PERCEIVED STRESS, SPIRITUALITY, RESOURCEFULNESS AND SEXUALITY

IN PATIENTS WITH RECTAL CANCER UNDERGOING CANCER TREATMENT

By

TSAY-YI AU

Submitted in partial fulfillment of the requirements

for the degree of Doctor of Philosophy

Dissertation Adviser: Dr. Jaclene A. Zauszniewski

Frances Payne Bolton School of Nursing

CASE WESTERN RESERVE UNIVERSITY

January, 2010
 CASE WESTERN RESERVE UNIVERSITY

SCHOOL OF GRADUATE STUDIES

We hereby approve the thesis/dissertation of

______________________________________________________
Tsay-Yi Au

Ph.D.
candidate for the ________________________________degree *.

(signed)_______________________________________________
Jaclene A. Zauszniewski
(chair of the committee)

________________________________________________
Barbara J. Daly

________________________________________________
Faye A. Gary

________________________________________________
Gary T. Deiming

________________________________________________

________________________________________________

(date) _______________________
November 10, 2009

*We also certify that written approval has been obtained for any
proprietary material contained therein.
 TABLE OF CONTENTS

Page

Table of Contents …………………………………………………………………………i

List of Tables ……………………………………………………………………….……iv

List of Figures ………………………………………………………………………….. .vi

Acknowledgements & Dedication……………………………………………………….vii

Abstract …………………………………………………………………………………..ix

CHAPTER I: INTRODUCTION

Background and Significance .……………………………………………………1

Gaps in the Literature ...………………………………………………………….11

Purpose …………………………………………………………………………..14

Theoretical Framework ………………………………………………………….15

Research Questions ……………………………………………………………...33

CHAPTER II: REVIEW OF LITERATURE

Significance ……………………………………………………………………...35

Gaps in the Knowledge Base ……………………………………………………39

Literature Review of Theories …………………………………………………..42

Review of Related Concepts …………………………………………………….61

Conclusion ……………………………………………………………………..104

CHAPTER III: METHOD

Design ………………………………………………………………………….107

Setting ………………………………………………………………………….109

i
 Sample and Sampling Issues …………………………………………………...110

Procedures for Conducting Research …………………………………………. 115

Data Analysis …………………………………………………………………..140

Statistical Analysis ……………………………………………………………..142

CHAPTER IV: RESULTS

Pilot Study ……………………………………………………………………..150

Descriptive of Sample Characteristics ………………………………………....151

Relationships between Demographics and Cancer-related Variables …………159

Description of Study Variables ………………………………………………...161

Testing the Assumptions ……………………………………………………….175

Results of Research Questions………………………………………………….180

Additional Analyses …………………………..………………………………..198

Summary of Research Findings ……………………………………...……….. 204

CHAPTER V: SUMMARY AND DISCUSSION

Summary ………………………………………..…………………………….. 214

Discussion …………………………………………………………………….. 217

Limitations ……………………………………………………………………. 244

Influence of Cultural Issues ………………………………………………….. .245

Impact of Instrument Translation ……………………………………………... 246

Implications …………………………………………………………………… 248

Recommendations …………………………………………………………….. 255

APPENDIXES

APPENDIX A Data Collector Manual………………………………………..259

ii
APPENDIX B Data Collection Instrument…………………………………...260

APPENDIX C Demographic Information ………….………………………...261

APPENDIX D Sexual History Questions.…………………………………… 264

APPENDIX E Informed Consent…………………………………………….265

BIBLIOGRAPHY.....………………………………………………………….. 269

iii
 LIST OF TABLES

Table 3.1 Research Questions and Required Statistical …………………………..143

Table 3.2 Summary of Measurements Tests ……………………………………...144

Table 4.1 Comparison of Sample Age and Taiwan Government Study ………….153

Table 4.2 Description of Characteristics of the Sample …………………………..157

Table 4.3 Intercorrelations between Age and Cancer-related Variables …………160

Table 4.4 Descriptive Statistics of Study Variables ……………………………....163

Table 4.5 International Index of Erectile Function and Score Distribution ………169

Table 4.6 Female Sexual Function Index and Domain Score Distribution..……...170

Table 4.7 Sexual Self-Schema Scale-Male and Domain Score Distribution..…….172

Table 4.8 Sexual Self-Schema Scale-Female and Domain Score Distribution..….173

Table 4.9 ENRICH-Communication Scale and Score Distribution……………….174

Table 4.10 ENRICH Sexual-Relationship Scale and Score Distribution...………...175

Table 4.11 Pearson’ correlation coefficients between Age and Study Variables ….182

Table 4.12 Comparison of Genders on Major Study Variables…………………….184

Table 4.13 Comparison of Educational Levels on Major Study Variables ………..187

Table 4.14 Comparison of Religion on Major Study Variables …………………...189

Table 4.15 Intercorrelations Between Stage of Disease and Major Study

Variables ……………………………………………………………….192

Table 4.16 Intercorrelations Between Type of Treatment and Major Study

Variables…….. ………………………………………………………...192

Table 4.17 Correlations between Time since Operation and Study Variables .……195

Table 4.18 Correlations between Comorbid Conditions and Study Variables……..195

iv
Table 4.19 Correlations Matrix of Major Study Variables ………………………...199

Table 4.20 Comparison of Colostomy vs. Non Colostomy on Major Study

Variables ……………………………………………………………….201

Table 4.21 Comparison by Length of Time Since Diagnosis of Major Study

Variables ……………………………………………………………….202

Table 4.22 Gender Differences on Perceived Stress and Sexuality ………………..203

Table 4.23 Gender differences on Spirituality and Sexuality ……………………...204

Table 4.24 Gender differences on Resourcefulness and Sexuality ………………...204

Table 4.25 Associations Between Concerning Scores on Major Study Variables

and Respondent Characteristics...………………………………………212

v
 LIST OF FIGURES

Figure 1.1 The Theoretical Framework …………………………………………….32

Figure 1.2 Study Model …………………………………………………………….34

Figure 3.1 Flow Chart for Data Collection ………………………………………..117

Figure 4.1 Distribution of the Sampling Recruitment ……………………………..152

Figure 4.2 Relationships among Demographic and Cancer-related and Study

Variables………………………………………………………………..213

vi
 ACKNOWLEDGEMENTS

I would like to express my deepest gratitude to my advisor and the chair of my

committee, Dr. Jaclene Zauszniewski for her invaluable guidance, generous sharing of

knowledge and experience, gracious support, and prompt feedback. As a doctoral

research student and a project manager, I had the privilege of interacting with her and

working under her supervision, which has been a unique instructive experience for me

and extended my perspective in nursing research. She has been a great “resource” of

inspiration and encouragement throughout my years at Case.

I would also like to express my appreciation to my committee member, Dr.

Babara Daly, who provided insightful expert advice during the preparation of my

dissertation. Especially, she provided her time, valuable comments, and extreme support

during almost one year of waiting for the approval of human subjects review board.

Special thanks is also due to Dr. Faye Gary, for her practical comments, encouragement,

and concerns about me and my family. I am extremely thankful to Dr. Gary Deimling for

his valuable advice and for taking the time to read my dissertation and sharing his

experience. I would also like to give special thanks to all the committee members for

their generous sharing of knowledge and time with me and providing constructive

comments in the pre-defense meeting.

I would like to express my gratitude to Dr. Chris Burant and Mr. Greg Graham for

providing statistical advice and guidance while performing my data analyses. This study

was financially supported by the Frances Payne Bolton Alumni Association and the

Alpha Mu Chapter of Sigma Theta International. This support is gratefully acknowledged.

vii
 I would like to express deepest gratitude to the chief of the department of

colorectal surgery at the medical center in Taiwan, Dr. Tai-Ming King and his colleagues

for their generosity in providing research opportunities and support, and for helping me

with recruitment during my data collection. Special appreciation goes to all the study

participants who were involved in cancer treatment for contributing their invaluable

feelings, thoughts and experiences to this research study.

I would like to express my gratitude to all my friends in the Cleveland Chinese

Christian Church, and the Bread of Life Christian Church in Taiwan, who have been

praying for me during these years. Special thanks go to Wang, Hsu, and House’s families

and friend Sheau-Huey Chiu in Cleveland, and Chou’s families in Taiwan. Especially, I

would like to thank friends Hsueh-Chih Chou, Chi-Mei Shih, Tsui-Yen Lee, Cheng-Hui

Chou in Taiwan for their prayers, encouragement, and support during these years.

Special appreciation goes to the vice president of Fooyin University in Taiwan, Dr. Chi-

Hui Kao Lo who provided guidance and inspired me to enter nursing doctoral program.

I would like to thank the Au family (my parents, sisters, brothers, brothers-in-law,

nieces, and nephews) for all their generous love and support during these years. I would

also like to thank my son, Eric and daughter, Ann, for their understanding, independence,

and sharing in doing the housework with me. Most of all, I would like to thank my

beloved husband, Tai-Ming for his patience, tolerance, assistance, and encouragement.

He was always been there for me all these years. This dissertation is dedicated to him.

Last but not least, I would like to thank the Lord for His grace and Words that

have guided me through this journey, which made me experience His deep love and

faithfulness.

viii
 Perceived Stress, Spirituality, Resourcefulness and Sexuality
In Patients with Rectal Cancer undergoing Cancer Treatment

Abstract

By

TSAY-YI AU

Colorectal cancer is one of the most prevalent malignancies in Taiwanese adults

and its treatment has been associated with sexual dysfunction. Experiencing sexual

dysfunction in conjunction with a cancer diagnosis can produce overwhelming stress and

compromise one’s ability to adapt to illness and change in sexual function. This study

examined relationships among demographic and cancer-related variables and perceived

stress, spirituality, resourcefulness, and sexuality in Taiwanese rectal cancer patients

using Neuman’s systems model, Lazarus’s stress and coping theory, and Zauszniewski’s

theory of resourcefulness. Using a cross-sectional, correlational design, a convenience

sample of 120 rectal cancer adults receiving treatment was recruited from a 1,500-bed

Medical Center in southern Taiwan. Data were collected during face-to-face interviews.

Participants’ ages ranged from 29 to 85 (M = 61) years; 32% had cancer classified as

stage A; 25% had a colostomy; 9% used a substance/lubricant to improve sexual function;

and average length of time since cancer diagnosis/operation was 36 months. Results

indicated that greater stress was associated with female gender, younger age, colostomy

performed, shorter time since operation, and lower scores on sexuality measures. Higher

appraisal of stress was associated with colostomy performed and lower scores on

sexuality measures. Lower resourcefulness was found in men and associated with more

comorbid conditions, less education, greater stress, lower spirituality, and lower scores on

ix
sexuality measures. Lower spirituality was related to greater stress and lower scores on

sexuality measures. Lower sexual function was correlated with older age, less education,

colostomy performed, higher tumor stage, greater number of cancer treatments and

greater stress. The findings have important implications for theory development, clinical

practice, nursing education and health policy. Advanced practice nurses should focus on

stress reduction while establishing a standard assessment of sexuality in rectal cancer

patients before and after surgery. In addition, health promotion programs for long-term

survivors should include the use of well-developed screening measures to assess rectal

cancer patients at risk for high stress, who may also have low resourcefulness, low

spirituality, and low scores on measures of sexuality. Future research with larger, diverse

samples is important for further examination of sexuality over time.

x
 CHAPTER I: INTRODUCTION

Introduction

This study explored relationships among perceived stress, spirituality,

resourcefulness, and sexuality among Taiwanese patients with rectal cancer undergoing

cancer treatment. The relationships between and among demographic and cancer-related

variables and each independent and dependent variable were also examined. This chapter

describes the background, outlines the significance of the problem, the purpose of the

study, and the theoretical framework. The assumptions and the hypotheses are described

and the research questions are proposed.

Background and Significance

Health is the major concern of the nursing discipline, which strives to help the

individual attain, maintain, or regain wellness. Sexual health involves the integration of

the somatic, emotional, intellectual, and social aspects of sexual being (WHO, 1975),

which reflects a holistic perspective of human beings. Sexuality is unique to each couple

or individual. Cancer of the colon and rectum is reported as the second most common

cancer in Taiwan with 10,248 new cases annually (Taiwan Report, 2006), and also the

second most common cancer in the United States with 146,970 new cases per year

(National Cancer Institute [NCI], 2009). Nowadays, the survival rate for cancer patients

is better because of advanced cancer surgery and adjuvant therapy. The 1- and 5-year

relative survival rates for patients with colorectal cancer are 81% and 61%, respectively

(American Cancer Society, 2002). However, the complications derived from the cancer

treatments for patients with rectal cancer are usually unavoidable. Sexual dysfunction

1
remains a significant problem following cancer surgery for patients with rectal cancer

(Camilleri-Brennan & Steele, 2001).

Cancer as a Stressor, Appraisal, and Perceived Stress

Stress occurs when situational demands exceed a person’s resources for

adjustment (Lazarus & Folkman, 1984). Lazarus and Folkman (1984) asserted that

appraisal and psychological resources are important for understanding the experiences of

individuals dealing with stressful events (Lazarus & Folkman, 1984). Cancer diagnosis

and treatment can be appraised as mostly stressful. Studies indicate that a cancer

diagnosis is usually appraised as a stressful event that poses a threat (Krause, 1991; Lev,

1992). Cancer is a threat to the individual’s whole existence and the satisfaction of the

individual’s fundamental needs (Mishel, Hostetter, King, & Graham, 1984). Elliot and

Eisdorfer (1982) indicated that having a chronic and debilitating medical illness and

unremitting sexual dysfunction are chronic stressors (Derogatis & Coons, 1993). The

cancer patient’s perception of the degree of current stress may influence how he or she is

adapting to the illness process. Stress exists when the individual perceives that he/she has

difficulty in coping with the demands related to cancer and its treatment and the

individual’s sense of wellness is being threatened.

Adaptation, Coping Strategy, Spirituality and Resourcefulness

Coping can be viewed as adaptation (i.e., routine modes of getting along under

relatively difficult situations) (White, 1985). Cancer involves a wide range of situations

that require coping, such as painful or frightening symptoms, feelings of ambiguity about

the prognosis, and changes in social relationships (Dunkel-Schetter, Feinstein, Taylor, &

Falke, 1992). Miller (1980) indicated that coping consists of the learned behavioral

2
responses that are successful in lowering arousal by neutralizing a dangerous or noxious

condition (Miller, 1980). Coping involves behavioral, psychological, and social efforts

aimed at reducing the individual-environment dissonance (Brennan, 2004). The stress

derived from illness and disability often causes a disequilibrium of mind, body, and spirit

that requires coping resources (Soeken & Carson, 1987). Ahmad’s (2005) study

demonstrated that coping strategies are stimulated when an event is appraised as stressful

(threat, harm/loss, and or challenge) but not as benign/irrelevant, which is consistent with

Lazarus and Folkman’s (1984) theory.

Spirituality may be an important coping strategy for patients facing the multitude

of stressors associated with cancer and its potential life threat. There is evidence that

within Lazarus and Folkman’s (1984) transactional model of stress, spirituality among

cancer patients may be conceptualized as a form of emotion-focused coping, when

reducing the emotional distress associated with the disease becomes major focus

(Dunkel-Scheter et al. 1992). Additionally, spirituality has been conceptualized as a

flexible coping mechanism, which is consistent with the operational definition found in

empirical literature on spirituality and religiosity (Feher & Maly, 1999; Lamdan, Taylor,

Seigel, O’Connor, & Moran, 1997). Specifically, religious and /or spiritual coping

strategies have been found to be helpful in dealing with the emotional impact of cancer

(Feher & Maly, 1999; Jenkins & Pargament, 1995; Lamdan et al. 1997). Research

suggests that spiritual coping strategies involving relationship with self, others and

Ultimate other / higher power / God or nature were found to help individuals to find

meaning and purpose in illness, resulting in self-empowerment to cope with the current

3
stress until adaptation takes place (Reed, 1986, 1987; Sodestrom & Martinson, 1987;

Burkhardt, 1994; Smith, 1995; Belcher, Dettmore, & Holzemer, 1989).

The importance of spirituality as a resource was identified in several studies of

coping with life threatening and chronic illness (Gotay, 1984; Mickely, Soeken, &

Belcher, 1992; O’Connor, Wicker, & Germino, 1990; McCormick, Holder, Wetsel, &

Cawthon, 2001). In Brennan’s (2004) study, spirituality and religiousness were

considered as important personal resources that may foster the process of adaptation

(Brennan, 2004). Chiu’s (2001) study revealed that spiritual resources for Chinese

immigrant women with breast cancer in the US include family closeness, traditional

Chinese values, religion, alternative therapy, art, prose and literature and Chinese support

groups. The Chinese women gained spiritual strength and support in their connectedness

with their family (Chiu, 2001). Spirituality is an intrinsic energy source that has a basis in

both religion and existentialism (Fryback & Reinert, 1999; Kendall, 1994; Landis, 1996;

Relf, 1997).

According to Ferrell and her colleagues’ (2003) study, resourcefulness and

optimism were demonstrated by patients with ovarian cancer through sharing coping

mechanisms and survival strategies for dealing with symptoms (Ferrell, Smith, Cullinane,

& Melancon, 2003). Social resourcefulness is one of many coping resources used by

some persons when acute and chronic demands threaten to disrupt their psychological or

social equilibrium (Rapp, Shumaker, Schmidt, Naughton, & Anderson, 1998). Appraisal

and resourcefulness may help caregivers modulate their thoughts, feelings, and sensations

that influence their interactions with care recipients, therefore, improve their

effectiveness in managing disruptive behaviors (Gonzalez, 1997). However,

4
resourcefulness and spirituality have not been examined as strategies for coping and

sexual adjustment for patients undergoing cancer treatment.

Stress and Resourcefulness

Personal resourcefulness. Resourcefulness assists individuals in coping with

undesirable reactions to negative and stressful events that may have an impact on their

well-being (Rosenbaum, 1983). Research reported by Zauszniewsk and her colleagues

(2001) revealed that when faced with a stressful situation, having resourcefulness skills

was the most significant predictor of health (Zauszniewski, Chung, & Krafcik, 2001).

Research indicates that highly resourceful people use adaptive coping methods more

often and more effectively when faced with stressful events, and have more trust in their

ability to control their emotions when faced with difficult and problematic situations

(Rosenbaum & Jaffe, 1983; Rosenbaum & Rolnick, 1983). Specifically, an individual

who possesses internal resourcefulness can overcome stressful situations more effectively

(Rosenbaum & Rolnick, 1983; Rosenbaum & Palmon, 1984; Rosenbaum & Ben-Ari,

1985). Because internal resourcefulness involves the efforts to change an individuals’

internal state or to control oneself, it may positively influence one’s ability to overcome

negative cognitions and affect in a variety of situations (Fingerman, Gallagher-Thompson,

Lovett, & Rose, 1996). Thus, internal resourcefulness can be viewed as personal

resourcefulness.

Social resourcefulness. Social resourcefulness or seeking help from others is

important when an individual is unable to cope independently with a difficult situation

(Zauszniewski, 2006). Bailey and her colleagues’ (2003) study revealed that differences

in age and social resources exist between patients with colorectal cancer who did and did

5
not receive adjuvant chemotherapy (Bailey, Corner, Addington-Hall, Kumar, Nelson, &

Haviland, 2003). Social support consists of various social resources that can influence

adjustment (Northouse, 1988). Social support may reduce the negative impact of a

disease because of its anti-stressor effect (Cohen & Wills, 1985). Several researches

found that social support is one of the most important determinants of psychological well

being, health and coping behavior of patients faced by illness process (Schwarzer &

Leppin, 1992; Baider et al. 1996; Baider et al. 2004). Family members and relatives are a

source of social support for patients and have a potential influence on coping, morbidity

and mortality (Kotkamp-Mothes, Slawinsky, Hindermann, & Strauss, 2005). Ferrell’s

(2003) study indicated there is a substantial need for support from family, friends, and

other women, in women diagnosed with ovarian cancer (Ferrell, Smith, Ervin, et al.

2003).

Stress and Spirituality

Spirituality is an important factor throughout the diagnosis and treatment phases

of cancer as well as during the period of remission (Mickley & Soeken, 1993).

Spirituality was found to be profoundly related to decreased discomfort, decreased

loneliness, increased emotional adjustment among seriously ill patients (Gibbs &

Achterberg-Lawlis, 1978; Miller, 1983; Reed, 1986). Spirituality may be perceived as

personal views and behaviors that express a sense of relatedness to a transcendent

dimension or to something greater than the self that empowers, values, and integrates the

self (Kaye, 2000; Reed, 1987). Hiatt (1986) referred to the spirit as a non-corporeal and

non-mental dimension of the person that is the source of unity and meaning. Thus,

spirituality refers to the concepts, and behaviors that are derived from one’s experience of

6
that dimension. Spirituality represents a holistic human characteristic that is important in

human health and well-being (Brallier, 1982; Catterall, Cox, Greet, Sankey, & Griffiths,

1998; Miller, 1995; Neuman, 1989; Pilch, 1988; Reed, 1992).

Cancer as a Stressor and Sexuality

Researchers have identified sexuality as the major component of one’s life that is

affected by gynecological cancer and related treatments (Anderson, 1993; Lamb, 1990;

McCartney & Larson, 1987). Molassiotis and his colleagues (2000) stated that the areas

of life most affected by cancer and its treatments in Chinese women with gynecological

cancers were psychological health and social relationships. Three of the most distressed

facets of life were sexuality, psychological health, and spirituality (Molassiotis, Chan,

Yam, & Chan, 2000).

Cancer and cancer treatments have the potential to negatively affect body image

and sexuality, and diminish sexual functioning and feelings of sexual attractiveness

(Burbie & Polinsky, 1992). Anderson and ven der Does (1994) indicated that compared

with their healthy counterparts, cancer patients are more likely to abandon sexual activity

before they are emotionally ready to do so. As a result of these difficulties, personal

relationships have heightened importance for people with cancer. While the meaning of

sexuality varies as much for the cancer patient as it does for the healthy individual, sexual

contact may have special meaning for the cancer patient: sexuality and sexual expression

convey being human and being alive, and may hold special significance for those whose

experience with disease and treatment cause them to doubt their “human-ness” and the

value of living (Rice, 2000).

7
 The prevalence of sexual problems following standard abdominoperineal

resection (APR) has been reported to be from 15- 100% (Balslev & Harling, 1983; La

Monica, Audisio, Tamburini, Filiberti, & Ventafridda, 1985; Santangelo, Romano, &

Sassaroli, 1987; Koukouras et al. 1991). Sometimes the injury of the pelvic autonomic

nerve during surgery for the cancer treatment of colon and rectum is unavoidable,

especially when there is evidence of tumor growth into the plexus (Maas, Moriya, Kenter,

Trimbos, & Veld, 1999). Partial or complete excision of the rectum leads to neuropraxia

or permanent damage to the autonomic nerve, which will alter bladder and sexual

function (Maas et al. 1999). The incidence of sexual dysfunction varies from 18-59%

(Havenga et al. 1996). Moreover, adjuvant treatments generate additional physiological

assaults that further affect body image, sexuality, and family functioning (Spagnola et al.

2003).

Spirituality and Sexuality

Spirituality and sexuality have commonly been viewed as antagonistic from the

Western cultural perspective. However, some authors (e.g., Ammerman, 1990; Anderson

& Morgan, 1994; Chavez-Garcia & Helminiak, 1985; Coll, 1989; Gallagher, 1985;

Murray, 1991; Schnarch, 1991) suggest that spirituality is an integral component of

human sexuality. The integration of sexuality and spirituality is nothing other than the

harmonious status of the integrated human being—organism, psyche, and spirit

(Helminiak, 1998). The sexual experience of the integrated person includes a world of

meaning and value, a life of shared commitments. At some level it involves interpersonal

engagement, not merely physical and psychological connection (Helminiak, 1998). Spirit

is the dimension of human mind that makes people self-aware, self-transcending, open-

8
ended (Helminiak, 1998). Spirituality is also perceived as an important dimension in

helping people reach their sexual potential.

MacKnee (1997) indicated that sexuality and spirituality are related aspects of the

whole person. They can be complementary, somewhat interdependent, and enhancing of

each other. They are similar in origin and expression, and they work toward facilitating

the growth of the whole person and human relationships (MacKnee, 1997). Sexuality is

thought to foster or hinder one’s spiritual growth to some extent. Where spirituality and

sexuality converge is in their mutual striving toward wholeness and by connecting with

one another (Ullery, 2004). Spirituality incorporates the integration of all aspects of the

person and the resultant actualization of one’s fullest potential (Helminiak, 1987). Throne

(2001) concluded that sexuality is an intrinsic feature of a spiritual journey (Throne,

2001).

Resourcefulness and Sexuality

Coping is determined by cognitive appraisal, however, the ways in which people

actually cope also depend heavily on the resources that are available to them and

constraints that inhibit the use of these resources in the context of a specific encounter

(Lazarus & Folkman, 1984, p.157-158). A resourceful person is one who has many

resources and/is clever in finding ways to use them to counter demands. These resources

are properties of the person from which he or she draws upon in order to counter

demands or cope with stressful situations (Lazarus & Folkman, 1984, p.159). Research

by Bailey and his colleagues (2003) indicated that differences in age and social resources

exist between patients with colorectal cancer who do and do not receive adjuvant

chemotherapy (Bailey et al. 2003).

9
Cancer, Treatment and Sexuality

Sexuality has been described as a holistic phenomenon comprised of biological,

emotional, intellectual, spiritual, behavioral, and sociocultural components (Allen, 1987;

Denney & Quadagno, 1992). Sexuality is not merely the identification of biological and

psychosocial sexual orientation throughout one’s life, but it is an important component of

well-being (Shell & Smith, 1994). Sexuality is an important part of everyday life and it is

widely acknowledged to be a crucial component of subjectivity and self-identity (Weeks,

1986; Nye, 1999). The World Health Organization (WHO) (Mace, Banneman, & Burton,

1974) promotes the inclusion of sexuality within health care, arguing that all individuals

should be able to enjoy and control sexual and reproductive behavior with freedom from

fear, shame, guilt, and false beliefs (Mace Banneman, & Burton, 1974). Woods (1987)

indicated that dimensions of sexuality encompass sexual function, sexual self-concept,

and sexual relationships.

Cancer Treatment and Cultural Beliefs and Sexuality

A study by Tang and his colleagues (1996) described the Chinese beliefs about

sex, the harmonious balance and interaction between Yin (symbolizing women and

associated with interiority, deficiency and coldness) and Yang (symbolizing men and

associated with exteriority, excess and heat), the misconceptions the Chinese women with

gynecological cancer have about their sexual functioning and their fears related to

sexuality after a cancer treatment (Tang, Siu, Lai, & Chung, 1996). Self-treatments of

sexual problems by those Chinese women through traditional methods (e.g., use of

classic sexual manuals, such as the Sui Nui Ching, use of herbs, nutritious foods and

tonics, or use of sex aids) are discussed in their reports (Tang et al. 1996). Such cultural

10
issues can influence the individual’s perceptions of distressful events, and therefore affect

the individual’s behaviors.

Gaps in the Literature

A comprehensive review of the literature relevant to perceived stress, spirituality,

resourcefulness, and sexuality of rectal cancer patients leads to the identification of the

following gaps in knowledge. To date, most people with rectal cancer do try to return to

normal life and deal with daily life issues. However, cancer diagnosis and treatment may

have a significant impact on sexual activity, including functional, emotional and mental

effects (Katz, 2005). Much of the literature exploring sexuality in cancer patients focuses

on the physical problems that result from the disease process or treatment rather than on a

holistic perspective. However, sexual problems occurring in cancer patients are often

multifactorial. Emotional factors may interact with physiological factors to create and

maintain sexual dysfunction, that is, the loss of desire or ability to engage in a physical

relationship with one’s partner, which may in turn further affect other aspects of sexuality

(Schover, 1987).

Few studies have addressed sexuality issues for patients with colorectal cancer

(Shell, 2002). For the most part, prior studies have primarily focused on the

psychological impact of a colostomy (Bekkers, van Knippenberg, van Dulmen, van den

Borne, & van Berge Henegouwen, 1997; Sprangers, Taal, Aaronson, & te Velde, 1995;

Thomas, Turner, & Madden, 1988; Salter, 1992; Jenks et al., 1997). Several studies

conducted by European and American physicians focused on factors influencing sexual

function and quality of life after rectal cancer treatment (Schmidt, Bestmann, Küchler, &

Kremer, 2005; Hendren, O’Connor, Liu, Asano, Cohen, Swallow, MacRae, Gryfe, &

11
McLeod, 2005; Guren, Eriksen, Wiig, Carlsen, Nesbakken, Sigurdsson, Wibe, & Tveit,

2005). There is limited research done in Taiwan to investigate the physio-psycho-social

adjustment and social support for colorectal cancer patients (Mo, 2002), and health care

demands of cancer patients receiving chemotherapy (Hsiao & Dai, 2001). There has been

no research on how Taiwanese patients with rectal cancer undergoing cancer treatment

adjust to the changes in sexual function over time. Very little is known about the impact

of perceived stress on rectal cancer patients’ sexual health/integrity. No research has been

done to investigate the role of spirituality and resourcefulness on sexual health in patients

with rectal cancer.

To date, for the most part, our culture understands sexuality merely in terms of the

physical and the romantic (Helminiak, 1998). Health care professionals, patients, and

partners are often reluctant to discuss sexual functioning (Glasgow, Halfin, & Althausen,

1987; Ganz, 1990; Auchincloss, 1991). The World Health Organization (WHO) set the

goal to ensure that people can enjoy their sexuality and reproduction, and receive

appropriate care when needed (WHO, 1995). Nevertheless, clinical experience continues

to show that the majority of health care professionals do not ask most patients about

sexual concerns following cancer treatment (Anllo, 2000; Thaler-DeMers, 2002).

