the Spanish version of the HADS. This 14-item scale evaluates the frequency of experiencing anxiety and depression symptoms. It includes somatic symptoms of anxiety and depression (headaches, fatigue, insomnia, anergia, etc.) that can be caused by side effects related to cancer and its treatment (Hyland et al. Reference Hyland, Hoogland and Gonzalez2019). Scores of 11 or more on either subscale are considered to be a significant “case” of psychological morbidity, while scores of 8–10 represent “borderline” and 0–7 represent “normal” (Zigmond and Snaith Reference Zigmond and Snaith1983).
Functional Assessment of Cancer Therapy: General
Health-related QOL was evaluated with the Spanish version of the FACT-G Version 4 developed by Cella et al. (Reference Cella, Tulsky and Gray1993). This is a 28-item scale designed to rate physical, social/family, emotional, and functional well-being using a 5-point Likert scale. A total general QOL score was generated by summing all subscale scores. Higher total scores represent better general QOL (Cella et al. Reference Cella, Tulsky and Gray1993).
Analysis
Quantitative statistical analyses were conducted using IBM SPSS Statistics 26 software. Descriptive statistics were used to report the sociodemographic (e.g., age, sex, and ethnicity), clinical (e.g., cancer diagnosis and cancer stage), and background characteristics (e.g., education and employment status) of the 103 patients who participated in the quantitative phase. Pearson correlation analyses were conducted to examine associations between the FRI, HADS, and FACT-G.
Results
Participants
Table 1 summarizes the general characteristics of the patients in the present study (n = 103). Females comprised 60% (n = 61) of the sample, and most of the patients were married (n = 47, 46%). Spanish was the dominant language among 83% (n = 86) of the sample and 34% (n = 35) reported having less than high school education, while 20% (n = 21) of the sample were high school graduates. Patient’s cancer stages were IV (n = 63%) and III (n = 33, 32%).
Table 1. Participant demographic information
a Values are n.
b Frequencies may not be based on a total of 103 participants, due to missing data, and percentages may not sum to 100% due to rounding.
Associations between family function, QOL, depression, and anxiety
Results indicated that most of the participants had low family function (65%). Participants with higher family functioning (35%) had high levels of QOL [r(103) .318, p < .002]. A higher level of QOL was also strongly associated with lower levels of anxiety [r(95) −.653, p < .000], lower levels of depression [r(95) −.733, p < .000], and lower levels of hopelessness [r(95) −.585, p = .000]. A total of 22.3% of Latinx advanced cancer patients reported poor cohesiveness; those with low cohesiveness also had higher levels of depression [r(103) −.28, p = .004] and anxiety [r(103) −.27, p = .005]. Correlations between expressiveness and hopelessness were significant; namely, those with higher expressiveness had lower hopelessness [r(103) −.274, p = .005].
Discussion
This brief report aims to describe and determine the association of family functioning (e.g., cohesion and expressiveness) with psychosocial symptoms (e.g., QOL, anxiety, depression, and hopelessness) among Latinx patients coping with advanced cancers. Findings present a high correlation between family function and psychosocial symptoms. These findings are similar to those presented in Kershaw et al. (Reference Kershaw, Ellis and Yoon2015) and Friðriksdóttir et al. (Reference Friðriksdóttir, Sævarsdóttir and Halfdanardottir2011), suggesting the interdependence of family function, psychosocial symptoms, and the importance of simultaneous care. Specifically, they meant that patients’ and caregivers’ mental and physical health significantly influenced each other (Kershaw et al. Reference Kershaw, Ellis and Yoon2015) and that family members of cancer patients who experienced symptoms of anxiety and depression reported worse QOL than those who reported no such symptoms (Friðriksdóttir et al. Reference Friðriksdóttir, Sævarsdóttir and Halfdanardottir2011). Moreover, the results are similar to other Latina breast cancer studies, where they reported psychosocial interdependence between patients and their family caregiver (Segrin and Badger Reference Segrin and Badger2013; Segrin et al. Reference Segrin, Badger and Sikorskii2018 Reference Segrin, Badger and Sikorskii2020).
According to the present data, there is a positive correlation between higher levels of family functioning and better QOL among Latinx patients coping with advanced cancer. High rates of depression and anxiety, as measured by the HADS, were found in families with poor cohesion and expressiveness. These findings are consistent with the study of Park et al. (Reference Park, Jeong and Lee2018), which found that higher levels of family cohesion are associated with lower levels of depression in patients. These findings show the importance of including family members in Latinx cancer psychosocial care.
The present findings reveal the impact of family expressiveness in disease coping and the need to integrate healthy ways to train patients and family members with adequate communication skills. These data are similar to data presented in Cortés-Funes et al. (Reference Cortés-Funes, Bueno and Narváez2012), who found that patients with low family expressiveness show worse adjustment to the cancer diagnosis. The data underscore the importance of addressing family communication skills in the context of Latinx cancer psychosocial care.
There is some limitation to this study; for example, participants were recruited primarily from New York City and were born in the Caribbean. First, the results may not generalize to Latinos in different geographical locations in the United States and Latin America. Future studies should include samples from other geographical areas to enhance cultural fit. Second, we do not have information about the participants’ family caregivers or family members. Future studies should include the correlation between patients’ and caregivers’ psychosocial symptoms. Third, the sample of patients was not homogeneous in terms of cancer stage, and the experiences of cancer patients are different at both stages. In future studies, an analysis should be conducted by stage. Finally, the need to include family-related content and future studies should examine culturally sensitive interventions among Latinx patients coping with cancer.
Conflicts of interest
The authors report no conflict of interest.
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