Research indicates that nurses wait for patients to raise sexual issues (Waterhouse &

Metcalfe, 1991). Barriers to discussing sexuality include cultural issues, discomfort about

the topic, and lack of educational preparation. Sexual response after colorectal surgery

remains an insufficiently understood area, particularly in view of the current high

prevalence of this tumor in the population (Monga, 1995).

12
 Additionally, competent clinicians usually discuss sexual issues with their patients

from a medical, therapeutic perspective, yet not from a philosophical point of view. It is

important for health professionals to formulate their values and philosophy towards

sexuality. Exploring this issue is also important for nursing professionals because

spirituality is a relevant topic in working with couples’ sexual-marital difficulties (David

& Duda, 1977; Schnarch, 1991).

A presumption exists that the issue of survival overrides the issue of sexuality

(Thaler-DeMers, 2002). Sexual functioning can be considered as a “luxury” when

survival has been the primary issue (Schover, 1987). As a result, the sexual outcomes

following cancer diagnosis and treatment are often overlooked (Thaler-DeMers, 2002).

Professional nurses are in a unique position to explore the phenomenon in patients with

rectal cancer undergoing cancer treatments. It is important that the treatment of cancer

patients should look beyond survival and address the issue of sexuality. Currently, no

research has been done to specifically examine perceived stress, spirituality,

resourcefulness, and sexuality in patients with rectal cancer. Therefore, the investigation

of spirituality and resourcefulness in relation to human sexuality in research is of

paramount importance.

Significance

The exploration of relationships among perceived stress, spirituality,

resourcefulness, and sexuality in patients with rectal cancer undergoing cancer treatments

is a significant contribution to the nursing discipline. The study findings contribute to

increased nursing knowledge by unraveling the mystery and clarifying misconceptions

about sexuality and its relationships with other phenomena and by demonstrating

13
relationships among demographic characteristics and cancer-related variables, perceived

stress, spirituality, resourcefulness, and sexuality.

From the theoretical viewpoint, this study extends knowledge of the phenomena

explicated within the Neuman Systems Model, Zauszniewski’s mid-range theory of

resourcefulness, and Lazarus’s stress and coping theory, through the examination of

relationships among perceived stress, spirituality, resourcefulness, and sexuality in rectal

cancer patients undergoing treatment in this study. In addition, the study results

contribute to filling the gap in scientific knowledge concerning the relationships among

perceived stress, spirituality, resourcefulness and sexuality that have been identified

through systematic literature review.

From the clinical and academic perspective, the study’s findings serve as a

beginning point for establishing future assessment of sexuality before treatment for rectal

cancer patients, and for the development of relevant educational programs for nursing

professionals and the advancement of health policy related to impairment of sexual

function.

The concept of holistic care appears to be central to contemporary nursing

practice, nursing professional are in a unique position to identify stressors, prevent illness,

and to promote the individual’s optimum wellness/harmony. For further research

methodology, this study is the first step in providing data for future experimental and

qualitative research studies. Therefore, this descriptive and exploratory study is the first

step in investigating these phenomena of interest and in providing the foundation for

future program of research.

14
 Purpose

The purposes of this study were: (1) to examine the relationships between

demographic characteristics and cancer-related variables, perceived stress, spirituality,

resourcefulness, and sexuality among rectal cancer patients, and (2) to explore the

differences in perceived stress, spirituality, resourcefulness, and sexuality for

demographic characteristics and cancer-related variables.

Theoretical Framework

The Neuman Systems Model (Neuman, 1995) provided a coherent and systematic

theoretical framework for guiding the study. The Neuman Systems Model fits well with

the holistic concept of optimizing a dynamic yet stable interrelationship of spirit, mind,

and body of the client in a constantly changing environment and society (Neuman &

Young, 1972). Theoretically, the model is related to Gestalt, stress, and dynamically

organized systems theories (de Chardin, 1955; Cornu, 1957; Edelson, 1970; Selye, 1950).

The Neuman Systems Model is based on the two major concepts of stress and the

reaction to stressors within the total environment of the client system. Stressors are

tension-producing stimuli with the potential for causing the client system instability

(Neuman, 1995, p.22). In addition, The Neuman Model can be described in terms of the

four meta-paradigm concepts of nursing: client, environment, health, and nursing

(Fawcett, 1989).

Neuman (1982) views the client (person) as an open system, composed of five

interactive dimensions: physiological, psychological, sociocultural, developmental, and

spiritual (Neuman, 1995). Physiological variables are bodily structures or functions, for

example, sexual function or dysfunction. Psychological variables are mental processes

15
and relationships, for example, family relationships or sexual relationships. Sociocultural

variables are combined social and cultural functions. Developmental variables refer to

age-related developmental processes and activities. The spiritual dimension includes

spiritual beliefs and influence (Neuman, 1995, p.28).

The concept of “system” can apply to any defined whole. Therefore, the client

system may be individuals, families, groups, community, an issue, and a society

(Neuman, 1995, p.22). The client is capable of interacting with the environmental intra-,

inter-, and extrapersonal influences by adjusting to it, or as a system, by adjusting the

environment to itself. The interaction adjustment process results in varying degrees of

harmony, stability, and balance between the client and environment (Neuman, 1995,

p.22). For example, stressors may be present in situational or maturational crises,

whether or not experienced as such by the client. In this study, the client system

represents individuals, patients with rectal cancer undergoing treatment.

Neuman (1982) suggests that the environment is the source of stressors and

provides resources for managing these stressors (Neuman, 1982). Stressors are occurring

within both the internal and external environmental boundaries of the client/client system.

Environmental stressors are classified as intrapersonal, interpersonal, and extrapersonal

in nature (Neuman, 1995, p.23). Cancer or reaction of surgery, radiation, and

chemotherapy are example of intrapersonal stressor. Interpersonal conflict, role

expectation or communication patterns are examples of interpersonal stressors. Resources

include coping skills, education, and strong family support (Neuman, 1982). Other

important considerations are the time of stressor occurrence, past and present condition of

the client, nature and intensity of the stressor, and the amount of energy required by the

16
client to adjust. An individual’s reaction to stressors is determined by the

interrelationships of these five variables (Neuman, 1995).

The flexible line of defense acts as a protective buffer system for the client’s

stable state and prevents stressor invasions of the client system. The normal line of

defense is impacted, while the invasion of particular stressor, a reaction to stress will take

place within the client system. In other words, when the normal line of defense has been

penetrated, the client presents with symptoms of instability or illness. Elements in each

line of defense and resistance are similar and related to the five variables: physiological,

psychological, developmental, sociocultural, and spiritual. Some examples are coping

patterns, life-style factors, and developmental, sociocultural, and belief system influences

(Neuman, 1995, p.27).

According to Lazarus (1981), coping is strongly associated with the client’s

perception and cognitions (Lazarus, 1981). Cognitive appraisal determines the degree of

stress felt (Lazarus & Folkman, 1984). The transaction model’s major focus on the

person’s perception of a stressor (such as life threat), which is extremely helpful for

dealing with feelings, attitudes, and beliefs that may affect the course of the disease and

the appropriateness of its management. Viewing oneself positively can also be regarded

as a very important psychological resource for coping. Those beliefs serve as a basis for

hope and sustain coping efforts in the most adverse conditions (Lazarus & Folkman, 1984,

p.159).

In Neuman’s Systems Model (Neuman, 1995), the concept of health or wellness is

viewed on a continuum. Wellness and illness are on opposite ends of the continuum.

According to Neuman (1995), health is equated with optimal system stability, that is, the

17
client’s best possible wellness state at any given time. The health of the client is

manifested in various, changing levels within a normal range, rising or falling through the

life span because of the client satisfactory or unsatisfactory adjustment to environmental

stressors. Neuman (1995) views health as a manifestation of living energy available to

preserve and enhance system integrity. The wellness-illness continuum implies harmony

or disharmony and that energy flow is continuous between the whole system of the client

and the environment (Neuman, 1995).

A conceptual framework for nursing, the Neuman Model is considered to be

predominantly wellness-oriented or holistic (Neuman, 1995, p.22). Neuman (1989) views

nursing as a “unique profession.” The Neuman Systems Model views nursing as being

primarily concerned with defining appropriate actions in stress-related situations or in

possible reactions within the client/client system; since environmental exchanges are

reciprocal, both the client and environment may be positively or negatively affected by

each other (Neuman, 1995, p.11). The goal of nursing in Neuman’s Model is to facilitate

optimum wellness through interventions aimed at “attaining, maintaining and retaining”

client stability (Neuman, 1989) by using primary, secondary or tertiary prevention as the

intervention strategy. The “intervener” can attempt to reduce the possibility of

encountering a stressor, and in some way, strengthen the individual’s flexible line of

defense in order to prevent a possible reaction (Neuman & Young, 1972). Primary

prevention occurs when stressors are suspected or identified, and varying degrees of

reaction to stressors have not yet taken place. The treatment of symptoms following a

reaction to stressors is known as secondary prevention. Tertiary prevention occurs when

intervention focuses on adapting, stabilizing, reeducating, or maintaining the individual

18
in a desired state of wellness after reconstitution has occurred (Neuman & Young, 1972;

Neuman, 1995, p.46).

Spirituality

Neuman (1989) views the concept of spirituality as “innate, a component of the

basic structure, whether or not it is ever acknowledged or developed by the client

system.” Spiritual development (e.g., growth in spirituality) is a two-directional (i.e.,

horizontal and vertical) dynamic process in which an individual becomes increasingly

aware of the meaning, purpose, and values in one’s life (Carson, 1989, p.26). Spirituality

is integrated within the physiological, psychological, sociocultural, and developmental

variables of the client (Neuman, 1989). The Neuman Systems Model (1989) emphasizes

that the spiritual dimension influences and is also influenced by all other variables. The

interrelationships of the spiritual variables, stressors, and reactions to stressors are seen as

the means to strengthen the spiritual nature of the person. For instance, suffering

(physical, mental, and spiritual) that occurs as a result of a stressor such as cancer and/or

cancer treatment may also have spiritual meaning and function as a source of motivation

for developing increase understanding and well-being (Neuman, 1989). Neuman (1989)

considers that the spiritual continuum can range from lack of awareness or denial of

spirituality to a highly developed spiritual consciousness that further influences the

client’s wellness and illness outcomes (Neuman, 1989). The physiological, psychological,

sociocultural, and developmental variables link with the spiritual variable to create a

unique individual person. In the ideal situation, there is a balance and harmony in all

variables that is seen as optimal wellness (Neuman, 1995, p.585). The relationship

19
between the spiritual variable and wellness can act as an energy source in achieving client

change and optimal system stability (Neuman, 1995, p. 29).

Spirituality is expressed and shaped by the accepted practices and by the beliefs

and values of a particular culture (Labun, 1988). Frankl (1952) views spirituality as a

person’s ability to give meaning to his or her life by creative values that facilitate the

achievement of important tasks. Experiential values make it possible for one to

experience goodness, beauty, truth, or a relationship with a special other. Ultimately,

attitudinal values affect how one chooses to endure unavoidable suffering (McSherry,

2000).

According to Frankl’s (1963) existential theory, people are able to find meaning

in their life and threatening circumstances by (1) what they take from the world (e.g.,

enjoying the pleasures of nature or receiving the love of others), (2) what they give to the

world (e.g., befriending and helping others), and (3) the attitude they choose for

themselves in response to suffering (Frankl, 1985). This theory may explain how

individuals with life-threatening illness such as cancer are able to attribute positive

meanings to their stressful situations.

Frankl (1987) and Travelbee (1966) suggest that spiritual needs are viewed as the

deepest requirements of self (McSherry, 2000, p.33). Several spiritual needs were

identified by authors, including meaning and purpose, love and harmonious relationships

(Shelly & Fish, 1988, Highfield & Carson, 1983; Narayanasamy, 1991), need for

forgiveness (Shelly & Fish, 1988; Narayanasamy, 1991), need for source of hope and

strength (Highfield & Carson, 1983; Narayanasamy, 1991), creativity, trust, maintain

spiritual practices, express one’s own belief in God or deity, and ability to express one’s

20
own personal beliefs and values (Narayanasamy, 1991). If the person’s spiritual needs

can be identified and fulfilled, then he or she can function harmoniously, find meaning,

value, purpose and hope in life even when life is threatened (Harrison, 1993).

Fulton (1995) extended Neuman’s theory by suggesting that providing spiritual

care can strengthen the client defenses against stressors (Fulton, 1995). The spiritual

component of care is an intervention resource for patients facing multiple challenges.

Spirituality can be modified by interventions to help patients maintain hope, optimism

and stability despite physical deterioration and environmental distress (Mattison, 2006;

Chan, Ng, Ho, & Chow, 2006). Spiritual interventions involving techniques of

psychosocial care are life review, story telling, constructivist approach, narrative

approach, the use of play and expressive art and movement to facilitate spiritual

integration for patients and their family members that the (Walsh, 1999). In addition, the

interventions consist of reflective, contemplation and meditation (e.g., guided imagery),

creative, interactional (Tuck, 2004), religious activities (e.g., prayer, acts of worship and

rituals), forgiveness therapy (Butler, Dahlin & Fife, 2002), and spiritual reading

techniques.

Spirituality is often overlooked or ignored by nurses as a resource for moving

clients toward wellness (Fulton, 1995). To promote client wellness within an

environment of stressors, nursing professionals should attend to all these variables,

including spirituality. Following this framework, spirituality can be viewed as an

emotion-focused coping strategy, because it is aimed at regulating the client’s emotional

response to the cancer and its treatment.

21
Lazarus’s Stress and Coping Theory

Lazarus and Folkman’s (1984) transactional model of stress defines coping as

constantly changing cognitive and behavioral efforts to manage specific external and /or

internal demands that are appraised as taxing or exceeding a person’s resources (Lazarus

& Folkman, 1984, p.141). Life-threatening illnesses, such as cancer, confront patients

with markedly different demands from one point in the illness to another (Lazarus &

Folkman, 1984, p.146). Lazarus and Folkman (1984) have asserted that various outcomes

of stressful situations primarily depend on the differences in an individual’s cognitive

appraisal of the stressor and his or her coping strategies and resources (Lazarus &

Folkman, 1984).

Cognitive appraisal is the process by which an individual evaluates a potentially

stressful event for meaning and significance to their own well-being (Lazarus & Folkman,

1984). Lazarus (1984) indicated that the cognitive process of appraisal is essential in

determining whether a situation is potentially threatening or harmful, and thus cognition

determines both the perception of stress (or appraisal), and the individual’s emotional

reaction to it. The perception of stress depends upon the extent of the environmental

demand and the amount of resources that an individual has to cope with that demand

(Lazarus & Folkman, 1984). Lazarus’s stress and coping theory proposes that stress

occurs when an event is evaluated as harmful or threatening (i.e., primary appraisal)

(Folkman & Lazarus, 1988; Lazarus & Folkman, 1984). In secondary appraisal, the ways

in which an individual actually copes depend heavily on the resources that are available

to him/her and the constraints that inhibit use of these resources in the context of the

specific encounter (Lazarus & Folkman, 1984, p.158). During secondary appraisal, an

22
individual assesses the availability and efficacy of resources for coping with the stressor

or altering the perceived threat or harm (Folkman & Greer, 2000). It would seem that to

cope with a situation is to attempt to control it by altering the environment, changing the

meaning of the situation, and/or managing one’s emotions and behaviors (Lazarus &

Folkman, 1984, p.170).

There are three forms of appraisal: irrelevant, benign-positive, and stressful. Also,

there are three types of stress appraisal: harm or loss, threat, and challenge (Coyne,

Aldwin, & Lazarus, 1981; Lazarus & Folkman, 1984; Lazarus, 1998). Lazarus and

Folkman (1984) indicated the meaning of stress in terms of appraisal; they asked whether

the stress-inducing event was perceived as a harm/loss, threat, or challenge, and whether

or not it was perceived as controllable. Each type of appraisal is expected to stimulate

different types of coping strategies (Lazarus & Folkman, 1984). No research study has

addressed how patients with rectal cancer appraise their cancer and treatment and

sexuality.

Coping strategies can include problem- or emotion-focused coping strategies. In

general, problem-focused coping is more probable when conditions are appraised as

amenable to change. Problem-focused coping is aimed at managing or altering the (cause

of the stress) problem causing the distress (Lazarus & Folkman, 1984). Emotion-focused

coping is directed at dealing with the individual’s stressful emotional response to the

situation. Emotion-focused coping is more likely to occur when there has been an

appraisal that nothing can be done to modify harmful, threatening, or challenging

environmental conditions.

23
 Three major adaptation outcomes of coping are identified by Lazarus and

Folkman: well-being, social functioning, and somatic health / illness (Lazarus & Folkman,

1984, p.181). Social functioning refers to the individual fulfillment various roles, for

example, as a parent, spouse, etc. Less frequently social functioning is defined

psychologically as satisfaction with interpersonal relationships and / or in terms of

requisite dispositions and skills. The result of coping may be directed at changing the

environment, or coping directed inward that changes the meaning of the event or

increases understanding (Lazarus & Folkman, 1984, p.142).

Resourcefulness

In Zauszniewski’s (2006) mid-range theory, resourcefulness consists of two

dimensions, self-help and help-seeking. Other constructs in the theory include

antecedents or contextual factors, intervening variables, and quality of life (Zauszniewski,

2006). Both self-help (personal resourcefulness) and help-seeking (social resourcefulness)

skills are considered to be learned through formal and / or informal processes

(Rosenbaum, 1990). Zauszniewski (1996) reported that healthy elders with both self-help

and help-seeking coping strategies had better psychological well-being and physical

functioning than elders who did not use these two strategies or elders who used only one

of these strategies (Zauszniewski, 1996). Thus, it has been proposed that teaching

personal and social resourcefulness strategies is beneficial for promoting and maintaining

healthy physical, psychological, and social functioning throughout life (Zauszniewski,

2006).

In addition, contextual factors influencing personal and social resourcefulness

involve intrinsic and extrinsic factors. Based on empirical studies, intrinsic factors

24
include demographic characteristics (e.g., age, gender, race), number of chronic

conditions, presence of illness symptoms, and perceived stress (Fingerman et al. 1996;

LeFort, Gray-Donald, Rowat, & Jeans, 1998; Zauszniewski & Chung, 2001;

Zauszniewski, Chung, & Krafcik, 2001). Extrinsic factors involve social network size,

social support, and health care orientation (Dirksen, 2000; Rapp et al. 1998). The intrinsic

and extrinsic factors within this theoretical model include the situational, physical, and

personality factors identified in Rosenbaum’s theory of self-control (Rosenbaum, 1990).

Process regulators are seen as intervening factors that may mediate or moderate

the effects of the intrinsic and extrinsic factors on personal and social resourcefulness

(Zauszniewski, 2006). Rosenbaum (1990) identified that process regulating cognitions

affect resourcefulness. Other process regulators, including motivation, energy, and affect

(e.g., self-esteem, negative affectivity), are suggested by theoretical knowledge and

empirical studies (Zauszniewski, 2006). Positive health outcomes, including adaptive

functioning in depressed adults (Zauszniewski, 1995, 1996), life satisfaction in persons

with chronic pain and in healthy elders (LeFort et al. 1998; Zauszniewski, 1996),

perceived health in caregivers and in diabetic women (Rapp et al., 1998; Zauszniewski &

Chung, 2001), and health practices in women with type II diabetes (Zauszniewski &

Chung, 2001), reflect the construct of quality of life.

The theory of resourcefulness has been applied in empirical research with healthy

college students, adults with various psychological and physical conditions, and

community-dwelling and chronically ill elders (Zauszniewski, 2006). However, empirical

studies of resourcefulness in patients with rectal cancer undergoing cancer treatment are

remarkably absent from current literature.

25
 Definition of Constructs, Concepts and Variables

Stress is defined as a process in which environmental demands exceed the

adaptive capacity of a person, resulting in psychological and biological changes (Cohen,

Kessler, & Gordon, 1995). Stress is an interaction, transaction or process mediated by

other factors (Fisher, 1986; Johnson, 1986).

Appraisal is defined as a process by which an individual evaluates a potentially

stressful event for meaning and significance to their own well-being (Lazarus & Folkman,

1984). Appraisals are categorized as positive, irrelevant, or stressful. Situations are

judged as more stressful when linked to greater psychological distress (Folkman, Lazarus,

Gruen, & DeLongis, 1986). In this study, appraisal was operationally defined as a

cognitive process by which an individual identifies or evaluates the properties of

situational factors (cancer and treatment) that are potentially threatening, harmful, or

challenging; the individual’s cognitions determine their perception of stress and their

emotional reaction to stress.

The perception of stress depends upon the extent of the environmental demand

and the amount of resources that an individual has to cope with that demand (Lazarus &

Folkman, 1984). In this study, perceived stress was defined as the degree of subjective

perception of situational demands resulting from cancer and cancer treatment that exceed

the individual’s resources for adjustment and is appraised as stressful.

Coping involves constantly changing cognitive and behavioral efforts to manage

specific external and/or internal demands that exceed a person’s resources (Lazarus &

Folkman, 1984, p.141). In this study, adjustment/adaptation was defined as a process of

coping by which the individual continuously appraises and reappraises the person-

26
environment relationship and changes his/her thoughts and acts to manage the stressful

situations, including minimizing, avoiding, tolerating, accepting the stressful events in an

attempt to control the environment and to find meaning in the situations (Lazarus &

Folkman, 1984, p.141-142). Coping strategies are intervening factors that may mediate

or moderate the effects of perceived stress on sexuality for patients with rectal cancer.

Spirituality and resourcefulness were considered as coping strategies in this study.

Spirituality is the unifying force of a person that permeates all of life and is

manifested in one’s being, knowing, and doing; the interconnectedness with self, others,

nature, and God / Transcendent (Dossey & Guzzetta, 2000). Spirituality refers to the

propensity to make meaning through a sense of relatedness to dimensions (Reed, 1992).

The operational definition of spirituality in this study was self-awareness in searching for

meaning or purpose of life and suffering, through the interconnectedness with others,

nature, or environment, and a Supreme Being; it generates strength and manifests an

inner peace and harmonious status. Resourcefulness was defined as a repertoire of the

individual’s learned behavioral skills, which included personal (self-help) and social

(help-seeking) resourcefulness for coping with negative and stressful events that may

have an impact on their well-being

Wellness was the outcome variable and it was defined as a person’s subjective

perception of sexual health including sexual function, sexual self-concept, social role,

communication and sexual satisfaction. The interrelationship of sexual function, sexual

self-concept, and sexual relationships provided the focus for considering sexual health

throughout the life span. Because each dimension is interrelated with the other two

dimensions, a change in one dimension produces changes in the others. The integration of

27
the three dimensions of sexual health produces well-being (Woods, 1987). Sexual health

is defined as the integration of the somatic, emotional, intellectual, and social aspects of

the sexual being in a way that is positively enriching and enhances personality,

communication, and love (WHO, 1975). In this study, sexual health was operationally

defined as sexual integrity, which involved the perception of sexuality that influenced

personal and social behavior, the expression of self, and relationships with others that is

important throughout adulthood. Each individual is comfortable with and recognizes

him/herself as a sexual being. Sexuality includes a person’s roles, relationships, values,

and beliefs (Yura & Walsh, 1983). Sexual function refers to the ability of a person to give

and receive sexual pleasure (Woods, 1987). The operational definition of sexual function

involves the integration of emotional, cognitive, behavioral, and physiological

components, which includes the sexual response cycle (i.e., libido, arousal, and orgasm),

values, and beliefs. Sexual dysfunction is defined as the inability to express one’s

sexuality as consistent with personal needs and preferences. In men, this includes

impotency and retrograde ejaculation; in women, this includes dyspareunia, decreased

lubrication, or inability to achieve orgasm (Clark, 1993).

Sexual self-concept is the image that one has of him/herself as a man or woman

and the evaluation of masculine/feminine roles, body image, and the evaluation of self

image against personal and cultural standards (Woods, 1987). A person’s self-views are

thought to be dynamic and multifaceted (Andersen & Cyranowski, 1994). Women’s

views of themselves as passionate / romantic, and open / direct to sexual experiences are

examples of positive sexual self-concept, while men’s views are passionate / romantic,

behaviorally open/liberal, and powerful/independent (Andersen & Cyranowski, 1994).

28
The operational definition of sexual self-concept in this study was a cognitive view about

sexual aspects of oneself derived from past experience and manifested in current

experience, and the evaluation of role function and body image based on personal and

cultural standards.

The perception of sexual satisfaction may depend on a wide range of sexual

behaviors and feelings that are relevant to a person’s definitions of satisfaction. Sexual

relationships are the interpersonal relationships in which one’s sexuality is shared with

another (Woods, 1987), whereas the overall sexual relationship is a critical determinant

of sexual satisfaction (Wellisch, Jamison, & Pasnau, 1978). The operational definition of

sexual satisfaction in this study was the extent of one’s subjective perception and feelings

about the sexual behaviors, interpersonal relationships, and role function as well as

communications with his/her partners.

Hypothesized Relationships among Research Variables

Hypothesized relationships at the theoretical level among stress, adaptation and

health/wellness were derived from the Neuman Systems Model (Neuman, 1995), and

Lazarus and Folkman’s stress and coping theory (1984). Stress and wellness/health

outcome are two major concerns in the whole client system (Neuman, 1995). Stress

occurs when situational demands exceed an individual’s resources for adjustment

(Lazarus & Folkman, 1984). An individual’s optimum state of wellness can be attained

through interactive adjustment process with the environmental stressors (Neuman, 1995).

Hypothesized relationships at the conceptual level were derived from empirical

evidence, Lazarus and Folkman’s stress and coping theory (1984), Zauszniewski’s

resourcefulness theory (2006) and Neuman’s Model (1995). The outcomes of stressful

29
situations depend heavily on an individual’s appraisal, coping strategies and resources,

whereas appraisal determines the degree of perception of stress. The process of cognitive

appraisal determines whether a situation is potentially threatening, challenging or harmful

(i.e., primary appraisal), and therefore cognition further determine both the perception of

stress and the individual’s emotional reaction to the situation. During secondary appraisal,

an individual assesses the availability and efficacy of resources to cope with the stressor

or to change the perceived threat or harm (Folkman & Greer, 2000). The perception of

stress depends upon the extent of the environmental demand and the available and

efficacy resources that an individual has to cope with the stressor (Lazarus & Folkman,

1984). There are three types of stress appraisal: harm or loss, threat, and challenge

(Coyne et al. 1981; Lazarus & Folkman, 1984; Lazarus, 1998). Each type of appraisal

may stimulate different types of coping strategies (i.e., problem-focused and emotion-

focused coping) which determine adaptive outcomes of coping: well-being, social

functioning, and somatic health /illness (Lazarus & Folkman, 1984). In this proposal, the

adaptive outcome is sexual health.

Hypothesized relationships at the variable level were derived from empirical

evidence, Zauszniewski’s resourcefulness theory (2006) and Neuman’s Model (1995).

Spirituality and resourcefulness (including personal and social resourcefulness) can be

regarded as coping strategies under this theoretical framework. Coping strategies can be

viewed as intervening factors that may influence an individual’s line of defense (Neuman,

1995). In this proposal, sexuality is the outcome variable.

In this study, perceived environmental stressor, which included cancer diagnosis

and treatment (i.e., type of surgery, radiotherapy, and/or chemotherapy), were measured

30
by 10-item version Perceived Stress Scale (PSS; Cohen, Kamarck, & Mermelstein, 1983)

and Cognitive Appraisal of Health Scale (CAHS; Kessler, 1998). Spirituality was

measured by the Body-Mind-Spirit Well-Being Inventory-Spirituality (BMSWBI-Sp)

(Ng, Yau, Chan, Chan, & Ho, 2005). Resourcefulness, which consisted of personal

resourcefulness and social resourcefulness, was measured by the resourcefulness scale

(i.e., 16-item Self-Control Scale (SCS) and 12-item Help-Seeking Resource Scale

(HSRS). Sexuality, consisting of sexual function, sexual self-concept, sexual satisfaction

involving communication and sexual relationship, was measured by the International

Index of Erectile Function (IIEF; Rosen et al. 1997) or Female Sexual Function Index

(FSFI; Rosen et al. 2000), Sexual Self-Schema Scale including female (SSSS-F;

Anderson & Cyranowski, 1994) and male versions (SSSS-M; Anderson, Cyranowski, &

Espindle, 1999), and two scales of Evaluating and Nurturing Relationship Issues,

Communication, Happiness, ENRICH; Olson, 1996): ENRICH Couple Scales-

Communication (ENRICH-CO), and ENRICH Sexual Relationship Scale (ENRICH-SRS,

Olson, 1996) (Figure.1.1 The Theoretical Framework Figure.1.2 Study Model).

31
Constructs Stress Adaptation Health/Wellness

Conceptual Appraisal Coping Strategies Sexual Health

Variables Perceived Stress Spirituality Resourcefulness Sexuality

Personal Social Sexual Sexual Sexual

function self-concept satisfaction

Empirical PSS CAHS BMSWBI-Sp RS IIEF/ SSSS-M/ ENRICH-

FSFI SSSS-F

CO SRS

Figure.1.1. The Theoretical Framework

Assumptions

Several assumptions supporting the guided theoretical framework for the study

are listed as follows:

1. The individual is in a state of wellness or illness in varying degrees in relation to

the dynamic composite of five interacting variables: physiological, psychological,

sociocultural, developmental, and spiritual.

2. The whole structure of the individual is maintained by interrelationships of

system components, through regulation that changes the dynamics of the open

system (Neuman, 1995).

3. Each individual is viewed as a unique sexual being.

4. Stress has the power to disturb the equilibrium of the client system (Neuman,

1995).

32
 5. The perception of stress (appraisal) depends upon the extent of external and/or

internal environmental demand and the amount of resources that an individual has

to cope with that demand.

6. The outcomes of stressful situations primarily depend on the differences in an

individual’s cognitive appraisals of the stressor and his or her coping strategies

and resources (Lazarus & Folkman, 1984).

7. The dynamics and change that characterize coping as a process are a function of

continuous appraisal and reappraisal of the shifting person-environment

relationship, focusing on what is happening, its significance, and what can be

done (Lazarus & Folkman, 1984).

8. Spirituality is innate to the client system and involves subjective meaning that a

stressor has for the client and the attitude the client chooses in response to a

distressful situation (Neuman, 1995).

9. Both self-help (personal resourcefulness) and the help-seeking (social

resourcefulness) skills are learned through formal and informal process

(Rosenbaum, 1990).

10. Nursing interventions attempt to assist the client to regain or maintain an optimum

wellness by using “intervening factor” (Neuman, 1995).

Research Questions

1. What are the differences in or relationships of major study variables (perceived stress,

spirituality, resourcefulness, and sexuality) in relation to the demographic characteristics

(i.e. age (A), gender (B), education (C), and religion (D) in rectal cancer patients? (Q1A-

Q4D)

33
2. What are the differences in or relationships of major study variables (perceived stress,

spirituality, resourcefulness, and sexuality) in relation to the cancer-related variables (i.e.,

stage of disease (E), type of treatment (F), time since operation (G), and comorbid

conditions (H) in rectal cancer patients? (Q1E – 4H)

3. What are the relationships between perceived stress and sexuality (Q5), spirituality and

sexuality (Q6), resourcefulness and sexuality (Q7), perceived stress and spirituality (Q8),

spirituality and resourcefulness (Q9), and perceived stress and resourcefulness (Q10) in

patients with rectal cancer?

Demographic and Q4
Cancer-related
variables Q1
Perceived Stress Q5 Sexuality
A. Age
B. Gender
Q2 Q8 Q6
C. Education
D. Religion Spirituality
Q7
E. Stage of disease Q3
F. Type of Q9 Q10
treatment
G.Time since Resourcefulness
operation
H. Comorbid Figure 1.2. Study Model.
conditions

34
 CHAPTER II: REVIEW OF LITERATURE

Introduction

This chapter provides an integrative review of literature relevant to each concept

of this study. Empirical studies of each concept of interest, including perceived stress,

spirituality, resourcefulness, and their relationships to sexuality are reviewed and their

strengths and weakness are evaluated. The Neuman Systems Model, a mid-range theory

of resourcefulness, and the stress-coping model will be described as foundational

frameworks for the study. Lastly, studies related to the demographic and cancer-related

variables are discussed.

Significance

Prevalence of Cancer

Cancer has been recognized as a life-threatening disease for many years and one

that has a profound impact on a person -- physically, psycho-sociologically, emotionally

and spiritually. Colorectal cancer is the second most prevalent cancer and the third

leading cause of cancer death world-wide (Parkin, 2001). Every year approximately one

million new cases of colorectal cancer are diagnosed (Ferlay, Bray, Pisani, & Parkin,

2001). Colorectal cancer is currently the second most common cancer among females and

males in the United States (U.S.) (NCI, 2009) and Taiwan (Taiwan Report, 2006), and

third most common in Europe (Becker, Muscat, & Wynder, 2001; Weir et al. 2003).

Rectal cancer is one of the most prevalent cancers with an estimation of 146,970 new

cases annually in the U.S. (NCI, 2009). Incidence rates of colorectal cancer increase with

age and over 40% of cases occur in subjects over the age of seventy-four (Arveux,

Boutron, Mrini, Arveux, & Liabeuf, 1997).

35
 Survival rates for colorectal cancer vary depending upon stage of the disease. The

Dukes staging system, devised in the 1930s and modified in 1978, was the most widely

used classification which uses the letters A, B, C, and D to describe the stage of the

cancer. Until 1987, the American Joint Committee on Cancer (AJCC) developed a new

classification for colorectal cancer, the TNM staging system, (T stands for the extent of

tumor invasion, N for the extent of lymph node involvement, and M for distant metastasis

(spread) to other organs or tissues), which is more precise than the other systems and is

consistent with the way many other types of cancers are staged (Levin et al., 2006, p.77-

93; Oncologychannel, 1998-2009). In the U. S., the five-year overall survival rate for

patients diagnosed with stage II and III colorectal cancer was 64% (stage IIB ~ IIIB:

72~64%) (O’Connell, Maggard, & Ko, 2004). About 90% of surviving five years was

reported for patients with localized disease that has not yet grown through the bowel wall

(stage I) (Levin et al. 2006, p.94).

Cancer Treatment (Surgery and Adjuvant Therapy)

Cancer treatment involving surgery and adjuvant therapy impose major

physiological stress, disrupting many organs and systems. For patients with advanced

colorectal cancers (i.e., disease confined to the pelvis), treatment consists of rectal

resection and often preoperative or postoperative radiotherapy and/or chemotherapy

(Enker, 1992).

Surgery has been considered as the predominant treatment for patients with rectal

cancer over the past 20 years. In 1970, an abdominoperineal resection (APR) with a

permanent colostomy was the major treatment for most patients with a carcinoma of the

middle or low rectum (Chatwin, Ribordy, & Givel, 2002; Levin et al. 2006, p.180); the

36
surgeon performs a “sphincter-sacrificing” proctectomy by removing a portion or all of

the sigmoid colon, the entire rectum, the adjacent mesentery, and the anus. A permanent

colostomy is constructed and the patient wears a pouch to collect stool and gas from the

colon (Levin et al. 2006, p.180).

To date, because of the evolution of surgical techniques, most patients with rectal

cancer (80 to 90%) receive surgery of low or ultralow anterior resection (LAR) (Williams

& Johnston, 1984; MacFarlane, Ryall, & Heald, 1993; Frari & Tschmelitsch, 2002). The

surgeon is able to do a sphincter-sparing protectomy (anterior resection) with a very low

anastomosis deep in the pelvis but may be concerned that the connection may not heal

properly and that feces could leak from the anastomosis. In such case, the surgeon may

decide to do a temporary proximal diversion will temporarily divert feces into an ostomy

pouch and prevent stool from going through the new connection. Once the anastomosis is

totally healed after six to 12 weeks, a second operation is done to reverse the temporary

colostomy or ileostomy (Levin et al. 2006, p.180-181). Accordingly, the advantages of

LAR are physical, psychological and social comfort in comparison of APR (Chatwin et al.

2002). Avoiding a permanent colostomy is one of the goals of surgery for rectal cancer

(Frari & Tschmelitsch, 2002).

In cancers of the mid- or low rectum, a total mesorectal excision (TME) is the

standard procedure, which inevitably leads to an anastomosis within 5 cm from the anal

verge (Heald, 1988; Heald & Ryall, 1986; Frari & Tschmelitsch, 2002). It achieves

complete excision of the rectum together with its draining lymphatics, and results in low

rates of local recurrence (Heald, 1988). This technique employs dissection in the tissue

plane that separates the mesorectal fascial envelope from the presacral fascia (Heald,

37
1988). In the process of total mesorectal excision, the rectum with its surrounding layer

of fatty tissue, the mesorectum, is resected as an intact capsule with negative tumor

margins in the majority of cases (Havenga, Maas, DeRuiter, Welvaart, & Trimbos, 2000).

However, care must be taken because excessive traction during the dissection or lateral

dissection outside this plane may lead to neuropraxia or permanent injury to the

sympathetic and parasympathetic nerves that course along the lateral pelvic side-walls.

Inadvertent damage to these nerves will result in postoperative bladder and sexual

dysfunction, the severity of which will be dependent on the extent of the injury and the

relative components of the autonomic supply affected (Masui, Ike, Yamaguchi, Oki, &

Shimada, 1996; Maas et al. 1998; Nesbakken, Nygaard, Bull, Carlsen, & Eri, 2000).

Nowadays, the use of adjuvant therapy has been recommended to decrease the

risk of local recurrence and improve survival. The local recurrence (defined as pelvic

recurrence occurring in the presence or absence of distant metastasis disease) rates of

patients undergoing adequate surgery alone range from 4% to 35% (Havenga et al. 1999).

Radiotherapy is often considered as part of the adjuvant treatment in rectal cancer

(Martenson et al. 1999). Thus, curative radiation therapy may be used in colorectal cancer,

with the goal of eradicating disease that is local, or at most regional in character. In

addition, adjuvant chemotherapy with 5-FU and levamisole administered intravenously

for one year has proved to be effective after curative surgical resection of Duke’s stage C

colon carcinomas (Penna & Nordlinger, 1996). In the U.S., post-operative chemotherapy

plus radiotherapy is the most widely used approach, whereas in Europe there has been a

move towards pre-operative radiotherapy (Martenson et al. 1999). Combined radiation

and chemotherapy has shown statistically significant improvement in local and distant

38
disease control as well as in overall survival for stage II and III rectal cancer (Tepper et al.

1997).

Complications

Despite the improvement in outcomes for rectal cancer patients, a variety of

sexual problems caused by cancer and its treatment (i.e., surgery and adjuvant therapy)

were identified (Schover, Schain, & Montague, 1989; Tepper et al. 1997). The

detrimental effect on sexuality is recognized as a complication after surgical resection of

the rectum (Chorost, Weber, Lee, Rodriguez-Bigas, & Petrelli, 2000; Pocard et al. 2002).

The incidence of sexual problems or dysfunction following various cancer treatments has

been reported to range from 40% to 100% (Derogatis & Kourlesis, 1981) or 15 to 100%

(Balslev & Haring, 1983; La Monica et al. 1985; Santangelo et al. 1987; Koukouras et al.

1991) or 18 to 50% (Quah, Jayne, Eu, & Seow-Choen, 2002), which varies greatly and

depends on the extent of resection and the surgical technique used (Quah et al. 2002).

Gaps in the Knowledge Base

Ignorance of Sexual Function

Sexual function is often considered less important than cancer-oriented treatments

(Butler, Banfield, Sveinsen, & Allen, 1998; Dunn, Croft, & Hackett, 1998; Schover, 1999;

Lemieux, 2004). Reports indicated that more than half of the respondents (56%) were

sexually inactive after a multimodality treatment for advanced rectal cancer (Mannaerts,

Rutten, Martijn, Hanssens, & Wiggers, 2002). Although these detrimental effects on

sexuality are not as immediately life threatening as cancer itself, as treatment goes on,

day to day stress becomes overwhelming and many concerns related to coping with

cancer and its treatment emerge for long term cancer survivors.

39
Inadequate / Inconsistent Assessment of Sexuality

One reason for variation in percentage of sexual dysfunction ranging from 15 to

100% may be the inconsistent approaches to the assessment of sexual dysfunction across

studies (Schmidt, Bestmann, Küchler, & Kremer, 2005a). The inconsistent assessments

of sexuality result in various outcomes that do not adequately indicate the extent of

sexual problems and do not allow for comparisons across studies.

Misconception from Culture Effect

Despite the influence of western culture on Chinese society, the Chinese

perspective and behavior toward sexuality has greatly changed; nevertheless, the

traditional Chinese sexual beliefs is still predominant over contemporary Chinese

societies such as Taiwan, China, Hong Kong, and Singapore (Tang et al. 1996).The

perception of sexuality in the Chinese society is deeply influenced by Confucian and

Taoist beliefs that a disharmony of Yin (represent for women) and Yang (represent for

men) factors is a result of excessive sexual activity. Confucian sexual philosophy

emphasizes procreation and social order, whereas the Taoist sexual philosophy is related

to the balance among Yin (women) and Yang (men), personal health, and longevity

(Tang et al. 1996). Sexual dysfunctions of Chinese women with gynecological cancer are

deemed as an imbalance of Yin and Yang elements (Ngan, Tang, & Lau, 1994). The

misconception of stopping or reducing sexual activities among Chinese women with

gynecological cancer is related to the prevention of the spread of cancer to partners,

preservation of energy for postoperative recovery, and the submissive and passive roles

of women in the patriarchal traditions of men rejecting their partners during illness,

which reflects the impact of cultural beliefs (Ngan et al. 1994). Similarly, Mo’s (2001)

40
study from Taiwan indicated that patients with colorectal cancer would stop or reduce

their sexual activities, because such activities may make their cancer worse.

Difficulty in Discussing Sexual Issues

To date, it is still considered improper and embarrassing to speak about sexual

issues. A retrospective review of the medical records indicated that the majority of

patients (37 of 52 or 71%) were not provided an opportunity to discuss the risk of sexual

dysfunction before treatment (surgery and radiation) (Chorost et al. 2000). Sexual

dysfunction of the patient is rarely taken into consideration not only in the preoperative

discussion, but also, in the postoperative treatment (Hendren et al. 2005). Health care

professionals find it difficult to discuss sexuality as an important aspect for patients’

quality of life (Lemieux, 2004). Evidence supports that both health care professionals and

patients don’t bring themselves to speak about the sexual issues.

Studies of Sexuality Focusing on Physiological and Prevalence

Sexuality is an integral part of every human being (Shell & Smith, 1994).

Sexuality refers to sexual integrity, which involves not only a physical perspective but

also an emphasis on psychosocial needs involving role function, relationships, values,

and beliefs (Steinke & Patterson-Midgley, 1998). Sexuality has received little attention in

the process of cancer care (Butler et al. 1998; Schover, 1999). Evidence demonstrates that

sexuality has been studied in prostate, breast, and gynecological cancer survivors.

Nevertheless, the sexuality of colorectal cancer patients has seldom been addressed in

studies (Shell, 2002). There are limited studies exploring the individual psychosocial

impacts of colostomy for patients with rectal cancer (Sutherland, Orbach, Dyk, & Bard,

1952; Sprangers, Taal, Aaronson, & te Velde, 1995). The issues of sexuality are actually

41
and clinically encountered by the subject. A tendency was reported for medicine to

conduct a series of retrospective studies regarding the prevalence of sexual function or

dysfunction and quality of life undergoing rectal cancer surgery among the developed

countries since 2002 (Chatwin et al. 2002; Camilleri-Brennan & Steele, 2002; Hendren et

al. 2005; Schmidt, Bestmann, Küchler, Longo, & Kremer, 2005b). Moreover, sexuality

has recently started receiving attention in the palliative care of rectal cancer patients

(Lemieux, 2004). A qualitative study mentioned that only one subject (N=10) had

previously been asked about sexuality as part of clinical care, whereas all subjects

suggested that changes in sexuality resulting from cancer treatment should be addressed

by health care professionals and included in holistic care (Lemieux, 2004).

Additionally, in reality, our society tends to focus on the physical aspect of

sexuality and the feeling of romance (Helminiak, 1998) rather than viewing sexuality

holistically. Sexual issues after colorectal surgery remain an insufficiently understood

area, particularly in view of the current high prevalence of this tumor in the population.

Literature Review of Theories

Neuman Systems Model

The Neuman Systems Model was developed in 1970 as a total person approach to

patient problems (Neuman & Young, 1972). The Neuman Systems Model (1995) has

proven to be a reliable, scientifically wholistic, easily understandable theoretical base for

nursing and other activities (Neuman, Newman, & Holder, 2000).

The Neuman Systems Model is predominantly wellness oriented and wholistic. It

is based on stress and reaction within the total environment of the defined client as a

system (Neuman & Fawcett, 2002, p.12). Four concepts of nursing’s metaparadigm --

42
person, environment, health, and nursing -- are composed of the content of the Neuman

Systems Model (Neuman & Fawcett, 2002, p.4), which is derived from and is explicitly

related to Gestalt, stress, and dynamically organized systems theories (de Chardin, 1955;

Cornu, 1957; Edelson, 1970; Lazarus, 1981, 1999; Selye, 1950). Theoretically, the

Neuman Systems Model has some similarity to Gestalt theory, which implies that each

client system is surrounded by a perceptual field that is in dynamic equilibrium. The

word Gestalt literally means whole (Brallier, 1982, p.42). The Neuman Systems Model

also relates to field theories, which reflect that all parts of the system are intimately

interrelated and interdependent (Edelson, 1970). The organized system of the field is the

primary concern. In the wholistic Neuman Systems Model, the system considers (1) the

occurrence of stressors, (2) the reaction or possible reaction of the client to stressors, and

(3) the particular client as a system, involving the simultaneous effects of the interacting

variables - physiological, psychological, sociocultural, developmental, and spiritual. de

Chardin (1955) and Cornu (1957) suggest that in all dynamically organized systems the

properties of a system part are determined by the whole. This means that no part can be

isolated and each must be viewed as part of the whole. A single part influences our

perception of the whole, and the patterns or features of the whole influence our awareness

of each system part (Neuman & Fawcett, 2002, p.13).

In the Neuman Systems Model (1982), disharmony among an individual’s

biological, psychological, sociocultural, spiritual, and developmental components reduces

wellness or stability. The Neuman Model describes the individual as having a basic

survival core surrounded by three levels of defense against environmental stressors: 1)

lines of resistance – homeostatic mechanisms that attempt to stabilize and maintain the

43
individual’s normal line of defense; 2) normal lines of defense – the stability factors

developed over time, including intelligence, coping abilities, outlook on life, and

problem-solving abilities; 3) flexible lines of defense – protective buffers for preventing

stressors from breading through the line of defense.

Few studies address the application of the Neuman Systems Model to rectal

cancer patients. However, systems approaches are evident in the following publications.

The Neuman Systems Model was used in Molassiotis’s (1997) study to guide the

assessment of quality of life in clients with cancer who had a bone marrow transplant.

Adaptation to illness / treatment and quality of life was influenced by physiological,

psychological, sociocultural, and developmental variables (Molassiotis, 1997). In a case

study, Weinberger (1991) described an analysis using the Neuman Systems Model to

determine the effects of a colostomy on a client with colon cancer (Weinberger, 1991). In

addition, applying the Neuman Systems Model and Rosenbaum’s learned resourcefulness

theory as conceptual frameworks, Klainin (2002) examined the relationships among

occupational stress, dissatisfaction with family relationships, learned resourcefulness on

women’s health (Klainin, 2002). In a study by Nagia and Hoda (1989), the examination

of the effect of psychoeducational preparation 1 to 2 days prior to surgery on

postoperative state anxiety among Egyptian bladder cancer patients with urinary

diversion was based upon the Neuman Systems Model. The results revealed that stress

was associated with being cancer patients followed by the impact of surgery on their

bodies and on their social and marital life (Nagia & Hoda, 1989). However, there is no

study applying the Model on patients with rectal cancer undergoing treatment. This

model will be applicable to adult patients with rectal cancer as the presence of stresses

44
(i.e., cancer and cancer treatment) does not reduce the client system from

stability/wellness as long as the client is able to maintain harmony.

A conceptual framework provides a foundation for nursing practice and forms the

structure for organizing its systems, methods, and tools (Christmeyer, Catanzareti,

Langford, & Reitz, 1988). The Neuman Systems Model presents a comprehensive

systems-based conceptual framework for nursing (Neuman, 1989). There are a number of

reasons for choosing the Neuman Systems Model as a nursing model in this study. Since

the patient with rectal cancer receiving treatment is constantly impacted by his/her

environment, it is imperative and important that the nursing model chosen would view

the individual as a client system. What is included within the boundary of the system

must have relevance to nursing. One of the critical reasons for choosing the Neuman

Systems Model is the view of the client from a wholistic framework, in which five

variables -- physiological, psychological, sociocultural, developmental, and spiritual --

interact harmoniously with the environment to mitigate possible or potential harm from

internal and external stressors (i.e., cancer and its treatment). Its conceptual breadth,

flexibility, and systemic properties will provide an integrated view of sexuality for rectal

cancer patients undergoing treatment.

Lazarus’s Stress and Coping Theory

People experience stress and cope with it by using learned patterns of thoughts,

feelings, and behaviors. Stress appraisal by the individual in the Lazarus’s stress

transaction model explicitly plays a significant role in the coping process. The word

stress was initially used by Hans Selye (1936) to describe a physiologic pattern that

prepared the individual for “flight or fight” or the defense reaction, involving the

45
sympathetic nervous system and the adrenal-medullary system (Brallier, 1982, p.42).

Since the 1960s there has been growing recognition that while stress is an inevitable

aspect of the human condition, it is coping that makes the big difference in adaptation.

Lazarus (1966) suggested that stress be treated as an organizing concept for

understanding a wide range of phenomena of great importance in human and animal

adaptation (Lazarus & Folkman, 1984, p.11). Stress involves a cognitive process and a

physiological event with sociocultural and psychological antecedents as well as

consequences. There are wide individual differences in the perception of what is stressful

and when it is stressful (Eisdofer, Cohen, Kleinman, & Maxim, 1981, p.176).

Psychological stress involves a particular relationship between the person and the

environment that is appraised by the person as exceeding his or her resources and

endangering his or her well-being (Lazarus & Folkman, 1984, p.19). Grinker and Spiegel

(1945) indicated that appraisal of the situation requires mental activity involving

judgment, discrimination, and choice of activity, based largely on past experience

(Lazarus & Folkman, 1984, p.25). Appraisal processes illustrate the cognitive mediation

of the stress reaction and the coping process (Lazarus & Folkman, 1984, p.37). Cognitive

appraisal can be understood as the process of categorizing an encounter, and its various

facets, with respect to its significance for well-being. Because cognitive appraisal

depends on the individual’s subjective interpretation of a transaction, it is

phenomenological (Lazarus & Folkman, 1984).

When a person interprets an encounter as damaging, threatening or challenging,

psychological stress resides in both the situation and the person. It arises from the

adaptational relationship as it is appraised by the person. Such a relationship is best

46
termed a transaction, which means that not only does the environment affect the person,

but also that the person affects the environment; both influence each other mutually in the

course of an encounter (Lazarus, 1981, p.183).

Cohn and Lazarus (1979) indicated that illness can induce several threats

including threats to one’s self-concept (loss of autonomy and control, one’s self-image

changes), threats to bodily integrity and comfort (bodily disability, permanent physical

changes, other negative symptoms of illness or treatment), threats to one’s emotional

equilibrium, and threats to the fulfillment of customary social roles (separation from

family, friends, and other social supports), which the individual must cope with. In this

study, coping involves external stimuli such as dealing with threats of adjuvant

chemotherapy and / or radiation therapy, alterations in sexual function, as well as internal

psychic phenomena such as threatened sexual self-concept, perceived alteration of sexual

satisfaction and relationships. Coping strategies are the specific techniques that a sick

individual selects to deal with the illness and its consequences. Coping is context-specific

behavioral and emotional processes in which an individual appraises, encounters, and

recovers from contact with a stressor, whether a minor daily hassle or a major life change

(Lazarus & Folkman, 1984). Coping consists of “efforts, both action-oriented and

intrapsychic, to manage (i.e., master, tolerate, reduce, minimize) environmental and

internal demands and conflicts among them” (Lazarus & Launier, 1987, p.311).

Generally, the coping process may include a two-staged cognitive process of primary and

secondary appraisals (Lazarus & Folkman, 1984). With the primary appraisal, the

individual determines whether the adverse conditions or stressful events are a threat

(“Am I still okay with this situation?”), and the secondary appraisal includes a review of

47
choices of action if a threat is perceived (“What can I do now?”). Responses include

behaviors such as emotional, cognitive, and physical activities. In addition, coping

resources are important to an individual’s response to the diagnosis of cancer and its

subsequent treatment. Two coping resources that have been noted in the Zauszniewski’s

theory of resourcefulness and literature to have a significant impact on adjustment to

illness are self-help and help-seeking resources involving social support.

In summary, Lazarus’s transactional stress model provides guidance explaining

the individual’s perception of the stress (the process of cognitive appraisal of the situation)

and how the availability and the efficacy of resources to the individuals will influence the

ways (coping alternatives) they deal with adverse situations encountered. Thus, appraisal

of the situation and the coping alternatives are central to the transactional stress model of

Lazarus and Folkman (1984). In a transactional model, threat refers to the integration of

both separate personal and environmental factors in a given transaction to form new

meanings via appraisal. The transactional model is concerned with process and change

(Lazarus & Folkman, 1984, p.326). The meaning and significance of the stressful event

(appraisal) to the individual are key components of the model to determine the coping

strategies being used. However, Lazarus’s stress and coping theory only describes the

importance of available resources to the individual such as social support during

secondary appraisal that determines the perception of stress or the individual’s emotional

reaction to stress. Zauszniewski’s resourcefulness theory therefore provided direction for

this study.

Studies of stress and coping. Measurements of stress and coping focus on three

types of major variables, that is, stress, appraisal, and coping (Lazarus & Folkman, 1984,

48
p. 306). In a study done by Dunkel-Schetter and colleagues (1992), five coping strategies

are examined: social support/direct problem solving, distancing, positive focus, cognitive

escape/avoidance, and behavioral escape/avoidance. The cancer patients in the Dunkel-

Schetter et al. (1992) study rated their coping efforts concerning the aspects of cancer and

found that one of the most stressful cancer-related problems was limitations in physical

abilities, appearance, and lifestyle (24%) (Dunkel-Schetter, Feinstein, Taylor, & Falke,

1992).

A qualitative study, Lev (1992) described the coping strategies that were used by

47 patients including colorectal cancer for adapting to adjuvant treatment (chemotherapy

and radiotherapy). Results indicated that whether or not cancer treatments were

perceived as stressful depended on individual’s resources and coping mechanisms (Lev,

1992). Krause (1991) conducted an exploratory study to determine the coping process of

patients with cancer. The results showed that 68% of patients with cancer have feelings

of shock, fear, sorrow, and bitterness. The subsequent methods of coping included

emotional evaluation of their situation in life, in comparison with earlier experiences and

those of other cancer patients, and appeals for social welfare assistance (Krause, 1991).

In short, researchers identified that available resources and coping strategies to

cancer patients determined their perception of stress or emotional reaction to stress

(cancer and treatment) during appraisal process. One study addressed the adaptation of

adjuvant therapy on population of colorectal cancer. These findings indicate that coping

process of an individual involves cognitive appraisal and seeking for social resources.

49
Resourcefulness Theory

When a person experiences stressful events, resourcefulness plays a critical role in

his or her appraisal process. Resourcefulness has been studied over two decades.

Zauszniewski’s (2006) mid-range theory of resourcefulness incorporates two essential

forms of resourcefulness: personal (self-help) and social (help-seeking) resourcefulness

(Zauszniewski, 2006, p.3). Miller (1980) indicated that coping consists of the learned

behavioral responses that are successful in lowering arousal by neutralizing a dangerous

or noxious condition (Miller, 1980). Learned resourcefulness (LR) is a basic behavioral

repertoire learned not only through conditioning but also through modeling as well as

formal and informal instructions (Rosenbaum, Franks, & Jaffe, 1983, p.57). Rosenbaum

(1990) emphasized only the independently performed cognitive-behavioral skills that are

used for managing potentially disturbing internal processes, whereas the Zauszniewski’s

theory of resourcefulness also recognizes the importance of depending on others for help

or assistance in managing adversity. Nadler (1990) viewed seeking help from others as

the “other side of the coin” of resourcefulness, and Rapp and colleagues (1998) used the

term “social resourcefulness” to describe the behaviors used to establish and maintain

supportive relationships and obtain help from others (Zauszniewski, 2006, p.7). This

study of rectal cancer patients who are receiving treatment used this more recently

developed mid-range theory of resourcefulness, which involves self-help and seeking

help from others.

According to Rosenbaum (1983), resourcefulness involves self-control skills that

allow an individual to control the potential suffering associated with stressful events,

including the cognitions, emotions, and sensations that interfere with the performance of

50
daily activities (Rosenbaum, 1990). Self-control of internal processes following the

effects of a stressful event may include minimization or elimination of disturbing

thoughts, feelings, or impulses so that the individual may function at an optimal level

(Rosenbaum, 1990). Self-control behavior is always associated with certain process

regulating cognitions (PRC). Specifically, the execution of the self-control behavior

comprises of a number of cognitive phases. First, in the representational phase, the

individual experiences an emotional and/or a cognitive reaction to real or imagined

changes within oneself, or within the environment. For instance, the result of rectal

cancer surgery and adjuvant therapy may cause temporal or permanent impaired sexual

function and disruption of individual’s self-images and depression. Counseling may be

recommended to the individual and / or a change in his/her well-established sexual life-

style. Second, during the self-evaluation phase, the individual engages in Lazarus and

Folkman’s (1984) “primary and secondary appraisals.” In the primary appraisal, the

individual evaluates whether the event is harmful or threatening. If the event is

undesirable, the individual may ignore it, and no self-control behavior will happen as a

result. On the other hand, if the individual feels threatened or in danger by the disruption,

the individual may begin a secondary appraisal process. For example, the individual

receiving cancer treatment may appraise the availability of resources that he / she can use

to improve his / her sexual health. During the secondary appraisal stage of the self-

evaluation phase, the individual develops expectations for the future. According to

Bandura, (1977, 1982) there are two basic expectations that guide human behavior:

outcome expectations and self-efficacy expectations. Outcome expectations refer to the

individual’s belief that a specific course of action will lead to a desired goal. On the other

51
hand, self-efficacy expectations refer to the individual’s belief that he or she is capable of

performing the necessary actions to attain the desired goal (Rosenbaum, 1990, p.7).

Personal (self-help) resourcefulness is viewed as the ability to maintain

independence in daily tasks despite potentially adverse situations (Rosenbaum, 1990).

Personal (self-help) resourcefulness consists of the cognitive-behavioral skills learned

throughout life, which are labeled “learned resourcefulness” (LR), to reinforce the

performance of daily activities despite the presence of disturbing thoughts, feelings,

sensations, or impulses (Rosenbaum, 1990). Rosenbaum’s (1983) theory of learned

resourcefulness (LR) proposes that resourceful individuals will not be affected by the

environmental and cognitive factors presumed to cause anxiety and depression, and that

they will be able to independently perform daily tasks despite potentially adverse

circumstances. Thus, learned resourcefulness (LR) serves as a basis for coping with

stressful situations (Rosenbaum & Palmon, 1984). In Rosenbaum’s perspective, learned

resourcefulness (LR) is an intervening variable between potentially disturbing internal

processes (cognitions, emotions, sensations) and the performance of target behaviors

(Rosenbaum, 1983).

According to Rosenbaum’s conceptualization (1980, 1990), the skills of learned

resourcefulness (LR) encompass three dimensions. First, redressive self-control refers to

the use of positive self-instruction and cognitive restructuring of thoughts, mood, and

pain control to resume the normal functioning that has been disrupted. Second,

reformative self-control is the application of problem-solving strategies to delay

immediate gratification for better future outcomes and to disrupt the customary way of

functioning and, thereby, adopt a new behavior. Third, perceived self-efficacy involves a

52
general belief in one’s ability to cope effectively with internal processes or stimuli

evoked by a stressful event (Rosenbaum, 1980, 1990).

The other form of resourcefulness, social (help-seeking) resourcefulness, is

viewed as the ability to seek help from others when unable to function independently

(Nadler, 1990). Social resourcefulness may involve formal help-seeking sources such as

professional or informal help-seeking sources such as family or friends (Zauszniewski,

1996, 2001). According to Zauszniewski (1996), personal and social resourcefulness

should be viewed as two complementary dimensions, both of which are important for

physical and psychological health (Zauszniewski, 1996). Other major constructs of the

theory of resourcefulness involve antecedents or contextual factors, process regulators or

intervening variables, and quality of life or positive health outcomes (Zausniewski, 2006).

According to Zauszniewski’s (2006) research on resourcefulness, the target

populations have included healthy college students, adults with various psychological and

physical conditions, and community-dwelling and chronically ill elders (Zausniewski,

2006). Empirical studies of resourcefulness have used research methods that range from

standard psychometric studies, to designs that characterize individuals with high or low

resourcefulness and investigation of predictive models, to testing of interventions that

teach resourcefulness to elders (Zauszniewski, 2006). However, there are a few studies

related to resourcefulness among male and female patients with rectal cancer.

Studies of personal (self-help) resourcefulness. Personal resourcefulness involves

the use of self-help strategies for coping with adversity or challenge. Braden (1990)

tested a self-help model in 396 subjects with diagnoses of rheumatoid arthritis or

arthritis-related conditions. The results showed that one of the self-help model variables,

53
enabling skill, was the strongest predictor of self-help (β = .42). The total explained

variance of self-help was 55% (R2=.55), which indicated that the greater the enabling

skill, the greater the ability for self-help and vice versa. Self-help was strongly related to

life quality (β = .62). Self-help and uncertainty explained 49% of the variance in life

quality (Braden, 1990).

A self-help model tested in Kreulen and Braden’s (2004) study supported the

linkage between self-help-promoting interventions related to self care, self-care outcomes,

and client morbidity. Client factors such as age, size of social network, disease stage,

receipt of chemotherapy, resourcefulness, and uncertainty significantly influenced

predicted relationships. The patterns of relationships for women receiving treatment for

breast cancer (N=307) were examined, and the results revealed delayed behavioral

responses to the interventions (Kreulen & Braden, 2004).

In Dirksen’s (2000) study, a conceptual model predicting well-being among 84

breast cancer survivors was tested; the findings indicated that social support and

uncertainty were significant predictors of resourcefulness and explained 12% of the

variance in resourcefulness. Resourcefulness and social support were significant

predictors of self-esteem and explained 33% of the variance in self-esteem. In

combination, social support, resourcefulness, and self-esteem were significant predictors

of well-being and explained 42% of the variance in well-being (Dirksen, 2000).

In a sample of 137 chronically ill elders, Zauszniewski and associates (2001) used

model testing to examine the relationships among social cognitive factors reflecting

enabling skills (learned resourcefulness), internal motivation for health (health self-

determinism), help responses (coping responses) and a measure of physical and

54
psychosocial health for predicting health. The results indicated that learned

resourcefulness was associated with the use of informal help, which can be defined as

help from others including family, friends, and over-the-counter medications, whereas

health self-determinism was related to self-help and formal help. Resourcefulnesss had a

direct effect on the informal help response. Thus, resourcefulness (β=.24, p < .01) was a

significant predictor of health (Zauszniewski et al. 2001).

On the basis of Rosenbaum and Palmon’s (1984) study on helplessness and

resourcefulness in 25 female and 25 male subjects coping with epilepsy, the findings

demonstrated that subjects with greater resourcefulness coped better with their disability

and were emotionally impacted by depression and anxiety significantly less than subjects

who demonstrated lower resourcefulness. Moreover, subjects with greater

resourcefulness perceived greater control over their health (Health Locus of Control

Scale (HLC), F(1,44) = 6.11, p < .05) and the occurrence of seizures (Perceived Control

of Seizures (PCS), F(1, 44) = 4.41, p < .05) (Rosenbaum & Palmon, 1984).

In addition, Rosenbaum and Ben-Ari (1985) investigated the role of self-control

processes (i.e. resourcefulness skills) in learned-helplessness by assessing the differential

reactions to uncontrollability of individuals who had a high or low resourcefulness after

exposure to failure. Results revealed that the resourcefulness determines the subjects’

self-reactions during exposure to uncontrollability or failure (Rosenbaum & Ben-Ari,

1985). These studies confirmed that the individuals with a greater resourcefulness can

control their situations more effectively.

In a study by Fingerman and associates (1996), the relationships among 143

caregivers’ internal resourcefulness, demands of the caregiving situation, and caregivers’

55
self-reported coping behaviors were examined relative to changes in dysphoric affect

over time. The findings indicated that internal resourcefulness was the only significant

predictor of changes in dysphoric affect over time. In this study, internal resourcefulness

was defined as the individuals’ repertoire of skills and behaviors to deal with negative

affective states. Internal resourcefulness therefore involved the ability to use self-control

to combat difficulties that arise. Thus, internal resources may allow individuals to

overcome negative cognitions and affect in a variety of situations, similar to personal

resourcefulness (Fingerman et al. 1996).

In conclusion, numerous studies have investigated the relationships between

enabling skills, self-help, and life quality or health. These results reflect the importance of

internal resourcefulness (i.e., personal resourcefulness or learned resourcefulness) in

promoting independence and healthy, productive lifestyles in adults with cancer and

chronic illness.

Studies of social (help-seeking) resourcefulness. Perceived social support is

modulated by the patients’ coping behavior (Kotkamp-Mothes et al. 2005). According to

the “buffer hypothesis” (Cohen & Wills, 1985), social support acts as an anti-stressor

reducing the negative impact of a disease.

In a study of 337 (a total sample of 383 subjects) older patients with colorectal

cancer before and after treatment, Bailey and colleagues in UK (2003) examined social

resources by using a self-reported severity of morbidity scale. Results showed that an

association existed between patients’ social resources rating and treatment with adjuvant

chemotherapy. In addition, Duke’s C patients who received adjuvant chemotherapy were

less likely to be impaired in social resources than Duke’s C patients who did not

56
(adjusted odds ratio 0.14-1.03, p= 0.06). In that study, the key social resources were

deemed to be meaningful and productive relationships or contacts, including: 1) the

number of people whom the respondent knows well; 2) the number of home

conversations; 3) the number of visits outside the home; 4) availability of a trusted

confidant relationship; 5) frequency of loneliness; 6) frequency of visits to / from

relatives and friends, and 7) availability / amount of help during illness. After controlling

for age, patients who were treated with adjuvant chemotherapy were, in general, less

likely to be impaired in social resources. Thus, there were differences in age and social

resources between patients who receive treatment and who did not receive it (Bailey et al.

2003).

Hunter and colleagues (2003) explored symptom perceptions and health beliefs as

predictors of intentions to seek medical help in 546 women with breast cancer. Results

showed that the cognitive component of the self-regulation model accounted for

approximately 22% of the variance in intention of help-seeking. Identity (β=0.45, p <.001)

was a significant predictor of intention to seek help. Intention to seek medical help may

be mediated for potential breast-cancer symptoms (Hunter, Grunfeld, & Ramirez, 2003).

A qualitative study of social concerns of women with ovarian cancer (with a total

sample of 766), which was conducted by Betty and colleagues from 1994 to 2000 (2003),

examined social well-being; the theme of social support was the most common (N=251),

followed by support offered by family and friends (N=163) and support gained from

other ovarian cancer survivors (N=122). The statements related to social support were

addressed as follows: “the things that have helped me the most is my wonderful family

and some great friends;” “a number of our neighbors have offered to help in any way that

57
they can;” “I have learned to accept help and not to try to do this alone;” “people in

hospital has been so supportive of me..,” etc. (Ferrell, Smith, Ervin, et al. 2003).

In Baider and colleagues’ (2004) randomized, prospective study, factors

influencing the psychological distress of breast cancer patients (n=210) and their

husbands during remission were identified. Results showed that women whose partners

refused to participate in the interview reported significantly less perceived family support

(Baider et al. 2004).

In summary, based on these qualitative and quantitative studies, cognitive factors

can explain about 22% of an individual’s of help-seeking intentions. In addition, help-

seeking may serve as mediator in the study. The social support resources include family,

friends, neighbors, and other cancer survivors. Patients learned to access resources not

only from within themselves or their own abilities, but also to seek help from others

(social support) that enhance greater adaptation toward adverse situations; patients,

thereby, maintain or promote physical and psychological health, and, eventually, life

satisfaction. Among these studies, the majority of the target population was cancer

survivors; however, there is only one study focused on colorectal cancer patients. Thus,

more empirical studies related to patients who are receiving treatment for colorectal

cancer will be needed to provide additional evidence.

Studies of personal and social resourcefulness. Pedro (1998) described the

relationships between self-esteem, learned resourcefulness, and social support to health-

related quality of life (HRQL) as well as their predictive value to HRQL for 456 long-

term cancer survivors. The findings revealed a strongly positive relationship between

self-esteem and HRQL (r = .69, p=.00), a moderately strong inverse relationship between

58
learned resourcefulness and HRQL (r = -.32, p =.01), and a statistically significant

inverse relationship with HRQL (r = -.38, p=.00), which was only associated with the

total loss of social support. In addition, taken together self-esteem, learned

resourcefulness, and the loss of social support explained over half the variance (R2 = .53)

of HRQL (Pedro, 1998).

In a study by Zauszniewski (1996), self-help and help-seeking behaviors in

relation to depressive cognitions, adaptive functioning, and life satisfaction among 120

healthy elders were examined. The results showed that self-help was significantly

correlated with greater adaptive functioning, but help-seeking was not. Additionally, the

study found that elders who used both self-help and help-seeking reported greater life

satisfaction. The study reported that elders who used both self-help and help-seeking

strategies had better psychological well-being and physical functioning than elders who

did not use these two strategies or elders who used only one of these types of strategies.

However, self-help and help-seeking were not associated (Zauszniewski, 1996).

In short, personal resourcefulness (self-help/learned resourcefulness) and social

resourcefulness (help-seeking) can be considered predictors of physical and

psychological well-being. Learned resourcefulness, lack of help-seeking, and self-esteem

can explain about 50% of the variance of HRQL. Moreover, two forms of resourcefulness

play an important role for health promotion and maintenance, especially among elders.

Measurement of personal resourcefulness. On the basis of the cognitive-

behavioral literature on self-control (Meichenbaum, 1977; Goldfried, 1980), Rosenbaum

(1980) developed a Self-Control Schedule (SCS), which was found to be both valid and

reliable and has since become the most widely used measure for assessing learned

59
resourcefulness/personal resourcefulness (Rosenbaum, 1980, 1990). Rosenbaum (1980,

1990) believed that three dimensions (redressive self-control, reformative self-control and

self-effective) can be captured by SCS. However, Zauszniewski’s (1997) study revealed

that 11 of the 36 items did not load on the expected factor, and 9 had significant cross-

loadings. These results suggested that the three dimensions of personal resourcefulness

are interrelated and not clearly distinct (Zauszniewski, 1997). In addition, LeFort’s (2000)

study indicated low correlations between self-efficacy and resourcefulness for both

pretest and posttest (r = .13 and r =.25, respectively). Both studies suggested that self-

efficacy may not be a dimension of personal resourcefulness. Thus, personal (self-help)

resourcefulness encompasses redressive and reformative self-control dimensions

(Zauszniewski, 2006).

Measurement of social resourcefulness. The social resourcefulness scale (SRS)

was developed by Rapp et al. (1998), whereas personal resourcefulness (i.e., learned

resourcefulness) was measured by Rosenbaum’s Self-Control Schedule (SCS). However,

to date, no published studies were found that use a measure that captures both personal

and social resourcefulness. However, in 2006, the development and testing of such a

resourcefulness scale was described in the context of a psychometric study (Zauszniewski,

Lai, & Tithiphontumrong, 2006).

Measurement of both forms of resourcefulness. Currently, the newly developed

Resourcefulness Scale (RS) by Zauszniewski and her colleagues (2006) is the only

measure that captures both personal and social resourcefulness and has been found the

importance for health promotion and maintenance for older adults (Zauszniewski et al.

2006). The RS is composed of 16-item personal (self-help) resourcefulness which was

60
associated to Rosenbaum’s Self-Control Scale (SCS) and 12-item social (help-seeking)

resourcefulness. The RS has been tested in the population of chronically ill elders from

U.S., however, it has not been tested in a diversity of sample ranged from young or

middle-age to older adults, such as male and female rectal cancer patients in Asia.

Review of Related Concepts

Perceived Stress (cancer and treatment)

Stressful life events are assumed to increase the risk of disease when they are

appraised as threatening or otherwise demanding, and coping resources are judged as

insufficient to address that threat or demand (Cohen & Williamson, 1988, p.31). It is

generally believed that stressful events detrimentally influence health status. When

current demands imposed by stressful events exceed ability to cope, a psychological

stress response is elicited (Lazarus & Folkman, 1984).

In this study, the concept of perceived stress was operationalized as the degree of

subjective perception of situational demands resulting from cancer and cancer treatment

that exceed the individual’s available and efficient resources for adjustment and are

cognitively appraised as stressful events. Measurements that have been used to capture

perceived stress include three versions of the Perceived Stress Scale (PSS4, PSS10, and

PSS14), and 32-item Cognitive Appraisal of Health Scale (CAVH; Kessler, 1998) or 13-

item CAVH (Ahmad, 2005). The Perceived Stress Scale-10 (PSS10) appears to provide

at least as good a measure of perceived stress as does the longer scale (Cohen &

Williamson, 1988).

Studies of perceived stress. Empirical studies related to perceived stress and

health practices were reviewed and supported as below. Frequency of serious illness and

61
both serious and nonserious symptoms of illness were positively related to perceived

stress. Small correlations were also observed between perceived stress and health

practices, such as shorter periods of sleep, infrequent consumption of breakfast, smoking

cigarettes, decreased frequency but increased quantity of alcohol consumption, less

frequent physical exercise, and increased frequency and variety of illicit drug use (Cohen

& Williamson, 1988).

In Cohen and his colleagues’ (1993) study, data from a large (N=2,387

respondents) probability sample of US citizens collected in 1983 reported that

psychological stress increases susceptibility to infectious agents. A mediator effect was

found between stressful life events and illness (Cohen et al. 1993). The results of a study

by Cohen and Williamson (1988) indicated that the relationship between Perceived Stress

Scale (PSS) scores and scores on measures of health and health behavior were not

definitive as to whether stress acted as the causal agent, whether stress resulted from

those related factors, or whether both factors were influenced by other variables (Cohen

& Williamson, 1988, p.45). The researchers used the Perceived Stress Scale 10-item scale

in this study (Cohen & Williamson, 1988). In another study, Ho and associates (2004)

examined emotional control in Chinese female cancer survivors. Correlation analyses

suggested that cancer survivors with greater emotional control tended to have greater

stress, anxiety, and depression and tended to adopt negative coping strategies for the

cancer (Ho, Chan, & Ho, 2004).

In summary, based on these study findings, perceived stress was assumed to be a

mediator of the relationship between stressful events and health and health practices.

Associations between perceived stress and illness, symptoms of illness, and a wide range

62
of health behaviors were also demonstrated. No causal inference was illustrated from

these reports. However, these findings cannot be generalized to the population of

Taiwanese adults who have been diagnosed with rectal cancer. Moreover, the

relationships between the perception of stress associated with rectal cancer and its

treatment, and the issues of sexuality have not been explored.

Sexuality

Cancer represents a threat to the well-being of the individual, as well as a

potential detriment to interpersonal relationships and sexuality (Anderson, Anderson, &

deProsse, 1989). Sexuality was conceptually defined in the literature related to

reproductive health care in medicine (such as contraception), sociology, and a few in the

palliative care literature. Empirical studies of sexuality include women with breast or

gynecological cancer and men with testicular or prostate cancer.

Sexuality derives from a complex interplay of culture, society, family structure,

gender, and biology (Lamb & Woods, 1981). Sexuality is an essential component of an

individual’s wellness and personality throughout his/her life span (Waxman, 1996;

Fallowfield, 1992; Shell & Smith, 1994). Sexuality does not diminish in importance as a

result of chronic or terminal illness (Fallowfield, 1992; Shell & Smith, 1994).

Dailey (1984) described five components of sexuality: 1) sensuality, related to our

need to be aware of and acceptance of our own body through all five senses; 2) intimacy,

described as our need and ability to experience emotional closeness to another human

being, and to have that emotional closeness predictably returned in kind; 3) sexual

identity, described as a continual process of discovering who we are in terms of our

63
sexuality; 4) reproductive aspects, deal involving how one deals with fertility and

conception, and child rearing; and 5) sexualization.

Human sexuality is viewed as complex and pervades one’s biological being, sense

of self and interpersonal relationships; specifically, this includes sexual dimensions such

as sexual function (ability to give and receive sexual pleasure), sexual self-concept (self-

image as male or female and masculine or feminine roles, body image, and inclusion of

cultural standards), and sexual relationships (interpersonal relationships inclusive of

sexual sharing) (Woods, 1987). Sexuality is more than the sex urge and sex act; sexuality

is a way to express loyalty, passion, affection, esteem, and affirmation of one’s body and

its functioning (Bulter & Lewis, 1993).

Self-concept or self-schema is integrally related to one’s sense of sexual well-

being (Gordon & Snyder, 1980, p.272). Self-concept is the individual’s total thoughts and

feelings about self (Rosenberg, 1979). Self-concept is composed of physical self (body

image), functional self (role performance), personal self (moral self, self-ideal, and self-

expectancy) (Driever, 1984), and self-esteem (self-worth). Self-esteem is a crucial

component of self-concept and a determinant of functioning. A feeling of worth is the

foundation to taking action to achieve improved health. Chronic illness has an impact on

self-concept (Miller, 2000).

Sexual self-concept involves cognitive generalizations regarding sexual aspects of

the self and represents a core component of one’s sexuality (Andersen, 1999). A sexually

schematic/conceptual man is one who views himself as loving and passionate, powerful

and independent, and open-minded in his sexual attitudes. Andersen’s (1999) study

suggested that schematic and aschematic men hold very different views of the sexual self,

64
and that these sexual self-views relate to differences in both sexual behaviors and

responsiveness. Women with positive and nonconflicting sexual self-views describe

themselves as emotionally warm and passionate individuals who are behaviorally open to

romantic and sexual relationships. These women tend to be liberal in their sexual

attitudes and are generally uninhibited by self-consciousness, embarrassment, or sexual

anxiety (Andersen, 1999).

Based on the review of literature, in this study, sexuality was operationalized as a

harmonious state of integrative characteristics that demonstrate attitudes and behaviors

composed of individual’s roles, inter- and intra-personal intimate relationships,

communication, values, beliefs, culture, physical functions, and self-concept, presented

through the means of sexual function, sexual self-concept, and sexual satisfaction

(Woods, 1987; Bulter & Lewis, 1993; Anderson, 1999; Miller, 2000; Steinke & Patterson,

1998).

A variety of measurements have been used to measure sexuality including the

Female Sexual Function Index (FSFI; Rosen et al. 2000), the International Index of

Erectile Function (IIEF; Rosen et al. 1997), women’s form of the Sexual Self-Schema

Scale (SSSS-F), men’s form of the Sexual Self-Schema Scale (SSSS-M; Andersen &

Cyranowski, 1994), Evaluating & Nurturing Relationship Issues, Communication,

Happiness (ENRICH) couples scales – communication (ENRICH-Co), and ENRICH

Sexual Relationship Scale (ENRICH-SRS) (Olson, 1996).

Studies of sexuality. Nosek (1996) studied the notion of wellness among women

with physical disability. Five themes related to sexuality emerged as follows: 1) having a

positive sexual self-concept; 2) having information about sexuality; 3) having positive,

65
productive relationships; 4) managing barriers; and 5) maintaining optimal health and

physical and sexual functioning (Nosek, 1996). Additionally, in a qualitative study, the

poems from cancer patients’ experiences showed that the damaged bodies of cancer

patients are still sexual in nature. This implies that cancer patients still perceived their

bodies to be sexual (Van der Riet, 1998). Patient’s sexuality is encompassed in the whole

person.

Platell and his colleagues (2004) from Australia assessed women’s sexual health

(between 1996 and 2002) and compared study (n=50) and control groups (n=62)

undergoing pelvic surgery for rectal cancer (22 of 50 subjects in the study group

completed questionnaires; 19 of 62 in the control group completed questionnaires).

Results showed that compared with those in the control group, women who had

undergone pelvic surgery were significantly more likely to feel less attractive (p=0.039),

feel that the vagina was either too short or less elastic during intercourse (p=0.012), or

experience superficial pain during intercourse (p=0.012). Women in the study group were

concerned that these limitations would persist for the rest of their lives (Platell,

Thompson, & Makin, 2004).

A qualitative study focused on conceptualizing sexual health was conducted with

17 women diagnosed with gynecological cancer (Bultler et al. 1998). The study described

sexuality as a much broader construct. Sexual functioning was found to be one aspect that

contributed to the view of the self as a sexual being. Women’s experiences with changes

in sexual function were related to physical comfort, sexual satisfaction, and feelings of

intimacy post-treatment.

66
 In a qualitative study of 10 palliative patients aged 44 to 81 years, face-to-face

interviews related to the meaning of sexuality were conducted (Lemieux, 2004). Two of

the ten subjects were diagnosed with colon cancer and received cancer treatment

including surgery and chemotherapy or/and radiation. Analysis of data revealed five

major themes: the meaning and expression of sexuality, sexuality and quality of life,

barriers to experiencing sexuality in institutional palliative care, discussing sexuality and

the study as a therapeutic intervention. Subjects’ statements indicated “If my partner sees

me as being sexual even though… you think you’re deformed, but you’re not. I think it’s

their attitude that helps me with my attitude about myself.” “Sexuality means more than

sexual intercourse. It’s a broad, broad spectrum of feeling… closeness.” Moreover, in a

longitudinal study of 123 Taiwanese cancer patients receiving chemotherapy, Hsiao and

Dai (2001) assessed their health care needs upon discharge and 7-10 days after discharge.

Results showed that the information relevant to sexuality was cancer patients’ last

concern based on the priority of health care needs.

Additionally, in the review of the literature focusing on patients with ostomies, a

study by Gloeckner (1982), 60% of 40 patients with ostomy reported feeling less

attractive during the first year after surgery. Hurny and Holland (1985) reported that up to

one-third of the patients treated for bladder or colon cancer completely stopped any

sexual activity even though the majority of them did not suffer from physical impairment

of sexual function. The results of the study reflected that patients with the colostomies

may impair sexual enjoyment.

In short, the concept of sexuality was used interchangeably with sexual health.

The review of these studies shows that sexuality is multidimensional including not only

67
physiological, but also psycho-sociological aspects. There are three qualitative research

studies involving women with chronic illness (i.e., gynecologic cancer or physical

disability), and only one experimental comparative study done from the Australia; all of

these studies had small sample sizes of rectal cancer patients. Nevertheless, the study

findings reflect a subjective perspective related to the dimensions of sexuality involving

sexual self-concept, sexual function, and sexual satisfaction. Results revealed that sexual

self-concept was a core component of one’s sexuality. However, the majority of these

studies used qualitative designs with small sample sizes and focused primarily on

female’s sexual perspective related to wellness. Moreover, the results are not

generalizable to rectal cancer patients because of their small sample sizes. Finally, the

findings exclude the male perspective toward sexuality.

Studies of sexual self-concept, sexual function and sexual satisfaction. A variety

of studies regarding the associations among sexual self-concept, sexual function and

sexual satisfaction are discussed below.

In a study of gynecological cancer females’ changes in sexual functioning after

cancer treatment, sexual self-schema has been examined as an important component

relevant to individual difference of sexuality. Using two hierarchical multiple regression

analyses, the results showed that only subjects’ sexual self-schema accounted for 34% of

the variance in predicting current sexual responsiveness and behavior after controlling for

frequency of pre-cancer intercourse, menopausal symptoms, and the extent of the cancer

and its treatment (Anderson, Woods, & Copeland, 1997; Cyranowski, Aarestad, &

Anderson, 1999).

68
 In a quantitative and qualitative study, Caldwell (2003) explored the

gynecological cancer survivors’ (n=21) experiences of sexuality and body image. The

quantitative findings revealed that women with gynecological cancer experienced

significant mood disturbance and sexual problems involving sexual desire, frequency of

sexual desire, pleasure, arousal, and orgasm. The most common themes that emerged

from an in-depth interview of 9 of the 21 gynecological cancer patients who experienced

the issues of sexuality and body image were: loss of pleasure (33%), feelings of isolation

(44%), loss of wholeness (56%), loss of desire (67%), a dramatic and abrupt shift in self-

identity due to loss of physical integrity (67%), a reluctance to initiate discussions about

sexual concerns (67%), a negative impact on body image (89%), and a negative impact

on intimate relationships (100 %) (Caldwell, 2003).

Yurek (1997) tested a model for predicting sexual and psychological morbidity

among women (n= 133) following surgical treatment of breast cancer. The results

indicated that sexual self-concept appears to mediate women’s stress reactions. Moreover,

women with a negative sexual self schema reported increased frequency of avoidant

behaviors and greater distress in sexually-relevant situations than women with positive

sexual self schemas. Sexual self schema also contributed significantly to the incremental

variance -- 55% in the reported frequency of sexually intimate behaviors following breast

cancer surgery. Measurements related to sexuality involved in this study included the

Body Satisfaction Scale, Sexual Response Cycle, and Sexual Self Schema measure

(Yurek, 1997).

In a pilot study from Canada, the influence of a broad-based stress management

program on sexual functioning in a study group (n=10) and a control group (n= 10) of

69
women with breast cancer was explored (Curran, 1999). Results found that there is a

relationship between the influence of emotional distress reduction, improvements in

sexual self-schema and improvements in global sexual functioning in women with breast

cancer. Measurements related to sexuality involved in this study are Sexual Self-Schema

Scale (SSS), Global Sexual Rating Scale (single item), Sexual Relationship Assessment

Scale (SRA), and Profile of Mood States (POMS) (Curran, 1999). The study results do

not support the additional investigation of a specific program of stress management as

related to improvement in sexual self-schema and sexual functioning of women with

breast cancer.

A cross-sectional study done by Ananth and colleagues (2003) from the United

Kingdom indicated that patients with all types of cancer in palliative care (n=64) and

oncology care (n=56) groups reported more sexual dysfunction than general practice

patients (n=67) (control group). In addition, despite lower strength and frequency of

sexual relationships in oncology patients than in general practice, there was little

difference in sexual satisfaction. In conclusion, patients in both cancer groups were found

to be significantly more willing to talk about their sexual lives (χ2 = 18.4; df =2, p<

0.001). The impact on sexual function was significant in comparison with the control

group of the same age. This result may promote greater awareness in health care

professionals, which is quite different from before (Ananth, Jones, King, & Tookman,

2003). In this study, the Derogatis subscale on sexual satisfaction, the General Health

Questionnaire (GHQ12) and the European Quality of Life (EuroQOL) were used.

In summary, there is evidence from the reviewed research studies that the

individual’s sexual self-schema accounted for 34% to 55% of the variance in predicting

70
current sexual responses/behaviors for women with gynecologic or breast cancer

(Anderson, Woods, & Copeland, 1997; Yurek, 1997). Results support the association

between stress reactions and sexual self-schema, and the association between sexual self-

schema and sexual function (Yurek, 1997). Only one study focused on all types of cancer

patients, which suggested that a communication/ discussion of sexual issues can be

employed as an approach for the resolution of sexual dysfunction. Incidentally, one

experimental pilot study with a small sample indicated that a stress management program

was not effective for improving sexual dysfunction in female breast cancer patients

(Curran, 1999).

Of these studies, the nonequivalent control study, a specific quasi-experimental

design, uses a comparison group that has not been designated by a randomization

procedure. The problem with the use of such a comparison group is the possibility that

the groups are initially different, which will most likely affect the study results (Ananth et

al. 2003). Those studies in which there was no control group may collect data at regular

time points (i.e., time series design). In addition, the triangulation technique, which uses

qualitative and quantitative data sources, was utilized in one study to improve credibility

of the outcomes reflecting sexual dysfunction, which encompass physiological and

psychosocial dimensions (Curran, 1999). Because the populations examined in these

studies (i.e., breast cancer or gynecological cancer) were relatively homogeneous with

respect to the variables of interest, a small sample size may have been adequate. However,

the accessible population for these studies was restricted to female cancer survivors; thus

the external validity was affected and the findings are not generalizable to Taiwanese

rectal cancer patients of both sexes.

71
Perceived Stress and Sexuality (from medical studies)

The association between cancer surgery and sexuality (sexual function or

dysfunction) was supported by the review of the relevant evidence-based medical studies.

In a retrospective study of the quality of life (QOL) between 1994 and 1999, Chatwin and

colleagues (2002) evaluated the indicators of sexual activity among 43 patients with LAR

surgery. Sexual dysfunction was reported by 9 of the 13 sexually active men and 2 of the

11 sexually active women in Switzerland (Chatwin et al. 2002). In a randomized clinical

trial conducted in the UK (1996 and 2002), sexual function of laparoscopically assisted

surgery (using TME technique) was compared with conventional open surgery among

male and female rectal cancer patients (N=794), using the International Index of Erectile

Function (IIEF), and the Female Sexual Function Index (FSFI) at 4 time points (pre-

surgery and 3, 6, and 18 months after surgery) (Jayne et al. 2005). Additionally, the

European Organization for Research and Treatment of Cancer Quality of Life

Questionnaire-Colorectal 38 (EORTC QLQ-CR38) questionnaire was used for making

comparisons. Results showed that overall sexual function in males tended to be worse

after laparoscopic rectal surgery (with TME technique) than after conventional open

rectal surgery. However, there were no differences in sexual function of females (Jayne et

al. 2005). In another study conducted in the UK, Camilleri-Brennan and Steele (2002)

reported on QOL before surgery for rectal cancer, on discharge home and at 3-month

intervals after operation for 1 year from 1997 to 1999 in a sample of 82 patients. Results

indicated that sexual enjoyment and sexual function of males on the QLQ-CR38 had

deteriorated in the postoperative period (compared with baseline in the early

postoperative period) and remained poor thereafter (Camilleri-Brennan & Steele, 2001).

72
 In Canada, Hendren and his colleagues (2005) also used the IIEF, FSFI, and

EORTC QLQ-CR-38/C-30 questionnaires to investigate the prevalence of male (n=99)

and female (n=81) sexual dysfunction following rectal cancer surgery (from 1980 to

2003). Reports indicated that 32% of women and 50% of men were sexually active

postoperatively, compared with 61% and 91% preoperatively (p<0.04); 29% of women

and 45% of men reported that “surgery made their sexual lives worse.” Specific sexual

problems in women were: decreased in libido (40%), arousal (29%), lubrication (56%),

orgasm (35%), and dyspareunia (46%); sexual problems in men were: decrease in libido

(47%), impotence (32%), partial impotence (52%), and decreased in the frequency of

orgasm (41%) and ejaculation (43%) (Hendren et al. 2005).

Schmidt and colleagues from Germany (2005) investigated quality of life and

sexuality in a ten-year cohort (from 1992 to 2002) of 516 rectal cancer patients. Results

showed that sexuality was most impaired for patients receiving APR. Significant

differences were seen in symptom and function scales between males and females

(Schmidt, Bestmann, Küchler, Longo, et al. 2005). However, both genders experienced

limitations in their sexual life; males had significantly higher cores for physical function

than female and felt more distressed by this impairment. Younger females felt more

distressed by impaired sexuality. In males, sexuality was impaired independent of age

(Schmidt, Bestmann, Küchler, Longo, et al. 2005). Schmidt and colleagues’ (2005) study

from Germany indicated that adjuvant therapy had no influence on sexuality but did have

an impact on quality of life one year after surgery (Schmidt, Bestmann, Küchler, Longo,

et al. 2005). In another prospective study from Germany, Schmidt and colleagues (2005)

evaluated the impact of age, gender, and type of surgery on sexual function for 819 rectal

73
cancer patients (412 males, 407 females) using the EORTC-QLQ-C30 questionnaire at 6

time points (i.e., before surgery, at discharge, 3, 6, 12, and 24 months postoperatively)

(Schmidt, Bestmann, Küchler, & Kremer, 2005). Comparisons were made across three

types of surgery (APR, LAR with / without Pouch and Sigmoid resection). The findings

confirmed that factors like type of surgery, gender, and age have tremendous impact on

sexual function and sexual enjoyment. Type of surgery such as APR and AR with Pouch

affect sexual function more than AR and resection of the lower sigmoid. Men experience

greater strain with impaired sexual enjoyment than women. Patients aged 69 years and

younger experience more stress from deteriorated sexual function (Schmidt, Bestmann,

Küchler, & Kremer, 2005).

Allal and his colleagues (2005) from Switzerland prospectively evaluated the

QOL of 53 patients with advanced rectal cancer following preoperative radiotherapy and

surgery (followed at a median interval of 45 days by APR in 11 patients and LAR in 42

patients). Two questionnaires, the EORTC QLQ-C38 and the EORTC QLQ-C30, were

used to measure QOL. The results showed that the sexual dysfunction scores increased

significantly, particularly in men (17 vs. 83, p=0.0045), and a lower body image score

(100 before RT, vs. 89 after RT (p = 0.068) was observed. In summary, one year after

combined treatment for locally advanced rectal cancer, patients exhibited statistically

significant improvement in some important QOL outcomes, despite a decrease in sexual

function and body image (Allal et al. 2005).

In addition, Ness and his associates from the US (1998) identified outcome states

of colorectal cancer and cancer treatment based on the stage and the location of the

disease at diagnosis using six patient focus groups (n=38). Results revealed that problems

74
with social interaction and cognition, changes in bowel habits, and sexual dysfunction are

associated with colorectal cancer (Ness, Holmes, Klein, Greene, & Dittus, 1998).

In Japan, Ameda and colleagues (2005) investigated long-term male sexual

function after pelvic nerve-sparing radical surgery in mailed survey using the American

Urological Association global problem questions (seven-grade measurement: delighted,

pleased, mostly satisfied, mixed mostly dissatisfied, unhappy and terrible) with 68 rectal

cancer patients. The results showed that 88% (28 of 52) of the men had some

postoperative deterioration in the erectile function, and 83% of the men had ejaculation,

regardless of the types of surgical procedures. Overall, 64% of men were unsatisfied with

their current sexual function (Ameda et al. 2005). Moreover, Guren and colleagues (2005)

from Norway assessed QOL and functional outcomes by using the EORTC QLQ-C30

and QLQ-CR38 questionnaires with female and male rectal cancer patients (N=319)

following anterior resection (AR) and APR. Results showed that mean QOL scores for

body image and male sexual problems improved following AR (e.g., LAR) than APR

(p<0.01), but there was no difference in QOL. However, this study emphasized that

sexual dysfunction in women is difficult to evaluate with the QLQ-CR38 questionnaire

because only 33% of the women responded to questions regarding female sexual function.

Thus, it is difficult to compare the sexual function across the two genders (Guren et al.

2005).

In summary, the impact of types of surgery (LAR, APR, APR with/without Pouch)

on sexual function or dysfunction or sexual health for rectal cancer patients was

examined in numerous studies across several developed countries including those in

Europe (UK, Germany, Norway), North America (Canada, United States), and Asia

75
(Japan). Retrospective studies were conducted over periods ranging from 5 to 26 years

with large cohorts and large sample sizes.

Ten empirical studies examined the relationship between cancer treatment (i.e.,

surgery and adjuvant therapy) and sexuality. The majority of these studies (retrospective

and prospective) indicated a significant association between cancer treatment and sexual

function, indicating that those undergoing cancer treatment, including types of surgery

(LAR, APR, APR with / without Pouch) and radiation therapy, reported sexual

dysfunction or impaired sexual life. The only report indicating no differences in sexual

function among females was a randomized clinical trial in the UK (Jayne et al. 2005).

Among these studies, the researchers investigated QOL, functional

outcome/outcome states, sexuality, and sexual health, in terms of sexual dysfunction,

sexual function, sexual problems, sexual life, and sexual enjoyment, dissatisfaction with

sexual function, dissatisfaction with appearance (less attractive), pain during intercourse,

impaired social interaction and cognition. Precision in defining the terms conceptually

and operationally has the advantage of communicating exactly what the terms mean

(Polit & Hungler, 1999, p.25). If each variable under consideration is not operationally

and explicitly defined, it is difficult for readers to understand the full meaning and

implications of the research findings.

Research has shown that despite these reports of sexual dysfunction from surgery

(LAR), most patients were satisfied with quality of life (QOL) or reported no difference

in their quality of life (Chatwin et al. 2002; Schmidt, Bestmann, Küchler, Longo, et al.

2005; Hendren et al. 2005; Allal et al. 2005; Guren et al. 2005). This implies that the

individual may have developed effective coping strategies for sexual problems. In

76
addition, the validity of the measures used needs to be considered. Instruments involving

IIEF, FSFI, and / or EORTC QLQ-C30 / QLQ-CR38 were used in two studies to assess

the sexual function or dysfunction for men and women (Jayne et al. 2005; Hendren et al.

2005). Other questionnaires, including the EORTC QLQ-C30 or / and the EORTC QLQ-

CR38, were used in four studies (Camilleri-Brennan & Steele, 2001; Schmidt, Bestmann,

Küchler, Longo, et al. 2005; Allal et al. 2005; Guren et al. 2005). Other studies adopted

different questionnaires for the evaluation of sexual function. Using inconsistent

approaches for measuring concepts related to sexual function has resulted in a variety of

outcomes across studies.

When random procedures have been used to select a sample from an accessible

population, there is no difficulty in generalizing the results to that group (Polit & Hungler,

1999, p.260). The only experimental study of sexual function to be found was a

randomized clinical trial (RCT) conducted in the UK (Jayne et al. 2005). The findings

from that study can only be generalized to that group in the UK with a sufficiently large

sample size and small sampling error (Polit & Hungler, 1999, p.240). The findings in a

particular situation in the UK may not be representative of all other rectal cancer patients

(target population) in the UK; furthermore, it also may not be representative of rectal

cancer patients in other countries, including Taiwan; one study is not adequate to

generalize the results to other populations, including those in Asian countries.

In short, because of the characteristics of most studies, surgery techniques and

adjuvant therapy may vary across studies. Questionnaires / measurements used in the

studies and questions used in the interviews were not standardized, and cultural

77
differences may influence the outcome; therefore, a direct comparison of results and

generalizability of the results are difficult.

Studies of adjuvant therapy and sexuality. The association between cancer

adjuvant therapy and sexuality (sexual function or dysfunction) were also examined in

the literature. Long-term QOL study of 165 anal cancer patients receiving radiotherapy

with chemotherapy or radiotherapy alone was assessed by Allal and colleagues (1999)

from the Netherlands. Results indicated a higher level of problems in sexual functioning

scales on the QOL-CR38 (Allal et al. 1999) and adjuvant therapy had significant

detrimental effects on the patient’s sexual function (Allal et al. 1999). In the U.S., Heriot

and colleagues (2005) prospectively evaluated the effect of radiotherapy on sexual

function (between 1998 and 2004) in 201 male patients undergoing oncologic resection

for rectal cancer at 7 time points (preoperatively, 4 months, 8 months, 1 year, 2 years, 3

years, and 4 years after surgery). Radiotherapy had an adverse effect on domains of

sexual function, including the ability to have an erection, maintain an erection, attain

orgasm, and being sexually active in comparison with patients undergoing surgery alone

(7.4%, 12.6%, 16.2%, and 13.7% reduction 8 months after surgery respectively; p<0.05)

(Heriot et al. 2005).

In short, adjuvant therapy had an adverse effect on sexual function. The advantage

of this study was the evaluation of sexual function at 7 time points which provide for

making comparisons over time; however, this study only focused on male patients.

Review of Medical Literature (Surgery and Radiation and Sexuality)

Based on a retrospective review of medical records, Chorost and his colleagues

(2000) assessed the pre-surgical and pre-radiation discussion of the risk of sexual

78
dysfunction after curative treatment among 53 consecutive patients (37 men and 16

women; age ranged from 38 to 85 years old) who underwent potentially curative therapy

for rectal cancer. Results showed that pre-surgical discussion of the risk of sexual

dysfunction was not documented in the consent of 37 of 52 (71%) patients (Chorost et al.

2000). Of the 6 males who received LAR, only 1 complained of sexual dysfunction after

surgery. Five of 15 males (33%) who were treated with APR alone reported post-therapy

sexual dysfunction, whereas 6 of 8 males (75%) who were treated with APR and

radiation reported sexual dysfunction. Of the entire group of female patients, only 1 of

the 16 reported sexual dysfunction post therapy (Chorost et al. 2000). Another review of

the medical literature focused on the anatomy, physiology, and surgical aspects of rectal

cancer (through the Medline database) done by Keating (2004) from New Zealand; the

review indicated that the incidence of permanent impotence remained higher (> 40%)

after APR but declined in the use of LAR. In addition, patient age was the most important

predictor of sexual dysfunction after surgery for rectal cancer (Keating, 2004).

Temple and colleagues in the U.S. (2003) reviewed the published data on sexual

and functional changes associated with radiation in rectal cancer patients and sphincter

preservation. These published data were from small retrospective studies. Results

indicated that sexual function was poorly studied, but radiation had a negative impact on

sexual function in both men and women (Temple, Wong, & Minsky, 2003).

In summary, the type of surgery (LAR or APR) had a substantial impact on the

extent of the individual’s sexual function, which has not been widely explored. The effect

of adjuvant therapy (radiation therapy) on sexual function of the individual was

controversial, based on the review of the research studies.

79
Spirituality

Concept of spirituality. The characteristics of spirituality were explicitly

addressed by scholars/theorists as follows. Spirituality is regarded as a basic

characteristic of humanness in human health and well being (Reed, 1992). Spirituality is

presented as a multidimensional concept that consists of both a vertical dimension of

connectedness, referring to a relationship with a higher being, and a horizontal dimension,

referring to relatedness to the social and physical environment (Stool, 1989). To these

transpersonal and interpersonal dimensions of relatedness, a third dimension -- the

intrapersonal -- can be included to represent a relationship to the inner self (Ruffing-

Rahal, 1984). Based on Banks’ (1980) description of characteristics of spirituality,

spirituality can be considered as a conscious or unconscious belief that relates the

individual to the world and gives meaning and definition to existence. Watson (1988)

indicated that spirituality encompasses in the nature of human needs and involves

multiple dimensions of connectedness within and beyond the self. Similarly, the themes

of development of a connectedness within and beyond the self are integral to Newman’s

(1986) theory of health as expansion of consciousness. In addition, Burkhardt (1989)

identified that a harmonious interconnectedness within self, with others, a higher power,

and with environment was an important empirical referrant of spirituality. A “state of

connectedness to God, to one’s neighbor, to one’s inner self” was addressed in Ley and

Corless’ (1988) definition of the concept of spirituality. Newman (1989) explicated the

nature of healthy human development in terms of human spirit. Watson (1999) believes

that a greater sense of harmony within a person’s mind, body, and spirit, or between the

person and the environment can be achieved through spiritual care.

80
 Differentiation of spirituality and religion. Spirituality is derived from the Latin

word spiritus, spirit, which implies the essential part of the person (Piles, 1990).

Spirituality is the nature of human beings, spans the entire developmental life process

(Reed, 1992). However, the term religion and spirituality have been often used

interchangeably in the literature of nursing and psychology. From the psychological

perspective, the results of the empirical studies found that most of their respondents

identified themselves as both spiritual and religious (ranged from 52% to 74%) (Shahabi

et al. 2002; Zinnbaner et al. 1997; Corrigan, McCorrde, Schell, & Kdder, 2003). From

these studies, most people view themselves as both religious and spiritual and spiritual

development for most may occur within the context of a supportive religious environment.

The splitting of religiousness and spirituality into compatible opposites does not reflect

the perspectives of all respondents.

McSherry (1997) and Burnard (1988) point out that if spirituality is defined only

synonymously with religion, then the use of spiritual coping strategies is restricted to

individuals who hold religious beliefs, as a result, all people who are irrespective of

religious affiliation would be excluded. Therefore, an individual’s spirituality needs to be

differentiated from his or her religiosity.

The word religion is derived from the Latin word relegare, which implies “to bind

fast, or tie together” (Mansen, 1993, p.141). Religion is concerned with public

participation in a faith community with specific practices and doctrines (Walker, 1992).

Religion refers to an organized entity, such as an institution with certain rituals of

conduct, values, practices, and beliefs about God or a higher power (Smith, 1995).

Religiosity may be an expression of a person’s spirituality / spiritual perspective (Stoll,

81
1989; Heriot, 1992; Mickley et al. 1992). From the psychological perspective, religion

may promote self-control which is viewed as the master virtue (Paloutzian & Park, 2005).

From a universal perspective, spirituality can be perceived as finding meaning,

purpose and fulfillment in an individual’s life from existentialist perspective (McSherry,

Draper, & Kendrick, 2002). Spirituality applies to both believers and nonbelievers,

including the presence of diverse cultural beliefs (Cawley, 1997) and religious beliefs

(Burnard, 1988; Narayanasamy, 1991; McSherry, 1996; Matthews, 1997).

Narayanasamy (1999) proposed spirituality is rooted in self-awareness.

Spirituality can be regarded as an expression of the capacity for self-transcendence (Reed,

1992). Awareness of transcendence involves a transformation of the perception of an

individual’s situation, in that the problems such as meaninglessness, fear of non-being,

and separation anxiety are solved (Belcher et al. 1989). Hafen and colleagues (1996)

indicated that spirituality may help an individual to interpret crisis in a “growth-

producing way” (Hafen, Kauen, Frandsen, & Smith, 1996). A spiritual perspective is

antecedent to self-transcendence (Haase, Britt, Coward, Leidy, & Penn, 1992).

Thus, spirituality is a much broader concept than religion (Cawley, 1997; Nagai-

Jacobson & Burkhardt, 1989; Oldnall, 1996; Peri, 1995; Fehring, Miller, & Shaw, 1997)

and may or may not incorporate religious rituals, behaviors, or association with religious

organizations (Oldnall, 1996; Peri, 1995). An individual may express spirituality in a

religious context, whereas a person’s religiosity is not always a result of spirituality

(Genia & Shaw, 1991).

Most definitions refer to spirituality as a human need involving many concepts

such as discovering meaning and significance in an individual’s life journey (Harrison,

82
1993), a belief in and a relationship with a higher power (Mickley, Carson, & Soeken,

1995), and transcendence (Reed, 1987, Smith, 1994). Spirituality was described as the

desire to identify some meaning and purpose in our lives and existence that will assist us

in generating motivation or purpose, which will lead to a sense of fulfillment (McSherry,

2000). Other definitions found in the literature review defined spirituality as whatever a

person takes to be the highest value in life (Dyson, Cobb, & Forman, 1997). In this study,

spirituality will be operationally defined as self-awareness, searching for meaning of

purpose of life and suffering through the interconnectedness with self, others, nature or

the environment, and/or a Supreme Being; this interconnectedness generates strength or

force that manifests an inner peace and creates a harmonious status.

Numerous studies have found that spirituality provides an effective coping

mechanism for patients. Spirituality is a resource that chronically ill patients use to cope

with the physiological and psychosocial challenges of illness (Fryback & Reinart, 1999;

Relf, 1997; Landis, 1996; Soeken & Carson, 1987).

Several measurements of spirituality currently are in use including the Spiritual

Perspective Scale (SPS), formerly called the “Religious Perspective Scale” (Reed, 1986),

the Spiritual Well-Being Scale (Ellison, 1983), the Spiritual Health Inventory, and the

JAREL Spiritual Well-Being Scale (Hungelmann, Kenkel-Rossi, Klassen, & Stollenwerk,

1989), and the Patient Spiritual Coping Interview (PSCI); these were designed to

described a patient’s use of spiritual coping strategies directly related to a relationship

with God or a higher being (McCorkle & Benoliel, 1981). The Spirituality Assessment

Scale (SAS) consists of four subscales: transcendence, inner resources, inner-

connectedness, and purpose and meaning (Howden, 1992). However, no studies to date

83
have examined the effect of spirituality on individuals dealing with potentially life-

altering events caused by rectal cancer such as the change in sexuality.

Studies of religiosity. In Gotay’s study (1984) on coping mechanisms among

cancer patients dealing with the advanced stages of cancer, faith and prayer were ranked

as first in importance of coping mechanisms (Gotay, 1984). In a convenience sample of

175 women with breast cancer, Mickley and her associates (1992) examined the role of

Spiritual Well-Being (SWB), religiousness, and hope in spiritual health. Reports

indicated that patients classified as intrinsically religious were found to have significantly

higher scores on SWB than those classified as extrinsically religious (Mickley et al.

1992). An extrinsically motivated person uses his/her religion for one’s own benefit,

whereas the intrinsically motivated lives religion according to his own beliefs in an

altruistic way (Allport & Ross, 1967).

Using a sample of 603 patients with various types of cancer, Dunkel-Schetter and

his associates (1992) identified five coping patterns, including “seeking or using social

support,” “focusing on the positive,” “distancing,” “cognitive escape-avoidance,” and

“behavioral escape-avoidance.” Forty-one percent of the sample indicated that fear or

uncertainty about the future was the most frequent problem associated with cancer. The

mean rating on stressfulness of cancer problems indicated a moderate level of stress (3.04,

SD=1.49). The specific cancer-related problem (e.g., fear of future) was also not

associated with how individuals coped. Although “type of cancer,” and “currently

receiving treatment” had few or no association with coping; perceived stress from cancer

was significantly related to coping through social support and both cognitive and

behavioral methods of escape avoidance. More religious patients were likely to use

84
coping methods involving cognitive reframing of the stressful situation and focusing

more on the positive. Religiosity was associated with greater cognitive escape-avoidance

and focusing more on the positive (Dunkel-Schetter et al. 1992).

Moreover, Lamban and colleagues (1997) investigated coping strategies in 35

African American women with breast cancer. The findings indicated that over for 75% of

these women, religion predominated as a coping strategy in all aspects of their lives. In

addition, many women reported that breast cancer was not the most difficult stressor in

their lives, which appeared to make it less burdensome (Lamban et al. 1997).

In short, the existing research suggests that religion plays a positive role in

patients’ adjustment to stress of chronic illness including cancer and treatment. Religious

is a means of expression of an individual’s spirituality.

Studies of religiosity and spirituality. Miller (1985) compared the spiritual well-

being of 64 rheumatoid arthritis patients with that of 64 healthy adults. Although there

was no difference between the groups in the level of existential well-being (i.e., a sense

of life purpose and satisfaction), those with arthritis reported a significantly higher level

of religious well-being (i.e., a sense of well-being in relation to God (Ellison, 1983).

Miller (1985) concluded that chronic illness may be a factor in stimulating the value a

person places on religion, faith in God, and a relationship with God.

In a secondary analysis of data from 30 cancer patients, obtained from a larger

study of search for meaning with 50 patients within 6 months of diagnosis of breast, lung,

or colorectal cancer), two significant factors, faith and social support, were found to assist

these patients in their search for meaning (O’Connor et al. 1990). Religious faith, prayer,

and the healing power of God helped 50% of the respondents to cope with their illness,

85
while faith was described as “the strongest support.” Approximately one-third (30%)

patients described their spirituality or God as a source of hope. One contradiction that

arose from this study was that although these subjects reported a frequent reliance on

faith, 87% of the sample reported that religion was not important in their lives. Since the

meaning of a situation is personal, awareness of how patients perceived stress through

cognitive appraisal is important.

In addition, in a qualitative study of 33 elderly women with recently diagnosed

breast cancer, the women were interviewed to identify and examine religious and

spiritual coping strategies (Feher & Maly, 1999). Three themes emerged: religious and

spiritual faith provided respondents with the emotional support necessary to deal with

their breast cancer (91%), with social support (70%), and with the ability to make

meaning in their everyday life, particularly during their cancer experience (64%) (Feher

& Maly, 1999).

In sum, based on the review of the existing studies, religion and spiritual faith

were acted as coping strategies in healthy adults and patients with chronic illness

including arthritis, breast cancer, lung, and colorectal cancer. However, faith in God or a

relationship with God was described as an important factor in their lives rather than their

religion which was inconsistent with the results of previous studies of religion.

Researchers among these studies used religion and spirituality interchangeably /

synonymously which may result in difficulty in differentiating these two terms/coping

strategies.

Studies of spirituality. These study findings provide evidence to support a

relationship between spirituality and psychosocial adjustment during illness. Using two

86
groups of 57 adults, Reed (1986) compared terminally ill ambulatory patients (having

stages III or IV cancer) with healthy adults. Regardless of age, terminally ill patients had

significantly greater religiousness (i.e., the levels of one’s beliefs and behaviors

associated with spiritual dimensions). Similar findings were reported by Reed (1987);

based on a comparison of 100 terminally ill hospitalized cancer patients, 100 non-

terminally ill hospitalized patients and 100 healthy non-hospitalized adults. A

significantly larger number of terminally ill cancer patients indicated greater spirituality

than both the non-terminally ill and healthy adults.

Sodestrom and Martinson (1987) described the spiritual coping strategies of 25

hospitalized cancer patients. The results showed that 88% of patients used a variety of

spiritual activities (e.g., personal prayer, reading religious books, television, etc.) and

resource people (e.g., health care professionals including nurses and physicians) while

coping with cancer. They found their meaning and purpose in illness through their belief

in and relationship with God.

In an ethnographic, qualitative analysis of 21,806 letters, cards, and e-mails from

1994 to 2000, Ferrell and colleagues (2003) described that spirituality in women with

ovarian cancer was relied on heavily as coping mechanism, as well as a method of

deriving meaning from the cancer experience (Ferrell, Smith, Juarez, & Melancon, 2003).

Chiu (2001) conducted a qualitative study with a synthesis of ethnographic and

phenomenological approaches to explore spiritual resources of Chinese immigrants to the

U.S. who had been diagnosed with breast cancer. Six themes emerged: family closeness,

traditional Chinese values, religion, alternative therapy, art, prose, and literature and

Chinese support groups (Chiu, 2001).

87
 In summary, evidence from the existing studies illustrates that spirituality not only

exists among healthy, chronic or terminally ill adults, but also may function as a coping

mechanism or coping resource for them. Spirituality, as a variable, is related to emotional

adjustment, low levels of fear and discomfort, and positive attitudes among cancer

patients. However, spirituality as a coping strategy for enhancing sexuality, in terms of

sexual function, sexual self-concept, and sexual satisfaction, of rectal cancer patients

receiving treatment, has not been previously examined in a quantitative analysis. In the

present study, religion and spirituality will be considered separately.

Perceived Stress (Cancer and Treatment) and Spirituality

Laubmeier and her colleagues (2004) examined whether the degree of perceived

life threat moderated the relationship between spirituality and emotional well-being in

various types of cancer patients (N=95). In addition, the importance of religious versus

existential well-being in relation to psychological adjustment was also examined. The

findings showed that spirituality, particularly the existential well-being component, may

be associated with reduced distress symptoms in cancer patients regardless of the degree

of perceived life threat (Laubmeier, Zakowski, & Bair, 2004).

A review of research on psycho-spiritual well-being in advanced cancer patients

from 14 world-wide countries was completed by Lin (2003); three of the six themes that

emerged from that work were: “coping and adjusting effectively with stress,”

“relationships and connectedness with others,” and “living with meaning and hope.”

Tuck and colleagues (2001) conducted a pilot study in persons (N=52) living with

HIV; in their study, the relationships among spirituality and psychosocial factors were

examined (Tuck, McCain, & Elswick Jr., 2001). Spirituality was measured by using the

88
Spiritual Perspective Scale, the Spiritual Well-Being Scale, and the Spiritual Health

Inventory. Aspects of stress and coping were measured by five psychosocial instruments

(the Mishel Uncertainty in Illness Scale, Dealing with Illness Scale, Social Provisions

Scale, Impact of Events Scale, and Functional Assessment of HIV Infection Scale). The

results showed that the Existential Well-Being (EWB) subscale of the Spiritual Well-

Being Scale was positively related to social support and effective coping strategies and

negatively related to perceived stress, emotional-focused coping, psychological distress

and uncertainty.

In a sample of 184 HIV-positive female subjects, Sowell and associates (2000)

examined the moderator role of spiritual activities on the adaptative outcomes of HIV-

related stressors. The study findings indicated that spiritual activities lessened emotional

distress (b= -.21, p< .05) and improved HIV-positive women’s quality of life while

controlling their physical impairments (Sowell et al. 2000).

A study tested the assumption that perception of racist experiences would predict

differently self-report symptoms in 155 undergraduate students of African compared to

an objective measure of health (Bowen-Reid & Harrell, 2002). The report indicated that

spirituality acted as a significant moderator between racial stress and negative

psychological health symptoms. Kim and Seidlitz (2002) examined the relationship of

spirituality with emotional and physical adjustment over time (time one and two) in 113

college students. Spirituality was measured by the 8-item Spiritual Transcendence Index

to assess individuals’ differences in spirituality at time one only. The results revealed that

spirituality buffered the adverse effect of stress on adjustment while controlling for the

use of various coping strategies. In a study of stress and physiological outcomes in older

89
adults and among gynecologic cancer patients, Lutgendorf (2005) found that several

physiological factors correlate with the stress response. Moreover, social support and

participation in spiritual and religious services acted as moderators of the stress on

physiological effects.

In summary, this review of studies supports the associations between

spirituality/spiritual well-being and stresses. Spirituality was found to act as a moderator

between stress (from racial, college students) and psychological and/or physical

adjustment/health. Stress in these studies resulted from minority groups, college students,

and HIV patients; only three of them focused on the cancer population including various

types of cancer, including gynecological cancer and terminal illness/advanced cancer.

However, no existing study demonstrated the effects of spirituality on stress (cancer and

its treatment) and sexuality in persons with rectal cancer.

Perceived Stress and Spiritual Intervention

There are limited studies that include spiritual interventions. Tuck (2004)

indicated that the lack of consensus in definitions of spirituality has made it difficult to

capture the essence of the spiritual phenomenon and to develop interventions (Tuck,

2004). Kristeller and associates (2005) evaluated the feasibility and acceptability of the

OASIS (oncologist assisted spiritual intervention study) approach including spiritual /

religious concerns, and the impact on satisfaction with care and on QOL among patients

with mixed cancers. The results showed that improvement in Functional Well-being was

accounted for primarily by patients lower on baseline spiritual well-being (beta = .293,

p<.001). The study supports the acceptability of the spiritual intervention approach

related to coping with cancer (Kristeller, Rhodes, Cripe, & Sheets, 2005). In another

90
study, Erwin and colleagues (1992) applied spirituality as prevention program in terms of

sharing the experience of African American women who suffered from breast cancer

(Erwin, Spatz, & Turturro, 1992). Additionally, in Margolin and associates’ (2006)

controlled study, a spirituality-focused intervention was offered to increase the

motivation of 72 drug users for HIV prevention. The results showed a positive

significance related to spiritual practice and to motivation among participants for HIV

prevention following completion of the intervention (Margolin, Beitel, Schuman-Olivier,

& Avants, 2006). Similarly, the Spiritual Self-Schema therapy for HIV-positive drug

abusers promoted a spiritual self view that reduced negative beliefs and behaviors

(Marcotte, Avants, & Margolin, 2003).

Philips and associates (2002) offered a seven-week semi-structured, spiritual

psycho-educational intervention in which participants discussed religious resources,

spiritual struggles, forgiveness and hope (Philips, Lakin, & Pargament, 2002). In a study

of a 12-week complementary and alternative medicine support intervention (CAM)

involving the use of meditation, affirmation, imagery and rituals, a sample of 191 breast

cancer women was assigned to the CAM group and sharing group. Levine and Targ

(2002) reported that measures of spirituality and spiritual well-being accounted for 40%

of the variance in functional well being of breast cancer patients. Both groups

experienced better QOL, decreased depression and anxiety, and increased spiritual well-

being.

Astin’s (1997) study indicated that an 8-week stress reduction meditation

decreased physical and psychological symptoms and increased the sense of self-control

and spiritual awareness among the participants. Germer (1996) provided a spiritual

91
awareness group in a sample of 17 adults. The findings showed that learning from others,

being able to express difficult emotions related to spirituality in a supportive atmosphere,

and gaining motivation to work on spiritual dimensions of one’s life were unanticipated

outcomes of the intervention.

Accordingly, spirituality is the integrative force for existence of the individual.

The empirical evidence provides positive effects of interventions promoting spirituality

on physical, psychological and spiritual well-being.

Resourcefulness (Personal and Social Resourcefulness)

Using structural equation modeling, associations between psychosocial

adjustment and biodemographic variables, coping, and social support of 87 (N=251)

women with early stage breast cancer were examined (Vos, Garssen, Visser,

Duivenvoorden, & de Haes, 2004). The results revealed that in the period shortly after

surgery, coping style, especially illness-specific coping, was of high relevance for

psychosocial adjustment. However, the role of social support on psychosocial adjustment

found in other studies was not confirmed in this study (Vos et al. 2004).

Schulz and Mohamed (2004) from Germany examined personal and social

resources in 105 cancer patients one month after surgery and their perception of positive

life changes as a consequence of illness. Using correlational and path analyses, the results

demonstrated a relationship between personal resources (self-efficacy) and social

resources (received social support) and benefit finding. In addition, the mediating role of

coping was supported between the resources and benefit finding when the effect of self-

efficacy disappeared. Social support had a direct effect on benefit finding. In this study,

92
social support was measured by the Berlin Social Support Scale (BSSS) to assess various

facets of social support for cancer patients.

In summary, women with early stage breast cancer use the illness-oriented coping

styles most commonly. Although both personal and social resources were used in these

two studies, however, the effect/role of social support on psychosocial adjustment of the

individual was inconsistent, based on the review of these two research studies (Schulz &

Mohamed, 2004).

Perceived Stress (Cancer and Treatment) & Resourcefulness

The literature to date has suggested that social support, self-help and cognitive

appraisal of current adverse/stressful events play a significant role in how well patients

adapt to their situation. Studies related to the relationship between perceived stress and

resourcefulness will be reviewed in the following paragraphs.

A test of four competing theories completed by Gifford (1987) indicated that the

learned resourcefulness factor, enabling skill, demonstrated the mediating effect that

enhanced self help (B= .44; R2 =.29). The Self Help Model operationalizes self help as a

learned response to chronic illness, which was found to explain 50% of the variance in

perceived self help and self help had a direct, positive impact on life quality (B = .61; R2

=.46). In additional, a semi-structured interview conducted by O’Connor and his

associates (1990) on 30 patients involving breast, lung, and colorectal cancer revealed

that over half (53%) the respondents suggested that inner resources, such as a positive

attitude and a determination to “hold myself up” and “lick it” helped them cope with their

situations. Forty-seven percent of the respondents coped with their illness by drawing on

93
the support of others. Family members were a frequent source of support (O’Connor et al.

1990).

In an ethnographic, qualitative analysis of 21,806 letters, cards, and e-mails from

women with ovarian cancer, conducted from 1993 to 2000 by Ferrell and colleagues

(2003a), significant stressors that were identified within all phases of diagnosis, treatment,

remission and recurrence were described (Ferrell, Smith, Cullinane, & Melancon, 2003a).

Moreover, women with ovarian cancer demonstrated resourcefulness and

optimism/perseverance by sharing with others about their coping strategies for various

symptoms (Ferrell, Smith, Cullinane, & Melancon, 2003b).

Gonzalez (1997) examined the similarities and differences in appraisals of

behavior problems, resourcefulness, and coping efforts between 25 African American and

25 Anglo-American caregivers of relative who had been diagnosed with probable

Alzheimer’s disease. The results indicated that African American caregivers reported

benign appraisals of disruptive behavior in the impaired elders. Gonzalez’s (1997) study

results support the assertion of Lazarus and Folkman (1984) that appraisal and

psychosocial resources (resourcefulness) are critical in understanding the experiences of

individuals dealing with stressful events (Gonzalez, 1997).

In summary, stressors are identified during the disease process, and cognitive

appraisal and resourcefulness are crucial for the individual in dealing with stressors.

Evidence supported that resourcefulness may come from self-help (personal)

resourcefulness which accounted for 50% of variance to chronic illness, and from help

obtained from others. These results supported Zauszniewski’s theory of resourcefulness

(Zauszniewski, 2006). However, the majority of the existing studies with small sample

94
size have focused on chronic illness (i.e., breast, lung, colorectal cancer and Alzheimer’s

disease) and their findings cannot be generalized and applied to persons with rectal

cancer in Taiwan.

Perceived Stress and Sexuality (from nursing studies)

Evidence from the review of relevant nursing studies demonstrated the association

between perceived stress (cancer and cancer treatment) and sexuality. In Ferrell and

colleagues’ (2003) qualitative study of women with ovarian cancer, results did address

the concept of sexuality. The statements related to sexuality as a theme in the following

quotes: “I felt great stress that I could not accommodate my husband;” “It has been

extremely hard accepting all of these changes and it’s has been hard on my sex life;” “It

is usually a taboo subject, but I am only 39 years old;” “Sexuality? no one seems to want

to talk about this topic because I don’t feel that many doctors feel comfortable or have the

necessary information” (Ferrell, Smith, Ervin, et al. 2003).

Curran (1999) investigated the influence of a broad-based stress management

program on sexual functioning in two groups of women (n=10 per group) with breast

cancer. The results showed that the stress intervention was not associated with

improvement in sexual functioning and self-schema (Curran, 1999). There was no

significant difference between the two groups on satisfaction with the sexual relationship.

Caldwell (2003) combined quantitative (N=21) and qualitative (N=9) research

designs to explore gynecological cancer survivors’ experiences of sexuality and body

image. The results of the quantitative study from 21 cancer patients demonstrated that

patients experienced significant mood disturbance and sexual problems. The themes that

emerged from the qualitative study showed loss of desire (67%), a reluctance to initiate

95
discussion about sexual concerns (67%), a negative impact on intimate relationships

(100%), and heightened emotions (100%). The qualitative data provided some message

related to the real threat, loss or harm in this specific population. In this study,

measurements included the Sexual Arousal Index (SAI), Changed in Sexual Functioning

Questionnaires (CSFQ), and the Body Image and Sexuality Scale for Women Who Have

Had Cancer (BISSWC), which were used to evaluate how sexuality and body image of

women are affected by cancer.

In a prospective cross-sectional multi-center study, the impact of sexual outcomes

following treatment for 58 women with early-stage gynecological cancer was examined

by Leenhouts and colleagues (2002). The results showed that patients who had a higher

frequency of sexual problems reported a lower sexual satisfaction (Leenhouts et al. 2002).

A study of the relationship among functional limitations, patients’ negative

appraisals of functional limitations, and emotional distress in a sample of 224 patients

with bladder cancer post-cystectomy in the USA emphasized the importance of negative

appraisals of functional limitation in the prediction of emotional distress. Additionally,

patients who negatively appraised their sex lives and body image were at risk of

experiencing emotional distress (Hart, 1997).

In summary, these study findings revealed the importance of cognitive appraisal

associated with a stressful event through physio-psychological adjustment of sexuality

among patients with ovarian, gynecological and bladder cancer. The findings from these

studies describe changes in sexuality and stress, real threat, and loss or harm were

identified in the female patients. Additionally, changes in sexual function were found to

present a challenge to personal relationships, and required an opportunity of

96
communication and understanding. Stress management programs seemed to have no

effect on enhancing sexuality (sexual function, self-esteem, and satisfaction with the

sexual relationship) based on one controlled study with a small sample (Curran, 1999).

However, the external validity of this finding is threatened and generalization is limited

because of the small sample size. The fact remains that the association between perceived

stress and sexuality in rectal cancer patients has not been explored.

Spirituality and Resourcefulness

From the perspective of the psychologists, social support may partly mediate

religion and/or spiritual involvement-health associations (Paloutzian & Park, 2005). For a

longitudinal study of religion and/or spiritual factors and social support, Strawbridge and

colleagues (2001) reported that frequent service attendees over 28 years were less likely

to become or to remain socially isolated, and were more likely to remain married

(Paloutzian & Park, 2005, p.445). Thus, religion and/or spiritual factors are considered as

affecting bodily conditions through mediating factors, such as social supports. Changed

bodily conditions in turn can affect physical health and disease outcomes. From the

psychologists’ perspective, spirituality is used interchangeably with religion which may

not be appropriate for the nonbelievers for this study. The causal pathway (religious

and/or spirituality factors → mediators (e.g., Social Support) → physical health) also

may less likely be applied to the present study.

Moreover, very little empirical evidence and few studies have demonstrated

associations between spirituality and resourcefulness in patients, particularly for the

cancer patients. Potter and Zauszniewski (2000) examined variables reflecting reaction to

stress, lines of defense and resistance, and the basic core of humans in the context of the

97
Neuman Systems Model in a convenience sample of 47 elders with rheumatoid arthritis.

The study findings showed that the social impact of arthritis was a significant

independent predictor for spirituality (i.e., Social impact → Spirituality). Social,

emotional, and physical impact together predicted health perception. Moreover,

spirituality and health perception were significantly correlated (Potter & Zauszniewski,

2000).

In summary, there is an association between spirituality and health perception,

whereas the individual’s perception of health status (chronic illness) is affected by

physiological and psychosocial aspects. Additionally, social factors of chronic disease

play a crucial role in spirituality. However, spirituality and personal and social

resourcefulness as coping strategies have not been examined simultaneously. The

separate or combined effect of spirituality and resourcefulness on perceived stress and

sexuality in rectal cancer survivors has not been explored.

Spirituality and Sexuality

In a study of psychosocial needs in cancer patients, the presence of religious faith

has been identified as a significant factor in determining a range of psychosocial needs

(Mclllmurray et al. 2003). Eighty-three percent of the 354 respondents with religious

faith had less need for help with their sexuality than those without religious faith. Thus,

the knowledge of a patient’s spirituality should help to predict psychological needs.

Johnson (2001) used a feminist social constructionist framework to explore the

relationships between sexual self-esteem and spiritual orientation among healthy

heterosexual women (n=96) ranging in age from 18 to 50 years. The majority of the

women in this study were from church or church-related institutions. The study findings

98
suggest that there is a relationship between a woman’s feelings about her appraisals of

her sexual thoughts, feelings, and behaviors, and her awareness and experiencing of

herself as a spiritual being. Additionally, the relationships between sexual self-esteem

and spiritual orientation were also supported. In this study, measures included the

Spiritual Orientation Inventory (SOI) and the Attitudes Toward Women Scale (AWS);

these measures were used to assess spirituality and sexual self-esteem, respectively.

In a cross-sectional study, quality of life (QOL) of 62 Chinese women from Hong

Kong with gynecological cancers was assessed (Molassiotis et al. 2000). The results

indicated that sexuality and spirituality (meaning in life) are two of the most distressing

aspects in a patients’ life. Sexual relationships among the respondents were moderately

affected by reduced sexual desire and satisfaction with sex and activity. However, the

patients’ relationships with their partners were minimally affected, suggesting the men’s

understanding and support in the cancer trajectory of their female partners. Other

supports such as sexual functioning and psychosocial adjustment may be needed.

Additionally, in a qualitative study, the meaning of QOL and the areas of life most

affected by cancer and its treatment were examined. Almost half of 19 sample subjects

reported problems with their sexual life as a result of the cancer or its treatment. One

woman’s statement described her situation as “not having harmony in sex life.” Two of

them mentioned relationship problems (Molassiotis et al. 2000).

In summary, spirituality was described in terms of religious faith among religious

groups and cancer patients in two studies. In a study from Asia, spirituality was defined

as the meaning in patient’s life in Chinese culture. This different operational definition

requires the investigator to choose a specific measurement to assess the selected variables

99
accurately. The results supported that the association between religion and psychosocial

needs in sexuality adjustment, and the relationship between women’s perception of

sexuality (sexual thoughts, feelings, and behaviors) and awareness of herself as a spiritual

being when the use of spirituality and religious faith are interchangeable. Specifically, the

study indicated that sexuality and spirituality are two important dimensions in a Chinese

female cancer patient’s life. Although sexual relationship was moderately influenced, the

relationship between the patient and her partner was little affected. This may reflect the

role of spirituality on the adjustment of sexuality. Of particular interest, it is the first time

the importance of “harmony in sex life” has been mentioned in a series of studies. The

target population of the Chinese study focused on a mix of ovarian, endometrial and

cervical cancers; thus, the generalizability of the study was limited. Moreover, one third

of the sample did not complete the sexual relationship assessment; for this reason, the

accuracy of the results was also questionable. However, the findings were associated with

the Chinese culture, and important consideration for the study proposed here.

Resourcefulness and Sexuality(Sexual Function, Sexual Satisfaction,Sexual Self-Concept)

In a longitudinal study of the effects of cancer treatment on sexuality in

individuals with lung cancer, Shell (2002) reported that between time 1 and 2, mood

status was significantly related to the subjects’ sexual function (r =.691, p = .004; r

= .936, p = .002, respectively). Social support was found to significantly affect mood

status at three time points (r = .620, p = .003; r = .557, p = .000; r = 1.0, p = .000,

respectively). However, social support did not significantly affect sexual function at any

of the three time points (Shell, 2002). Kennedy (1996) tested a model of social support,

optimism, and self-efficacy as predictors of psychosocial adjustment to breast cancer.

100
The results revealed that optimism and self-efficacy played a role in mediating the effect

of social support on adjustment. Social support had a direct effect on sexual functioning

and also had an indirect effect on physical adjustment through self-efficacy. Mo (2002)

assessed physio-psycho-social adjustment and social support for 70 Taiwanese colorectal

cancer patients. The results indicated that there was a mild to moderate degree of

difficulty in adjusting sexual life among patients with colorectal cancer.

In short, these findings suggest that social support may play an indirect or direct

role on sexual function of cancer patients. However, the results cannot be applied to the

rectal cancer patients in Taiwan.

Control Variables Affecting Sexuality

Age. Although sexuality declined over the decades of life, Brecher (1984) found

that older adults’ sexuality is “manifest in the high proportion of those who are sexually

active, and the quality, quantity, variety and enjoyability of their sexual activities”

(Brecher, 1984, p.403). Societal attitudes about sexuality in aging tend to convey a

misconception or negative image. The media bombards us with sexual images,

particularly that of youth. The elderly are rarely portrayed in matters related to sexuality.

Because of the stereotypes, myths, and unanswered questions, older adults may withdraw

from any form of sexual expression (Steinke, 1994). Steinke (1994) compared the results

of two studies using mailed questionnaires to separate samples (759 subjects in the first

study and 400 wellness subjects for males and females in the second study) that explored

the knowledge and attitudes about sexuality of older males and females. The findings

showed that males and females are comparable on their knowledge and attitudes about

sexuality in ageing and although sexual satisfaction and sexual activity were variable,

101
most were sexually active. In addition, Steinke (1994) reported that many healthy older

adults were seeking further information on the impact of chronic illness and medications

on sexuality (Steinke, 1994). Their study suggested that even as people approach older

age, they still seek resources to deal with sexual problems that may result from disease or

treatment.

Gender. In a study of 161 community-based older adults, Johnson (1996)

described the multidimensional nature of sexuality in men (n= 69) and women (n= 92)

and also compared both gender groups on selected dimensions of sexuality. Gender

differences were found for satisfaction of sexual activities (i.e. interest, participation, and

satisfaction) (Johnson, 1996). The report indicated that dyspareunia and loss of vaginal

lubrication may be caused by vaginal irritation or fibrosis secondary to surgical trauma or

radiation therapy (Havenga et al. 2000). However, there is limited information on female

sexual function after rectal cancer surgery.

Belief. Most older adults approach old age with the belief that sexual desires and

physical function cease (Steinke, 1994). Tang and colleagues (1996) examined five

studies of sexual adjustment after gynecologic cancer in Chinese women from Hong

Kong (aged from 18-75 years; sample size ranged from 10 to 115) that were conducted

from 1984 to 1996. The results suggested that in contemporary Chinese societies, the

effect of Confucian and Taoist traditional beliefs on one’s sexuality is still evident;

therefore, these beliefs further influence one’s sexual attitudes and behavior. Chinese

women show decreased sexual activities, interest, drive, and satisfaction after

gynecologic cancer and its treatment. The sexual disorder rates are around 30-50%, but

marital relationships are minimally affected (Tang et al. 1996). The findings suggested

102
that Chinese women might experience negative situations / outcomes after gynecologic

cancer, which they do not perceive as problematic or stressful events under prevailing

cultural sexual beliefs about sexuality. Stamogiannou and associates (2005) reported that

sexual function and beliefs about consequences were significantly correlated with QOL.

Better sexual functioning was the strongest predictor of higher quality of life (β = 0.323,

p < 0.05) (Stamogiannou, Grunfeld, Denison, & Muir, 2005).

Religion. The role of religious resources was examined in a sample of 52 breast

cancer survivors (Gall, 2000). Relationship with God and religious coping behaviors, and

the greater use of the nonreligious coping behavior were positively related to cognitive

appraisal of the cancer situation. Gall (2000) concluded that religious resources predicted

emotional and spiritual well-being for these long-term breast cancer patients. The results

reflected that religious factors are important resources for adjustment to long-term breast

cancer survival.

Conclusion

Literature related to perceived stress, spirituality, resourcefulness, and sexuality

among female and male patients with rectal cancer undergoing cancer treatments has

been systematically reviewed. Neuman Systems Model (1995), Lazarus’s stress and

coping theory (Lazarus & Folkman, 1984), and Zauszniewski’s (2006) mid-range theory

are conceptual frameworks that provided guidance for the study reported here. The

studies that were reviewed identified that resources and coping strategies available to

cancer patients determined their perception of stress (cancer and treatment) during the

appraisal process.

103
 Sexuality is an integral part of multidimensional, which encompasses not only

physiological (sexual function), but also pychosocial aspects (sexual self-schema and

sexual satisfaction). The majority of empirical studies (retrospective and prospective)

from medicine across countries focused on the impact of cancer treatment (i.e., surgery

and / or adjuvant therapy) on quality of life including sexual function and the prevalence

of sexual dysfunction among colorectal or rectal cancer patients. Using inconsistent

approaches for measuring concepts related to sexual function has resulted in a difficulty

in comparison of various outcomes across studies. In addition, a variety of studies from

nursing tended to focus on the association between stress reactions and sexuality (i.e.,

sexual self-schema, sexual function or sexual satisfaction) among females with

gynecologic or breast cancer. Only one study from Australia focused on rectal cancer and

women’s sexual health undergoing surgery and a few studies focused on psychosocial

effects of colostomy on colorectal cancer patients. In other words, the male perspective

toward sexuality was excluded in these studies. Therefore, the aim of this study was to

examine the association between perceived stress and sexuality including sexual self-

schema, sexual function, and sexual satisfaction among female and male adults with

rectal cancer in Taiwan.

Resourcefulness plays a critical role in coping process of an individual. Personal

(self-help) resourcefulness is regarded as a person’s repertoire of skills and behaviors to

deal with adversity or stressful situation. Several studies have identified the important

role of personal (self-help) resourcefulness (i.e., learned or internal resourcefulness) in

promoting health and life quality in adults with cancer or chronic illness; whereas these

studies have not explicitly addressed the effects of personal resourcefulness on stress and

104
sexual health. Social (help-seeking) resourcefulness involves the ability to seek help /

support from others such as professionals, family, or friends. The existing studies have

hypothesized that social resourcefulness may mediate the relationship between perception

of breast-cancer symptom and health. However, these studies have not demonstrated the

effects of social resourcefulness on stress and sexual health. Very few studies have

addressed simultaneously the effect of both forms of resourcefulness on physiological

and psychological health and life satisfaction. In addition, the moderating or mediating

effect of resourcefulness including personal and social resourcefulness on perceived

stress and sexuality among rectal cancer patients in Taiwan has not been investigated.

Currently, Resourcefulness Scale is the only measure that captures both forms of

resourcefulness, which have been found important for health promotion and maintenance

in older adults (Zauszniewski et al. 2006). However, the scale has not been used in

samples of younger or middle-aged men and women or in Taiwanese rectal cancer

patients.

Numerous studies have found that spirituality is an inner resource and serves as

coping mechanism for healthy adults and chronically ill persons, including cancer

patients. However, these studies have not explicitly addressed the relationships among

perceived stress, spirituality, and resourcefulness, and their associations with sexuality.

Accordingly, the study reported here addressed the gap in scientific knowledge with

respect to the exploration of relationships among perceived stress, spirituality,

resourcefulness, and sexuality among female and male patients with rectal cancer

undergoing cancer treatment. Examination of these relationships and the associations

between the variables and demographic and important cancer-related variables is an

105
important first step. In the future the investigation of the mediating or moderating effects

of spirituality and resourcefulness on perceived stress and sexuality might be pursued.

Finally, based on the evidence in the review, the effects of the extraneous

variables for this study including age, gender, beliefs, and religion cannot be ignored and

were also examined. Considering their potential associations, these variables and other

identified cancer-related variables were evaluated in the data analyses.

Contribution

The relationship of sexuality to rectal cancer and its treatment is at the center of a

growing body of knowledge. This study’s findings extend the knowledge of the

phenomena encompassed by the Neuman Systems Model, Zauszniewski’s mid-range

theory of resourcefulness, and Lazarus’s stress and coping theory, while the relationships

among perceived stress, spirituality, resourcefulness and sexuality in rectal cancer

patients undergoing treatment were examined in this study. The explication of

relationships among these variables will provide direction and inform the future

development and testing of interventions for persons with rectal cancer. Health policy

related to impairment of sexual function may be informed by the study’s findings.

Furthermore, the study provides direction for future research with the hope of inspiring

other researchers who are interested in filling in the remaining gaps.

106
 CHAPTER III: METHOD

Introduction

This chapter focuses on relevant methodological issues pertaining to this study.

First, a detailed description of research design was provided, followed by description of

the sample and sampling issues including sample specification, inclusion and exclusion

criteria, the approach to recruitment, protection of human rights, and sample size

determination by power analysis. The measures and measurement issues were addressed,

including description of instruments, scoring, interpretation, and psychometric properties.

A description of a pilot study and the procedure for data collection were also addressed.

Lastly, the methods of data management and statistical analysis were discussed.

Design

Designs guide investigation (Wood & Catanzaro, 1988). The general outline of a

study design can be established based on the research purpose and the nature of the

research question or hypothesis (Prescott & Soeken, 1989). The purpose of this study was

to examine the associations among demographic and cancer-related variables, perceived

stress, spirituality, and resourcefulness, and sexuality in Taiwanese rectal cancer patients.

Cross-sectional studies are appropriate for describing the status of phenomena at a fixed

point in time (Polit & Hungler, 1999). Cross-sectional designs involve measurements of

the variables of interest at one single point in time, with no follow-up period (Polit &

Hungler, 1999; Newman, Browner, Cummings, & Hulley, 2001). Cross-sectional data

can most appropriately be used to infer temporal sequence when there is evidence

indicating that one variable precedes the other; and when there is a strong theoretical

framework guiding the analysis (Polit & Hungler, 1999). Thus, a cross-sectional,

107
correlational design was appropriate to achieve the study goal of examining associations

between variables and for describing variables and their distribution patterns (Burns &

Grove, 1997; Newman, Browner, Cummings, & Hulley, 2001). Type of treatment was

categorized as surgery (e.g., LAR or APR), postoperative chemotherapy, postoperative

radiation, postoperative chemo- and radiation therapy and no adjuvant therapy. Sexual

dysfunction was defined as the inability to express one’s sexuality that is consistent with

personal needs and performance (Clark, 1993). In men, this definition includes impotency

and retrograde ejaculation. However, in women, sexual dysfunction includes

dysparenunia, decreased lubrication, or inability to achieve orgasm (Chorost et al. 2000).

Setting

This study took place in a 1,500-bed Medical Center in southern Taiwan,

Kaohsiung, a city of 1.5 million people. There were several reasons for selecting the

Medical Center as a target hospital of this study. First, the colorectal department at the

Medical Center located in southern Taiwan has more than 100 potential subjects

diagnosed with colorectal cancer every year. This report was confirmed by the colorectal

department of the Medical Center and is based on the prevalence of colorectal cancer in

2005. Second, the Medical Center has been qualified as a teaching hospital for more than

ten years. Third, because this Medical Center has colorectal specialists, the Medical

Center has attracted patients not only from urban and rural area of Kaohsiung but also

from mid-southern Taiwan. The sources of patients were also from small islands away

from Taiwan, such as PenHu. Moreover, the majority of patients with rectal cancer

usually returned to the outpatient department of this Medical Center for follow-up due to

108
the good quality of care. The attrition rate of patients at the Medical Center is less than

10%.

Sample and Sampling Issues

Specifying the Sample

Specification of the population for this study involved consideration of the problem

and purpose of the study, the study design, and accessibility of the potential participants

of interest (Wood & Catanzaro, 1988, p.99). With regard to the problem and the purpose

of the study, participants included female and male patients previously treated for rectal

cancer in the Medical Center who are making regular follow-up visit at the outpatient

department. Because patients with rectal cancer are normally instructed to refrain from

sexual activities for 3 months post-surgery, thus, patients were recruited for this study

when they came to outpatient department at least three months post-treatment.

Type

Review of the literature has indicated that sexuality has been a sensitive issue for

most people within the western and eastern culture. Thus, obtaining a sufficient sample

may have been challenging. Therefore, a convenience, non-probability sampling strategy

was used for accessing individuals that were easy to identify and contact. Available

subjects were entered into the study until the desired sample size was reached. This

method saved time, money, and effort (Wood & Catanzaro, 1988; Burn & Grove, 1997)

and it was useful for this exploratory study that was not intended for generalization to

large population, but to build knowledge in a substantive area of study (Burn & Grove,

1997). Recruitment of eligible participants was based on the sampling criteria that were

derived from the problem and the purpose of the study, the conceptual and operational

109
definitions of the study variables, and the study design. In correlational study designs in

general, the sampling criteria are determined to ensure a heterogeneous population with a

broad range of values for the variables being studied.

Accessibility of Potential Subjects

Inclusion and exclusion criteria are used to identify the desired sample (Burns &

Grove, 1997). In this study, exclusion criteria were 1) A prior history of sexual

dysfunction, 2) A prior history of any type of cancer, because patient with more than one

type of cancer might receive different regimen from the rectal cancer patient does.

Inclusion criteria were 1) a confirmed diagnosis of rectal cancer classified as

Dukes’ A to C: patients with rectal cancer classified as Dukes’ D usually have metastasis

and would have had modified surgery that differs from lower anterior resection (LAR) or

abdominoperineal resection (APR); 2) no previous cancer diagnoses; 3) receiving either

LAR or APR; 4) receiving or not receiving adjuvant treatment (e.g., radiation,

chemotherapy); 5) receiving post-surgery follow-up regularly over three months; 6) either

male or female who are making regular follow-up visit; 7) having a history of sexual

activities (i.e., individual participates in a sexual relationship producing human sexual

response cycle) with his / her sexual partner; 8) age 20 years old and older. The majority

of the population with rectal cancer tends to be older aged persons, thus the age criteria

will be 20 and older. Sexual interest and activity does not automatically diminish with

advancing age and may continue almost indefinitely (Kofoed, 1982). In addition,

extraneous variables such as age, gender, marital status, education, stage of diagnosis,

number of children, comorbidity, etc. will be taken into account within the specified

demographic characteristics.

110
Sample Size Determination

Cohen (1988) indicated that the reliability of a sample value depends upon the

size of the sample (Cohen, 1988, p.6). Statistical power analysis is an effective approach

that can be used determining optimal sample sizes (Cohen, 1965, 1988; Goodwin, 1984,

Kraemer & Thiemann, 1987; Polit & Sherman, 1990; Yarandi, 1994; Burns & Grove,

2001). In determining the sample size, factors affecting power are the effect size, the

number of variables, the types of research questions, and the statistical analysis (Cohen,

1988; Burns & Grove, 2001). Power is the long-term probability, given the ES of

population, alpha, and N (sample sizes) of rejecting null hypothesis (Cohen, 1990).

Statistical Power is a function of three parameters: 1) the significant level, or alpha (α), 2)

sample size (N), and ES of population (Cohen, 1988, p.4, 1992; Polit & Sherman, 1990).

The significance criterion of alpha for this study was set at .05, which meant that

the investigator was willing to assume the risk of committing such an error 5 times out of

100 (Polit & Sherman, 1990). The reason for setting alpha level of .05 was that the study

explored associations among perceived stress, spirituality, and resourcefulness related to

the individual’s sexuality. Moreover, the effects of spirituality and resourcefulness on the

relationship between perceived stress and sexuality were not known from prior studies.

Thus, the conventional 5 % risk of committing a Type I error was accepted in this study.

That is, the investigator would attain a correct conclusion 95 times out of 100, meaning

that demographic and cancer-related variables, perceived stress, resourcefulness, and

spirituality would have no effects on sexuality.

The beta (β) was set at .20 for this study, which meant that the risk of committing

a Type II error was .20. For a type II error, the investigator would fail to reject the null

111
hypothesis (Ho) when it is false. That is, the researcher confirms a finding that should

have been rejected. For example, claiming that there is no association between two

variables, when in fact, an association truly exists. In the case of this study, a type II error

would occur if the investigator mistakenly indicated that there was no relationship among

demographic and cancer-related variables, perceived stress, spirituality, resourcefulness,

and sexuality. Accordingly, statistical power (that is 1-β) set at .80, was the probability of

obtaining a significant result.

Effect size is the degree to which the phenomenon exists or the degree to which

the null hypothesis (Ho) is believed to be false (Cohen, 1988, p.4, 1992). In this study, ES

represented an index of the strength of the association among the study variables (e.g.,

demographic and cancer-related variables, perceived stress, spirituality, resourcefulness,

and sexuality). The value of the ES differs depending on the statistical test to be

performed (Polit & Sherman, 1990). The statistical analyses conducted in this study to

answer research questions involved Pearson’s correlation, t-test, and analysis of variance.

A more reliable ES value can be calculated on the basis of prior studies that have

examined similar phenomena. Also, conducting a small pilot study or pretest can be used

to estimate the value of ES (Polit & Sherman, 1990). One prior study that was similar to

the one reported here, which included spirituality and resourcefulness, was found. Potter

(1997, p.78) reported that spirituality and learned resourcefulness were significantly

correlated in patients with rheumatoid arthritis (r =.44, p < .001). According to Cohen

(1988), the conventional parameters for ES for correlational analysis are .10 (small), .30

(medium), and .50 (large) Cohen, 1988, p.83). Therefore, a correlation coefficient of .44

112
reflected a medium to large effect size. In addition, one study examined variables similar

to the dependent variables in the proposed analysis, including sexual self-schema,

sexuality outcomes (e.g., sexual behaviors and responses), sexual satisfaction, sexual

function. Yurek (1997) reported that relationships between sexual self schema and

sexuality outcomes, stress reaction (r = .26 ~.31) and sexuality outcome (r = - .29 ~ - .42)

were significantly correlated, indicating medium to large effect sizes (Yurek, 1997).

However, this study focused on persons with gynecological cancer and chronic illness as

the target population.

When no prior information is available and pretests are not feasible, the

investigator may estimate the effect size by considering the value of small, medium, or

large (Polit & Sherman, 1990). Since the effect size of the relationship among

demographic and cancer-related variables (age, gender, education, religion, stage of

disease, type of treatment, time since operation, and comorbidity of illness), perceived

stress, spirituality, resourcefulness and sexuality was not available for Taiwanese patients

with rectal cancer, a conservative estimate for a medium to large effect size, r = .40 was

used. Based on Cohen’s sample size table (p. 102), in order to detect the correlation

between variables (e.g., demographic and cancer-related variables, perceived stress,

spirituality, and resourcefulness) this study required a minimum of 46 subjects per group

to achieve power of .80 at alpha .05 (two-tailed test).

For the t-test, the effect size was estimated on the basis of means and standard

deviations of dependent variables. No prior studies were available, thus to achieve a

power of .80 at alpha .05, conventional estimation of medium to large effect size (d= .65)

for sexuality would yield a sample size of 39 per group (Cohen, 1988, p.55).

113
 With respect to the ANOVA, Curran’s (1999) study findings did not support the

effectiveness of the stress management program on sexual functioning and sexual self-

schema (SSS) in one group of women with breast cancer, one group healthy women.

Analysis of variance on the total SSS did not report significance for the factor of time,

F(2,22)= 3.05, p = .06 with a large effect size and a power of .53 (Curran, 1999, p.50).

However, the previous study focused on the effectiveness of the intervention between

breast cancer and healthy women, which may not apply to the present study. Based on

Cohen’s (1988, p. 275) power table for ANOVA with a conservative estimation of

medium to large effect size (f = .33), alpha .05, power .80, degrees of freedom equal 1

(df= 2 (gender) -1= 1), a maximum estimation of sample size of 40 per group was needed

(Cohen, 1988, p.384 table 8.4.4).

Accordingly, the sample sizes of 78 (t-test), 80 (ANOVA), and 92 (correlation)

for demographic and cancer-related variables, perceived stress, resourcefulness,

spirituality and sexuality were needed. Considering a possible nonresponse rate of 25%,

the required minimum sample size for this study was 120 subjects.

Procedures for Conducting Research

Access to Potential Populations

The study was approved by the institutional review board (IRB) at the Medical

Center in southern Taiwan. Afterwards, it was approved by Case Western Reserve

University Cancer IRB. First of all, the investigator met with the chief of colorectal

department to explain the purpose of the study. The investigator then obtained permission

from the colorectal department to attend the meeting of colorectal department. In the

meeting, the investigator gave a brief presentation of the study that included the research

114
questions, the methods and procedures to be used, and the duration of the study. The

researcher obtained a list of eligible subjects including names and contact information

through the colorectal specialist’s referral with the subject’s permission. The name list

was available for the researcher to directly contact subjects and obtain their consent to

participate in the study.

The researcher or data collector contacted eligible subjects by phone and provided

for them an introduction to the study. Recruitment strategies were based on eligible

subjects’ OPD follow-up visit. For those who came to OPD visit in the near future, the

researcher or data collector asked whether they would be interested in participating in the

study. The researcher or data collector obtained oral consent from the subjects and set an

interview time followed by the visit. One week before the interview, the researcher or

data collector made a reminder phone call about the appointment.

Training a Data Collector

A thoroughly trained data collector was needed in case several eligible subjects

arrived on the same day for follow-up. A face-to-face interviewer training session was

conducted so that the researcher and data collector would ask the questions in a consistent

and standardized way so as to not influence the subjects’ answers (Fowler, 1993; see

Appendix I). The procedures for training the interviewers involved several steps: 1) The

researcher provided a complete written description of interviewing procedures including

contacting subjects and method of introducing the study; 2) Role-playing: the researcher

demonstrated a standardized interview procedure; 3) Having the interviewer take turns

playing the respondent and interviewer roles; 4) Practice included handling the question-

115
and-answer process; 5) The researcher accompanied and observed the interviewer first

three times doing actual practice.

The selected female data collector was qualified as a nursing research assistant in

colorectal surgery department with the certificate of the hospital IRB. Basically, the data

collector was available enough to persist in making contact with subjects in this study.

Data Collection Procedures

Before or after their outpatient follow-up visit, the researcher or data collector

interviewed the subjects in a private room at the OPD to ensure the subject’s

comprehension of the questions. The purpose of the study was further explained to

eligible subjects and written informed consent was obtained at that time. This research

focused on the individual’s sexuality, a sensitive issue that might have the potential to

make subjects uncomfortable or cause mild embarrassment. As a result, the instruments

were organized to broach the topic gradually. The demographic data (Appendix C) was

first collected by a structured interview to warm subjects up to the issue and so that

subjects will feel more at ease with answering questions. At the same time, medical data

from the chart was collected by the researcher or data collector. Then, the subjects

completed the instruments in order: the Cognitive Appraisal of Health Scale (CAHS),

Perceived Stress Scale (PSS), the Resourcefulness Scale (RS), Body-Mind-Spirit Well

Being Inventory-Spiritual (BMSWBI-Sp), SSSS-M / SSSS-F, ENRICH Couple Scales-

Communication (ENRICH-CO), and ENRICH Sexual Relationship Scale (ENRICH-

SRS), and IIEF / FSFI.

The researcher or data collector gave the eligible subjects the option to either

complete the instruments independently or have the data collector read the questionnaire

116
items to them, which would save face for those with no or low literacy skills. This

allowed for immediate detection of misinterpretations by the data collector, and was less

anxiety producing (Frank-Stromborg & Olsen, 2004, p. 53). Adequate time to complete

instruments was allowed during one-to-one interviews. The questionnaires were returned

in sealed envelopes without names. Afterwards, the researcher or research assistant gave

them gift cards (Figure. 3.1. Flow chart for data collection).

Step Figure. 3.1. Flow Chart for Data Collection

1 Obtain a list of eligible subjects from physicians’ referral

2 Provide study information via mails and phone calls

3 Set up a date and time for the interview

4 Make reminder phone calls before appointment

5 Meet with subjects at OPD and restate study purpose

6 Obtain written informed consent

7 Conduct face-to-face interviews in a private room

8 Submit completed questionnaires in sealed envelopes without names

9 Give a gift card to the study participant

117
Protection of Human Subjects

The subjects were informed about the purpose of the study and signed a consent

form indicating their willingness to participate in this study. Subjects were informed that

their responses would be kept confidential. Their lack of participation would not

influence treatment decisions or jeopardize their future care. Due to the sensitive nature

of the study, a minimal risk of emotional upset or embarrassment was expected during

data collection. The collection of information related to perceived stress, spirituality,

resourcefulness and sexuality was not previously reported. To minimize these risks, the

investigator monitored the participant’s emotional status during data collection. If study

participants became emotionally distressed during the data collection, the investigator

was prepared to make an appropriate referral as needed.

Subjects were directly compensated with a gift card of Taiwanese Dollar $100

right after completing the questionnaires in appreciation for their contribution of

information. The data obtained for the study was believed to help health professionals to

better understand the association among perceived stress, spirituality, resourcefulness,

and sexuality, specifically in patients with rectal cancer. Based on the research findings,

relevant interventions might be developed for the specific population in order to retain or

maintain sexual health.

According to Norbeck (1985), in selecting instruments for use in a study, minimal

standards of psychometric testing need to be established. These should include: at least

one type of content validity, test-retest reliability, internal consistency reliability, and at

least one type of criterion-related or construct validity (Norbeck, 1985). The variables in

118
the study were measured using eight instruments that provided a sufficient basis for

evaluating these psychometric characteristics (e.g., validity and reliability).

Independent Variables

Perceived stress. Stress occurs when the situation is appraised as threatening or

demanding and insufficient resources are available to cope with the situation. Perceived

stress had been defined as the level of a person’s experienced stress (Cohen, Kamarck, &

Mermelstein, 1983). In this study, perceived stress was operationally defined as the

extent to which an individual’s cognitive appraisal of the meaning of the stress-inducing

event is perceived as a threat / loss, harm or challenge and the perception of situational

demands resulting from cancer treatment as exceeding his/her resources for adjustment.

Stress has been measured as perceptions or appraisals (Cohen et al. 1983; Sarason,

Johnson, & Siegel, 1978; Vinokur & Selzer, 1975).

In this study, perceived stress was measured by Cognitive Appraisal of Health

Scale (CAHS) developed by Kessler (1998) to measure multiple dimensions of primary

and secondary appraisals associated with health-related events (Kessler, 1998). This self-

report revised 32-CAHS was originally tested in a convenience sample of 201 women at

0.3-21 years after diagnosis with breast cancer and reduced to 28 items following

psychometric testing. Four separate scales that measure the cognitive appraisal

dimensions of threat, challenge, harm / loss and benign / irrelevant were supported by a

principal component analysis (PCA). A four-factor structure explained 60% of the total

variance (Kessler, 1998). Three of these four items (i.e., threat, challenge, harm / loss)

represent the coping options described within Lazarus and Folkman’s (1984) theory. The

fourth item, benign / irrelevant appraisal, was added to the instrument by Kessler (1998)

119
to represent another coping option. The standardized alpha and theta correlations for each

primary appraisal scale following factor analysis ranged from .72 to .88 and .76 to .88,

respectively. However, the benign / irrelevant appraisal showed no effect on the outcome

variables (coping and health status) in a prostate cancer study (Bjorck, Hopp, & Jones,

1999). Because the structure of CAHS was considered as a new instrument to measure

cognitive appraisal and only analysed by exploratory factor analysis (EFA), Ahmad

(2005) performed confirmatory factor analysis (CFA) using structural equation modeling

and an Analysis of Moment Structure procedure on a sample of 133 patients with prostate

cancer. Before doing the EFA, Kaiser-Meyer-Oklin (KMO) in the 13-item three factors

model was .82, which was greater than .50, and considered acceptable (Kaiser, 1974).

KMO is an approach to comparing the zero-order correlations to the partial correlations

between pairs of variables (Munro, 2001). In addition, Bartlett’s Test of Sphericity was

significant (p < 0.001) in Ahmad’s study indicating that enough shared variance was

present. Confirmatory factor analysis was implemented for the 23-item, 16-item, and 13-

item three-factor models. Finally, the 13-item model yielded highly acceptable fit indices

including the goodness of fit index of .93 (GFI), comparative fit index of .99 (CFI), and

incremental fit index of .99 (IFI), all with a range 0-1 and with values > 0.90 indicating a

good fit (Wang et al. 1996). The root mean square of approximation (RMSEA) of 0.02

indicated a “close fit” (less than .05) (Browne & Cudeck, 1989). Accordingly, the results

support the three factor 13-item model for the CAHS to measure the cognitive appraisal;

it has a robust structure and excellent goodness-of-fit indices. Moreover, in the Principal

Components Analysis with Varimax rotation, the reduced version of 13-item, three factor

model accounted for more than half of the variance (55.48%) (Ahmad, 2005).

120
 The Cronbach’s alphas for the 13-item three factors model of CAHS in Ahmad’s

study were 0.79 for harm / loss appraisal, 0.74 for threat appraisal, 0.70 for challenge,

and 0.70 for the total scale. Internal consistency coefficients were acceptable in the

reduced version. Using CFA to evaluate the appropriateness of the CAHS in examining

how patients with prostate cancer appraise their diagnosis provided evidence for

construct validity for the instrument by assigning the items to their respective factors

according to theoretical expectations. Internal validity of the CAHS three-factor model

was established by principal component factor analysis. Construct validity was confirmed

through SEM by examining the standardized regression coefficients in the regression of

observed variables on latent variables. All the items had t-values above 4.23 (p < 0.01),

which indicated that the three-factor model has strong constructs. This finding is

consistent with Lazarus and Folkman’s theory (1984), which states that coping strategies

are stimulated when an event is appraised as stressful (threat, harm/loss, and or challenge)

but not as benign/irrelevant (Ahmad, 2005). In the proposed study, the 19-item version of

CAHS was used to measure perceived stress. All items are scored on a 5-point Likert

scale from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicate more

agreement with the appraisal item or scale (Ahmad, 2005).

Perceived stress. Perceived stress was also measured by Perceived Stress Scale

(PSS), which was developed based on Lazarus’s concept of appraisal (Lazarus, 1966;

Lazarus & Folkman, 1984) and was used to assess the degree to which situations during

the past month in a person’s life are appraised as stressful (Cohen et al. 1983). PSS items

were designed to measure the degree to which respondents found their lives unpredictable,

uncontrollable, and overloading. These are central components of the experience of stress

121
(Cohen, 1986). Psychometric properties of the scale of three versions of PSS, the PSS-14,

the PSS-10, and the PSS-4, were established for studying perceived stress on a large

sample (N=2387 respondents) across gender, social economic status, age, race and other

demographic characteristics (Cohen & Williamson, 1988). The psychometric

characteristics (internal reliability) of the 10-item version are stronger in comparison to

those of a 14-item version (Cohen & Williamson, 1988). Although, the three versions

provide strong psychometric data and are related to relevant outcomes in expected ways,

the relative superiority of the 10-item version is cited by Cohen and Williamson (1988).

In the present study, the self-report 10-item version PSS (Cohen et al. 1983) was

used to assess globally perceived stress of patients with rectal cancer. Six of the items are

negative, and the remaining 4 items are positive. Scale items have a 5-point Likert-type

response (0 = never to 4 = very often). In scoring the measure, the 4 positive items are

reversed scored (i.e., 0=4, 1=3, 2=2, 3=1, 4=0), and then all the items are summed (total

scores range from 0 to 40). A higher total score indicates greater perceived stress. The

measure has demonstrated adequate validity (Cohen et al. 1983). The 10 items are

invariant with respect to race, sex, and education (Cole, 1999). The scale had good

internal consistency reliability, using Cronbach’s alphas, that ranges from .86 to .92 and

is consistent with previous studies (range from .75 to .91; Cohen et al. 1983; Cohen &

Williamson, 1988; Glaser et al. 1999). Test-retest reliability for a 12-month interval on

this measure ranged from .53 to .61, which was similar to those reported .55 for 6 weeks

by Cohen and colleagues (1983).

The theoretically expected 10 items of PSS were previously confirmed by factor

analysis, which supports the construct validity of the instrument (Golden-Kreutz, Browne,

122
Frierson, & Anderson, 2004). A factor analysis of the 10-item version PSS was first

assessed in 111 women following breast cancer surgery and at 12 and 24 months later by

Golden-Kreutz and his colleagues (Golden-Kreutz et al. 2004). One-, two-, and three-

factor solutions were calculated, which enabled the evaluation of alternative factor

models for the PSS. The RMSEA values, the magnitude and pattern of the factor loadings,

and confidence intervals were used to assess goodness of fit for each model. The data

showed that the one-factor solution had poor fit and the three-factor solution was unstable.

The two-factor solution provided the best fit and was stable over time. That study

proposed that PSS-10 perceived stress may be composed of two dimensions, one positive

(Factor 2/Counter Stress was composed of four positive items) and the other negative

(Factor 1/ Stress composed of six negative items). The longitudinal design allowed for a

replication of the findings. The finding showed that the two factors were highly related

manifestations of a single factor (perceived stress). This is consistent with the stress and

coping model of Lazarus and Folkman (1966, 1984).

Spirituality. Spirituality was defined as the unifying force of a person; the

essence of being that permeates all of life and is manifested in one’s being, knowing, and

doing; the interconnectedness with self, others, nature, and God or Transcendent (Dossey

& Guzzetta, 2000). Spirituality refers to the propensity to make meaning through a sense

of relatedness to dimensions (Reed, 1992). Spirituality (within the nursing literature)

generally connotes harmonious relationships or connections with self, neighbor, nature,

God, or a higher being that draws one beyond oneself (Emblen, 1992; Hungelmann et al.

1989; Reed, 1992). Spirituality provides a sense of meaning, purpose, and self-integration,

enables transcendence, and empowers individuals to be whole and to live life fully

123
(Emblen, 1992). Spirituality was operationally defined as the individual’s harmonious

relationships and a sense of meaning and purpose, as well as self-integration developed

through the connections with self, others, environment, heaven, or a higher being which

enables one to go beyond oneself and to live life fully (Reed, 1992; Emblen, 1992;

Hungelmann et al. 1989).

Spirituality was assessed by the Body-Mind-Spirit Well-Being Inventory-

Spirituality (BMSWBI-Sp) (Ng et al. 2005). The BMSWBI was based on the Body-

Mind-Spirit (BMS) model which has been applied to divorced women, infertile couples,

and most extensively, and cancer patients. The MBSWBI was developed by a

multidisciplinary task force and tested within a sample of 674 Chinese adults from Hong

Kong through exploratory factor analysis. The MBSWBI contains 56 items that are

divided into four components: physical distress, daily functioning, affect, and spirituality.

Spirituality is differentiated from religiosity and is ecumenical, and not anchored in a

particular religion (Ng et al. 2005).

The BMSWBI-Spirituality scale contains three factors which accounted for 65%

of total variance. The factor loadings of all of the items were above .45. The first factor,

Tranquility, contains 5 items and measures peace of mind. The second factor,

Disorientation, consists of 5 items that related to loss of direction and a lack of vitality.

The third factor, Resilience, consists of 3 items that pertained to being grateful and

responding to the challenge of predicaments. The 13-item MBSWBI-Spirituality is a

self-rating scale that assesses respondents’ core values, philosophy and meaning of life.

Eight items of the scale are positive and five items are negative. The items are scored on

a 10-point scale with response ranks from 0 (totally disagree) to 10 (totally agree).

124
Negative items are scored in the reverse direction, and then the scores are summated over

items. The spirituality subscale yields scores from 0 to 130. The higher total scores

indicate better health.

The MBSWBI scales and the subscale have high internal consistency reliability.

The Cronbach’s alpha coefficients for the BMSWBI total scale, the spirituality subscale

(13-item) and its three factors (Tranquility, Disorientation, and Resilience)

were .95, .89, .89, .83, and .76, respectively (Ng et al. 2005).

Concurrent validity was established by correlations with other theoretically

related measures. Three subscales of BMSWBI (Daily Functioning, Affect, and

Spirituality) were strong positively correlated between .66 and .73 with the SF-12 mental

health subscale. Moreover, there were strong correlations between the BMSWBI-Sp and

the Post-Traumatic Growth Inventory Scale. The total BMSWBI scales and its subscales

(Daily Functioning, Affect, and Spirituality) were moderately associated to Perceived

Stress Scale, with correlations ranging from .40 to -.72. This indicates the higher the

well-being in daily functioning, affect, or spirituality, the lower the perceived stress (Ng

et al. 2005).

The reason for selecting the BMSWBI-Sp as a measure of spirituality was that the

subscale is not biased or is neutral for a particular religious group. Furthermore, the

BMSWBI-Sp is a psychometrical measure of spiritual well-being which has been tested

in the population of Asia (Hong Kong). Thus, this subscale is most culturally relevant to

the population of this study.

Resourcefulness. Resourcefulness involves self-help skills to maintain

independence in daily tasks despite potentially adverse situations (Rosenbaum, 1990) and

125
help-seeking skills to obtain assistance from others when one is unable to function by

oneself (Nadler, 1990). Resourcefulness was conceptually defined as a collection of

cognitive and behavioral skills that involve self-help and help-seeking behaviors that are

used to attain, maintain, or regain health (Rosenbaum, 1990; Nadler, 1990).

Resourcefulness was operationally defined as a repertoire of the individual’s learned

behavioral skills that include personal (self-help) and social (help-seeking)

resourcefulness for coping with stressful events such as cancer and its treatment that may

have an impact on well-being (Rosenbaum, 1990; Zauszniewski, 2006).

The Resourcefulness Scale (RS) developed by Zauszniewski and colleagues

(2006) was used to assess resourcefulness in this study. The RS was originally developed

from Rosenbaum’s (1980, 1990) 36-item Self-Control Scale (SCS) and a parallel 12-item

measure called the Help-Seeking Resource Scale (HSRS) (Zauszniewski, 1998). The 28-

item Resourcefulness Scale (RS) (Zauszniewski et al. 2006) comprises two dimensions

with 16-item personal (self-help) resourcefulness and 12-item social (help-seeking)

resourcefulness. The items are scored on a 6-point scale with response options ranks from

0 (not at all like me) to 5 (very much like me). The Resourcefulness Scale yields total

scores from 0 to 140, with higher scores reflecting greater resourcefulness.

The Resourcefulness Scale has acceptable internal consistency reliability using

Cronbach’s alpha .85 for total scale and .84 and .80 for the personal and social

resourcefulness scales, respectively (Zauszniewski et al. 2006). In the personal

resourcefulness subscale, 8 items reflect redressive self-control and 8 items reflect

reformative self-control. This subscale is highly correlated (r = .85; p < .001) with

126
Rosenbaum’s SCS (1980, 1990). Construct validity was demonstrated by factor analysis

(Zauszniewski et al. 2006).

The reason for selecting the Resourcefulness Scale was that it is the only measure

that taps both personal and social resourcefulness. Although this measure has been tested

in elderly persons with chronic conditions, including cancer, it has not been tested for

diverse sample of younger and middle-aged adults, or specifically in persons with cancer.

Therefore, this study was the first to examine this resourcefulness scale in a population of

males and females with rectal cancer.

Dependent Variables

Sexual function. Sexuality includes a person’s roles, relationships, values, and

beliefs (Yura & Walsh, 1983). In this study, sexuality involves sexual function, sexual

self-concept, sexual satisfaction of role function / relationships and sexual

communication / intimacy. Sexual function was conceptually defined as the ability of a

person to give and receive sexual pleasure (Woods, 1987). The operational definition of

sexual function involved the integration of emotional, cognitive, behavioral, and

physiological components that included the sexual response cycle (i.e., sexual desire,

erectile function, lubrication, arousal, orgasm, and intercourse satisfaction) (Clark, 1993;

Rosen et al. 1997; Rosen et al. 2000). Sexual dysfunction was defined as the inability to

express one’s sexuality in a way that is consistent with personal needs and preferences. In

men, this includes impotency and retrograde ejaculation; in women, this includes

dyspareunia, decreased lubrication, or inability to achieve orgasm (Clark, 1993).

Male’s sexual function. Male’s sexual function was assessed by the International

Index of Erectile Function (IIEF), which addresses the five domains of male sexual

127
function, that is, erectile function (EF), orgasmic function (OF), sexual desire (SD),

intercourse satisfaction (IS), and overall satisfaction (OS) were identified by principal

components analysis with eigenvalues greater than 1.0 (Rosen, Riley, Wagner, Osterloh,

Kirkpatrick, & Mishra, 1997). The IIEF is a 15-item, self-administered questionnaire

with 10 items that are rated on a five-point from 0 (none) to 5 (almost always) and 5

items rated from 1 (very low) to 5 (very high/almost always) (Kim et al. 2001). This

questionnaire is easily self-administered in research and clinical settings and has been

linguistically validated in 10 languages (Rosen et al. 1997).

Internal consistency estimates (Cronbach’s alpha) have been computed separately

for the five domains and for the total scales (Rosen et al. 1997). Responses on total scales

and on the erectile and orgasmic function domains were highly consistent, with

Cronbach’s alphas between .91 and .96. In addition, Cronbach’s alpha ranged from .77

to .91 for the domain of sexual desire (SD), from .73 to .88 for the domain of intercourse

satisfaction (IS), and from .74 to .86 for the domain of overall satisfaction (OS) in the

population studied. Overall, the IIEF was shown to have strong internal consistency for

both the total scale and the individual domain scores. Test-retest reliability was examined

by computing correlations between the individual domain scores and total scores at

baseline and at four weeks. Correlations ranged from .64 to .84 (.64 for orgasmic

function, .71 for sexual desire, .81 for intercourse satisfaction, .77 for overall satisfaction,

and .84 for erectile function), and all were significant (Rosen et al. 1997).

The IIEF demonstrated adequate construct validity, and all five domains showed a

high degree of sensitivity and specificity for detecting treatment-related changes in

patients with erectile dysfunction (Rosen et al. 1997). Discriminant validity was assessed

128
by comparing the responses from patients with erectile dysfunction and with those from

control condition in two studies. Highly significant differences were obtained between

the patients with erectile dysfunction and age-matched controls for most domains.

Differences between domain scores for the two groups were greatest for the erectile

function domain (p≤ 0.0001), followed by intercourse satisfaction (p≤ 0.001) and overall

satisfaction (p≤ 0.001). The least degree of difference between patients and controls was

found for the sexual desire domain (Rosen et al. 1997).

Convergent validity was supported by the significant positive correlation between

the subscale score of five domains and sexual function of Lock-Wallace Scale. The

subscale scores for all five domains were significantly correlated with independent

clinician ratings of sexual function that measure marital adjustment (Locke-Wallace

Scale) (Rosen et al. 1997). Divergent validity was supported by no significant correlation

between domain scores and Lock-Wallace Scale or social desirability of Marlowe-

Crowne Scale (Rosen et al. 1997).

Female’s sexual function. Female’s sexual function was measured by the Female

Sexual Function Index (FSFI) (Rosen et al. 2000). A brief, multidimensional self-report

scale consists of 19 items that assess six domains of sexual function over the past 4 weeks.

The six domains of sexual function include desire (2 items), arousal (4 items), lubrication

(4 items), orgasm (3 items), satisfaction (3 items), and pain (3 items).

The FSFI was developed on a sample of 128 women with female sexual arousal

disorder (FSAD) and a control sample of 131 women without sexual difficulties (Rosen

et al., 2000). Moreover, the FSFI was also found to discriminate between women without

sexual dysfunction and women who met the criteria for female sexual orgasmic disorder

129
(FSOD) or hypoactive sexual desire disorder (HSDD; Meston, 2003). Significant

discriminant validity has been supported between women with sexual dysfunction and

with non-dysfunction on the six domains of sexual function and in the total scores in both

studies (Rosen et al. 2000; Meston, 2003).

The internal consistency indicated by Cronbach’s alpha was .82 for 131 normal

controls and 128 age-matched subjects with female sexual arousal disorder (FSAD) in

Rosen and his colleagues’ study (Rosen et al. 2000). In Wiegel and his colleagues’ (2005)

study, the total FSFI score and six domain scores were found to have good to excellent

internal consistency with Cronbach’s alpha greater than .90 for the combined sample and

greater than .80 for the sexually dysfunctional and nondysfunctional samples (Wiegel,

Meston, & Rosen, 2005). Overall, test-retest reliability coefficients for the individual

domains ranged from .79 to .88 (Rosen et al. 2000). Correlations between the FSFI and

the Locke-Wallace Marital Adjustment Test (Locke & Wallace, 1959) were generally

modest in magnitude (.53 and .22 for control and FSAD groups, respectively), with the

strongest correlation for the satisfaction domain of the FSFI.

Divergent validity with a scale of marital satisfaction was supported (Rosen et al.

2000). Good construct validity was established by highly significant mean difference

scores between the female sexual arousal disorder (FSAD) and control groups for each of

the domains (p≤ 0.001) (Rosen et al. 2000). The reliability and validity of the FSFI were

supported in assessment of important dimension of female sexual function in clinical and

nonclinical females (Rosen et al. 2000).

The psychometric properties of the FSFI were further investigated by Wiegel and

his colleagues (2005) in order to develop diagnostic cut-off scores using the

130
Classification and Regression Trees (CART) methodology (Wiegel et al. 2005). Their

investigation involved a heterogeneous sample of 568 women with mixed sexual

dysfunction and nondysfunction to develop diagnostic cut-off scores for potential

classification of women’s sexual dysfunction and to maximize the generalizability of the

resulting cut-off scores. An FSFI total score of 26.55 was reported to be the optimal cut

score for differentiating women with and without sexual dysfunction (Wiegel et al. 2005).

Sexual self-concept. Sexual self-concept was defined as cognitive generalization

about self as sexual well-being. This view is derived from past experience, manifested in

current experience, and influential in the processing of sexually relevant social

information and guiding sexual behavior (Anderson & Cyranowski, 1994).

Female’s sexual self concept. Female’s sexual self concept was assessed by a self-

report measure of Sexual Self-Schema Scale-Female (SSSS-F) for women. The Sexual

self schema scale was developed by Anderson and Cyranowski (1994) using trait

adjective methodology and extensive psychometric study. Some of the most common

methodological problems with sexuality measures, such as participation bias, refusal of

response to items, and over- and under-reporting (Catania, Gibson, Chitwood, & Coates,

1990), were avoided by using the trait adjective format. The 50-item Sexual Self-

Schema-Female scale includes 1) two positive aspects: an inclination to experience

passionate-romantic emotions and a behavioral openness to sexual experience; and 2) a

negative aspect embarrassment or conservatism, which may be a deterrent to sexually

relevant affect and behavior.

Using principal-axis factor analysis with an oblique rotation with examination of

eigenvalues and scree plot, three factors were identified: Passionate-Romantic, Open-

131
Direct and Embarrassed-Conservative. Respondents rate the trait adjectives items on a 7-

point rating scale, ranging from 0 “not at all descriptive of a sexual woman” to 6 “very

much descriptive of a sexual woman”, with higher ratings indicating greater descriptive

relevance and lower ratings indicating no descriptive relevance (Anderson & Cyranowski,

1994). The total Sexual Self-Schema Score is obtained by calculating the sum of factors 1

and 2 then subtracting them from factor 3. The total scores range from -42 to 102.

The factor intercorrelation data demonstrate a strong relationship of each factor to

the total score, with correlations ranging from .65 to .80. This indicates that the factors

are related, but not redundant. The internal consistency estimate, Cronbach’s alpha, for

the total Sexual Self-Schema scale was .82, for Factor 1 (Passionate/Romantic) was .81,

for Factor 2 (Open/Direct) was .77, and for Factor 3 (Embarrassed/Conservative) was .66.

These data along with the factor intercorrelations indicate adequate homogeneity of the

scale and the contribution of each factor to the overall score. Test retest reliabilities of the

overall measure over 2- and 9-week intervals were .89 (p< .0001) and .88 (p<.0001),

respectively, which indicate stability of the measure.

The sexual self-schema scale-female (SSSS-F) was found to have nonsignificant

correlations with the Marlowe-Crowne Scale (r = .11), which assesses social desirability,

and with negative and positive affect (r’s = -.13 and .26, respectively). Convergent

validity was supported by the correlation but distinguishable both from a broad band of

sexual construct and measures focusing on current sexual functioning (sexual desire,

excitement, and orgasm) (Anderson & Cyranowski, 1994). Discriminant validity was

found with personality measures, Rosenberg Self-Esteem Scale (Rosenberg, 1965) and

Factor I of Big Five Measure (Goldberg’s, 1992) (Anderson & Cyranowski, 1994).

132
 Male’s sexual self-concept. Sexual Self-Schema Scale-Male version (SSSS-M;

Anderson, Cyranowski, & Espindle, 1999) assessed the positive versus negative valence

of a man’s self-image as a sexual person. The 45-item adjective Sexual Self-Schema

Scale-Male version yields three subscales/factors: passionate/loving, powerful/aggressive,

and open-minded/liberal which were identified through a principal-axis factor analysis

with an oblique rotation. With the 7-point scale, the respondent rates himself on a scale

ranging from 0 (not at all descriptive of me) to 6 (very much descriptive of me). Higher

ratings indicate greater descriptive relevance, and lower ratings indicate not at all

descriptive of male sexuality. The measure provides equivalence of word chosen and

ratings for men ranged in age from 20 to 70. The three factor scores were calculated by

summing item scores on each factor to obtain three factor scores. The three factor scores

are then summed to obtain a total sexual self-schema score (Anderson et al. 1999).

The factor intercorrelation data demonstrate a strong relationship of each factor to

the total score, with factor/total correlations ranging from .58 to .82, which indicate that

the factors are related, but not redundant. The measure has a full scale internal

consistency coefficient of .86 (Factor 1 (Passionate/Loving) was .89, Factor 2

(Powerful/Aggressive) was .78, and Factor 3 (Open-minded/Liberal) was .65). These

internal consistency estimates and the factor intercorrelations indicate adequate

homogeneity of the scale and the contribution of each factor to the overall score. Test-

retest reliability over a 9-week interval was .81 (p = .0001), reflecting the stability of the

measure (Anderson et al. 1999). In Jenkins and his colleagues’s study of patients with

prostate cancer, the internal consistency, Cronbach’s alpha, for Factor 1

(Passionate/Loving) was .94 for African-American, .88 for White male respondents;

133
Cronbach’s alpha of Factor 2 (Powerful/Aggressive) was .78 for African-American, .77

for White male respondents; Cronbach’s alpha of Factor 3 (Open-minded/Liberal)

was .39 for African-American, .62 for white male respondents. Cronbach’s alpha of the

total score was .92 for African-American and .86 for White male respondents (Jenkins,

Schover, Fouladi, Warneke, & Neese, 2004).

The men’s sexual self-schema scale has convergent yet incremental validity with

other individual difference approaches, including measures of general relevance (e.g.,

self-esteem), and measures of specific relevance to sexuality (e.g., extroversion)

(Anderson et al. 1999). Discriminant validity has been shown with measures of

potentially relevant personality domains: self-esteem, extraversion, and neuroticism

(Anderson et al. 1999).

Sexual satisfaction. Sexual satisfaction includes attitudes and affect states (Moret,

Glaser, Page, & Bargeron, 1998). The conceptual definition of sexual satisfaction was the

extent of one’s subjective perception and feelings about sexual behaviors, interpersonal

relationships and role function as well as communication with partners (Woods, 1987).

Sexual satisfaction was operationally defined as the extent in which one verbally and

nonverbally communicates sexual feelings, perceptions and attitudes, and is satisfied with

the overall intimate sexual relationship with his/her partners (Wellisch et al. 1978; Moret

et al. 1998). Sexual satisfaction was measured by two scales of ENRICH (Evaluating &

Nurturing Relationship Issues, Communication, Happiness; Olson, 1996): ENRICH

Couple Scales-Communication (ENRICH-CO), and ENRICH Sexual Relationship Scale

(ENRICH-SRS, Olson, 1996).

134
 Communication. ENRICH Communication is a 10 item self-report scale that

assesses an individual’s feelings and attitudes toward communication in his or her

relationship. Items focus on the level of comfort felt by the partner in sharing and

receiving emotional and cognitive information (Fowers & Olson, 1989). The Cronbach’s

alpha reliability of the communication scale was .82 and the test-retest reliability was .90.

The highest correlation between Communication and Conflict Resolution was .83. The

results of the study were based on a national sample of 25,501 married couples.

Sexual relationship. In addition, the ENRICH Sexual relationship scale

(ENRICH-SRS) is taken from the 14 scales of ENRICH Marital Inventory (Olson, 1996),

which assesses theoretically and clinically the dimensions of marital relationship (Olson,

Fournier, & Druckman, 1983). The 10-item ENRICH Sexual Relationship Scale

examines the partner’s feelings related to his/her affection and sexual relationship

(Fowers & Olson, 1989). Respondents rate their level of agreement on a 5-point scale

with five positive statements and five negative statements which reflect his/her attitudes

about sexual issues, sexual behavior, birth control, and sexual fidelity (Fowers & Olson,

1989). The total score is obtained by summing these positive items and all the reversed

negative items. The range of scores is from 10 (strongly disagree) to 50 (strongly agree)

(Olson, 1996), with higher scores indicating greater satisfaction of expression of affection

and feeling about sexuality and lower scores corresponding to greater dissatisfaction of

expression of affection and feeling about sexuality.

The ENRICH Sexual Relationship Scale (ENRICH-SRS) has been found to have

good reliability, concurrent and discriminant validity (Fowers & Olson, 1989). In Olson

and his colleagues’ (1983) study of 7,261 couples (15,522 individuals), the ENRICH-

135
SRS has good internal consistency with a mean alpha coefficient of .85. The test-retest

reliability at 4 week was .92 among 115 individuals (Fowers, & Olson, 1989).

Concurrent validity of the ENRICH was supported by a national study of 1200

couples (Olson, McCubbin, et al. 1983). There were strong correlations for individual

scores (r = .73) and for couple scores (r = .81) between the ENRICH Marital Satisfaction

scale and the classic Locke-Wallace Marital Adjustment scale. Discriminant validity was

established by distinguishing the satisfied couples from the dissatisfied couples with 85 ~

95% of considerable accuracy (Fowers, & Olson, 1989) using either the individual scores

or couples’ scores. The results showed that the ENRICH scales are very good predictors

of satisfaction. The regression analyses confirmed that the most important predictors

were the Communication, Sexual Relationship, and Conflict Resolution scales (Fowers,

& Olson, 1989).

These measurement tools were selected for the study because they represent

important dimensions of theoretical framework related to the relationship between

perceived stress and sexuality undergoing cancer treatment and also because their good

validity and reliability.

Instrument Translation

The goal of the study guided the translation procedures and interpretation of

research findings (Jones & Kay, 1992). Because the goal of the study was to measure the

responses of Taiwanese patients regarding study variables, asymmetrical translation was

an appropriate method for cross-cultural studies due to its faithfulness to the original text

(Werner & Campbell, 1970).

136
 Ten instruments (PSS, CAHS, RS, BMSWBI-Sp, SSSS-F / SSSS-M, ENRICH-

Communication, ENRICH-Sexual Relationship Scale, IIEF / FSFI) that were used in this

study were developed and validated in English. However, only three of them (PSS,

BMSWBI-Sp and IIEF) have been translated into Chinese, which is a formal language in

Taiwan and only the PSS and IIEF were tested in the Taiwanese population (Note:

Taiwanese is a non-literal language). Translation of the seven other instruments was

guided by Brislin’s translation model (1986), which is a reliable approach and has been

used for the translation of the Medical Outcomes Study Social Support Survey (MOS-

SSS) into the Chinese (Yu, Lee, & Woo, 2004). The preferred translation procedure

involves use of panels of experts and multiple interpreters who engage in multistage back

translation procedures (Werner & Campbell, 1970). First, three bilingual health care

professional translators who were knowledgeable about the content of the instruments

and understood the population were invited to translate seven instruments from English

(original language) into Chinese (target language). Second, the Chinese version was

reviewed by a monolingual layperson who was not aware of the content of the original

English version. Incomprehensible or ambiguous wordings would be discovered through

this procedure. Third, the reviewed Chinese versions were back-translated into an English

version by three back-translators, another panel of bilingual health care professionals,

who were blinded to the original English version. The purpose of blinding in this step

was to ensure that the meaning of the original English version was adequately translated

into the Chinese language. Finally, the investigator compared the two versions (English

and back translation of the instruments) for linguistic congruence and cultural relevancy

(Yu et al. 2004). In addition, distortion in translation was identified to ensure the

137
equivalent meaning of items in both languages. This involved an item that may used

different words, the intent must be to convey an exact concept that has meaning and is

relevant to the target population (Varricchio, 2004).

If there were discrepancies between original (English) and target language

(Chinese), changes were made and the back translation process was repeated until the

investigator and the interpreters were satisfied that the original language (English) and

target language (Chinese) are concept equivalence (Jones & Kay, 1992; Varricchio,

2004).

Pilot study

Pilot testing the translated instrument was conducted with members of the target

population culture to check not only for the quality of the translation, but also for

practical aspects of test administration (Jones & Kay, 1992). The final Chinese version of

the seven instruments was tested in a small pilot group of patients with rectal cancer to

ensure that persons representative of the target population comprehend the meaning and

the content of the items. A sample of five patients with rectal cancer was recruited for the

pilot testing. The results of this pilot testing were used to revise the Chinese version of

instruments as needed.

Data Analysis

Data Management

The investigator immediately and carefully examined each datum and the clarity

of each questionnaire, and edited it for completeness after each interview. The

investigator entered the data from instruments into a computer file and carefully checked

138
it to minimize errors during data entry. Entering data and analysis were performed using

SPSS-PC software (version 15.0).

First, the investigator developed a code book in order to guide the data coding and

entry into the computer. To safeguard confidentiality, subjects were assigned a code

number at the time of data collection. Only this subject code number was on the data

sheets or computer file, and each form for each subject was checked to ensure they were

all present. Each questionnaire was assigned an identification number to ensure that the

investigator could attribute data to the correct subjects. The key linking the name to the

code number was placed in a locked file that was separated from the consent forms and

the data were stored on disk. All errors and discrepancies were corrected and the validity

checks were completed, then the edited records were stored using the Statistical Package

for Social Sciences (SPSS) software master and back-up files. All computer data files

were password protected, and access to data stored was restricted to the researcher’s

personal computer. These files were accessible only to the investigator and they will be

retained for three years after the completion of the study or final publication of the data in

accordance with the University Policy on the Custody of Research Data.

Second, before conducting the data analysis, the investigator performed the data

cleaning (i.e., check on accuracy of data entry), identified missing data, considered

transformation of the data for skewness or nonlinearity, and kurtosis through SPSS

FREQUENCIES and examined means, standard deviations for plausibility, and out-of-

range numbers (Tabachnick & Fidell, 2001). With a sample of 120 subjects, the

investigator performed data screening to ensure the accuracy of the data entry by

proofreading the printing computerized data against the actual data (Mertler & Vannatta,

139
2005, p.25; Tabachnick & Fidell, 2001). In addition, the investigator used the SPSS

Frequencies procedure to examine the data for distribution and to obtain descriptive

statistics.

Third, during data analysis, appropriate handling of missing data was important.

Missing data may occur when measurement equipment fails, subjects do not complete all

items of questionnaires, or errors occur during data entry (Mertler & Vannatta, 2005,

p.25). The investigator examined the patterns and amount of nonresponse / missing data.

If 5% to 10% of the data were missing, this is believed to have only a small influence on

results, particularly in light of the descriptive / exploratory nature of this study (Cohen &

Cohen, 1983). Missing data was managed by several methods, including mean

substitution, deletion, and regression. However, if the variable had more than 40%

nonresponse / missing data, the study results on outcome variable may have limited

generalizability. Thus, a judgment about missing data to ensure the availability of

sufficient data to perform analysis with specific study variables was needed (Burn &

Grove, 2001). Repeating data analysis with or without missing data was also

implemented (Tabachnick & Fidell, 2001).

Fourth, an outlier can distort the results of a statistical test so that assessing the

effects of extreme values in the analysis was essential. Outliers are extreme values on one

variable or on a combination of variables that distort the result of the study. The

investigator used visual inspection of the data by examining frequency distributions and

corresponding histograms, and by looking for unusual values that appeared far from the

others in the sample data set (Mertler & Vannatta, 2005, p.27). Also, extreme values that

were located far away from the box plot were considered as outliers. In addition,

140
univariate outliers can also be detected through statistical methods by transforming the

data to z-scores (standardized). In a normal distribution, if the z-score is not as located

within (or excess) three standard deviations of the mean (99.7%), then presence of an

outlier should be considered. A statistical procedure, Mahalanobis distance, was used to

identify both univariate and multivariate outliers (Mertler & Vannatta, 2005, p.29).

Fifth, checking three assumptions (i.e., normality, linearity, and homoscedasticity)

to see whether they were violated was essential to ensure that the results of the analysis

were not biased (Mertler & Vannatta, 2005, p.30).

Statistical Analysis

The purpose of statistical analysis was to make quantitative data meaningful and

intelligible (Polit & Hungler, 1999). Determining the appropriate statistical analysis

depends on the number of dependent variables (sometimes referred to as outcome

variables) and independent variables (sometimes referred to as predictors), as well as the

nature of variable, whether they are nominal, ordinal, interval or ratio variable, and all of

which influence the nature of the research questions being posed (Mertler & Vannatta,

2005, p.20).

Measurement of Variables

Three independent variables, including perceived stress, spirituality, and

resourcefulness and one dependent variable, sexuality, were all classified as ordinal or

interval level of measurement (e.g., five-, six- or seven-point likert scale). The

investigator treated these variables as interval level data so as to use statistics (linear

regression) that assumed the variable was interval.

141
 Demographic characteristics including gender (nominal), marital status (nominal),

education (ordinal), employment status (nominal), religion (nominal), and one of sexual

history questions (8-3 interval) were classified as categorical level of measurement. Other

demographic characteristics for age (interval), number of children (interval) and others

sexual history questions (ordinal) were classified as continuous level of measurement.

The medical data from chart review including present surgery received (nominal),

and received colostomy (nominal) were classified as categorical level of measurement.

Other medical data for length of being diagnosed cancer (interval), time since operation

(interval), type number of treatment received (ordinal), and stage of disease (ordinal), and

comorbid conditions (interval) were treated as continuous / quantitative level of

measurement (Table. 3-2 Summary of Measurements). Among these variables, age

(ordinal), gender (dichotomous), education (ordinal), religion (nominal), stage of disease

(ordinal), type of treatment (ordinal), time since operation (interval), and comorbid

conditions (interval) were identified as demographic characteristics and cancer-related

variables in the study model.

Preliminary Data Analysis

Both descriptive and inferential statistics were performed in data analysis process.

First of all, descriptive statistics were used for all quantitative / interval variables of the

demographic characteristics and the study variables (i.e., independent and dependent

variables) in terms of frequency distributions (e.g., histogram with normal curve), shape

of the distribution (e.g., symmetry / skewed distribution and unimodal / multimodal

distribution), central tendency (e.g., mode, median, and mean), and variability (range,

standard deviation) to describe the overall picture of the data (Polit & Hungler, 1999;

142
p.444-454; Munro, 2001, p.4). Four major inferential statistics, Pearson’s correlation,

Spearman’s rho, independent-samples t-test and one-way analysis of variance (ANOVA),

were used to address the research questions (Table. 3.1 Research Questions and Required

Statistical Tests).

Table 3.1. Research Questions and Required Statistical Tests

Research questions Statistical Analysis
1 What are the differences in or relationships of major study Pearson’s
variables (perceived stress, spirituality, resourcefulness, and correlations (A),
sexuality) in relation to the demographic characteristics Independent-
(i.e., age (A), gender (B), education (C), and religion (D) in samples t test (B),
rectal cancer patients? (Q1A – 4D) One-way ANOVAs
(C, D)
2 What are the differences in or relationships of major study Spearman’s rho (E),
variables (perceived stress, spirituality, resourcefulness, and Spearman’s rho (F),
sexuality) in relation to the cancer-related variables (i.e., Pearson’s
stage of disease (E), type of treatment (F), time since correlations (G)
operation (G), and comorbid conditions (H) in rectal cancer Pearson’s
patients? (Q1E – 4H) correlations (H)
3 What are the relationships between perceived stress and Pearson’s
sexuality (Q5), spirituality and sexuality (Q6), correlations
resourcefulness and sexuality (Q7), perceived stress and
spirituality (Q8), spirituality and resourcefulness (Q9), and
perceived stress and resourcefulness (Q10) in patients with
rectal cancer?

143
Table. 3.2. Summary of Measurements
Variables/ Empirical Indicators Psychometric Items Level of
Concepts Properties Measurement
Independent / Cognitive Appraisal of Construct validity 19 Ordinal/
Perceived Health Scale (CAHS) Alpha: .72 to .88 interval
Stress (Kessler, 1998)
Perceived Stress Scale Construct validity 10 Ordinal/
(PSS-10) (Cohen, Alpha: .86 to .92 interval
Kamarck, & Test-retest: .53
Mermelstein, 1983) to .61

Spirituality Body-Mind-Spirit Well Construct validity 13 Ordinal/

Being Inventory– Alpha: .76 to .89 interval
Spirituality (BMSWBI-
Sp) (Ng et al., 2005)

Resourceful- Resourcefulness Scale Construct validity 28 Ordinal/

ness (RS) (Zauszniewski, Lai, Alpha: .85 (total interval
& Tithiphontumrong, score)
2006) Alpha: .84
(personal)
Alpha: .80
(social)

Dependent / International Index of Construct validity 15 Ordinal/

Sexual Erectile Function (IIEF) Alpha: .91 to .96 interval
Function (Rosen, Riley, Wagner, (total)
Osterloh, Kirkpatrick, & Test-retest: .64
Mishra, 1997) to .84
Female Sexual Function Construct validity 19 Ordinal/
Index (FSFI) (Rosen et Alpha: .80 to .90 interval
al., 2000) Test-retest: .79
to .88

Sexual Self- Sexual Self-Schema Construct validity 45 Ordinal/

Concept Scale-Male (SSSS-M) Alpha: .86 interval
(Anderson, Cyranowski, Test-retest: .81
& Espindle, 1999) (p=.0001)
Sexual Self-Schema Construct validity 50 Ordinal/
Scale-Female (SSSS-F) Alpha: .82 (total) interval
(Anderson & Test-retest: .88
Cyranowski, 1994) to .89 (p<.0001)

144
Table 3.2. (Continued)
Variables/ Empirical Indicators Psychometric Items Level of
Concepts Properties Measurement
Sexual ENRICH Couple Scale- Construct validity 10 Ordinal/
Satisfaction Communication (Olson, Alpha: .92 interval
1996) Test-retest: .93
ENRICH Sexual Alpha: .85. 10 Ordinal/
Relationship Scale Test-retest .92 interval
(Olson, 1996)

Control / Gender Self-reported 1 Nominal

Demographic Marital status 1 Nominal
Characteristics Age 1 Interval
Education 1 Ordinal
Employment 1 Nominal
Religion 1 Nominal
Sexual history 8 Ordinal
Time since cancer 1 Interval
diagnosis
Surgery received 1 Nominal
Time since operation 1 Interval
Colostomy received 1 Nominal
Type of Treatment 1 Ordinal
Stage of Disease 1 Ordinal
Comorbid condition 1 Interval
Total items
(Female) 180
(Male) 171

Correlation

Correlational statistical test was used to analyze the degree of relationship

between the variables. The relationships were measured by the Pearson’s product

moment correlation coefficient and Spearman’s rho analysis. This coefficient was

computed when the variables being correlated have been measured on either an

interval/ratio or ordinal scale; the higher the absolute value of the coefficient, the stronger

is the relationship (Polit & Hungler, 1999, p.458). Also, from a scatter plot, the

investigator may determine both the positive or negative direction and approximate

145
magnitude of a correlation (Polit & Hungler, 1999, p.458). The maximum value of r is

|1.00|; r = +1.00 means a perfect positive correlation; r = -1.00 means a perfect negative

correlation; and r = .00 means no linear relation. The closer r is to 1, the stronger the

relation between the variables under consideration (Pedhazur & Schmelkin, 1991, p. 370).

Certain assumptions must be tested to make inferences about the population. A

major assumption underlying in the correlation coefficient is the relation between the

variables under consideration is linear, which indicates the points depicting scores on

both variables follow a trend that can be characterized by a straight line (Pedhazur &

Schmelkin, 1991, p.37). A unit change in the independent variable is associated with an

expected constant change in the dependent variable (Pedhazur & Schmelkin, 1991, p.371).

The assumption of linearity was examined to determine there was a relatively straight

line relationship within the scatterplot. In addition, the variables that were being

correlated must each have a normal distribution; that is, the distribution of their scores

must approximate the normal curve. The assumption of residual normality (normal

distribution of residuals) was tested by examining frequencies, a histogram, and a P-P

probability plot. The assumption of normality was met if a normal distribution was

evident on histogram and a straight line on the P-P plot (Mertler & Vannatta, 2005,

p.173). Skewness and kurtosis would be problematic if the values were greater than +/- 3

and 8, respectively (Kline, 1998). The assumption of homoscedasticity (i.e., have a

constant variance) was examined to make sure that the bivariate scatter plot was

randomly distributed (or dispersed evenly) around the reference line (zero line) (Mertler

& Vannatta, 2005, p.173).

146
 In terms of the research questions 1E to 4E (1E- stage of disease and perceived

stress, 2E- stage of disease and spirituality, 3E- stage of disease and resourcefulness, 4E-

stage of disease and sexuality), 1F to 4F (1F- type of treatment and perceived stress, 2F-

type of treatment and spirituality, 3F- type of treatment and resourcefulness, 4F- type of

treatment and sexuality), Spearman’s rho analyses were used to determine whether

significant relationships existed between the levels of cancer treatment (i.e., surgery,

surgery plus chemotherapy, and surgery plus chemotherapy and radiotherapy) and each

of the major study variables.

For the research questions 1A to 4A (associations between age and perceived

stress, spirituality, resourcefulness, and sexuality, respectively), 1G to 4G (associations

between time since operation and perceived stress, spirituality, resourcefulness, and

sexuality, respectively), and 1H to 4H (associations between number of comorbid

condition and perceived stress, spirituality, resourcefulness, and sexuality, respectively),

Pearson’s correlational analyses were performed to determine the relationships.

t test and one-way ANOVAs

The independent-samples t test was used to determine whether there were gender

differences (between-group) on perceived stress (research question 1B), spirituality

(research question 2B), resourcefulness (research question 3B), sexuality (research

question 4B), in the rectal cancer patients.

With respect to the research questions 1C to 4C (associations between education

and perceived stress, spirituality, resourcefulness, and sexuality, respectively), 1D to 4D

(associations between religion and perceived stress, spirituality, resourcefulness, and

sexuality, respectively), one-way analysis of variance (ANOVA) was used to

147
simultaneously test the significance of group mean differences on the dependent variables

between more than two groups.

In order to make accurate inferences of the study results, it is important to test

underlying assumptions prior to conducting analysis. Basically, the assumptions for a

one-way ANOVA are same as those for the independent-sample t test. First, dependent

variable is continuous variable and normally distributed, whereas independent variable

must be categorical data. This can simply look at the distribution of the data in each cell

by obtaining histograms and boxplots of the dependent variable. If there are no marked

extreme values departures from normality, then the assumption of normality will be

assumed met. Second, the groups should be mutually exclusive; that is one group must be

independent of one another. Lastly, the variances of the groups should be equivalent

(homogeneity of variance/equal variance). If Levene’s test shows non-significance, it

indicates homogeneity of variance among groups (Mertler & Vannatta, 2005, p.78). The

one-way analysis of variance is robust to violations of the normality and homogeneity of

variances assumptions (Mertler & Vannatta, 2005, p.70). In general, violation of the

assumption of homogeneity of variance is more crucial than a violation of the other

assumption.

The data were presented under the one-way program in SPSS for Windows. The

descriptive statistics were given first. The number of subjects in each group, group means,

standard deviations, standard errors, and 95% confidence interval for mean were listed in

the descriptive box. Levene’s test was showed for the test of homogeneity of variance

(equal variances). The ANOVA summary table was reported as between groups, within

groups, and total. Moreover, sums of squares, df, mean square, F ratio, and level of

148
significance were reported. The F test indicated the ratio of between groups to within

group variance. If overall F test was significant (the significance level is significant),

which indicates at least one group is significant than others (one of the group mean is

different from the others). Since overall F test in ANOVA can indicate only group

differences and not identify which groups are different, the Scheffe post hoc test was

conducted to compare all group combinations and determine the significantly different

groups (Mertler & Vannatta, 2005, p.78). The homogenous subset was reported. Mean

plots were examined.

149
 CHAPTER IV: RESULTS

Introduction

This chapter focuses on the presentation of data analyses, research findings, and

interpretation of the results. It also contains the results of the pilot study conducted before

the larger study and the preliminary data analysis for the larger study, which encompasses

descriptive analyses concerning demographic features of sample and their influence on

the major study variables and the testing of assumptions for statistical analyses used to

address the research questions.

Pilot study

A pilot study was conducted on a sample of five rectal cancer patients undergoing

cancer treatment to ensure clarity and understanding of the Chinese translated

questionnaire items. No missing data were found. The subjects included one female and

four male rectal cancer patients undergoing cancer treatment; all were married. Ages

ranged from 46 to 75 years, with a mean of 59.20 (SD = 11.35). Forty percent of the

subjects completed elementary school, 20% completed middle school, and 40%

completed high school. They reported having between 2 and 4 children. The length of

time since their operation related to the rectal cancer diagnosis ranged from 14 to 123

months, with a mean of 66.6 months (SD = 41.22). Sixty percent (n=3) of five patients

were diagnosed at stage A, reflecting cancer had grown into the colon wall, but it had not

spread outside of the colon wall. The five patients sampled in the pilot study were

representative of the larger study sample, but were not included in the analysis for the

larger study.

150
 Eighty percent (n=4) of the pilot study subjects understood the meaning and the

content of all items on the study questionnaires. Only one patient asked for clarification

on one item (#19) on the Resourcefulness Scale, which stated “If I would not have

enough money to pay my bills, I would borrow money from someone.” During the 45

minute data collection interview, subjects were observed for signs of fatigue; none

reported feeling tired or distressed. Therefore, no changes were made to the

questionnaires prior to the larger study.

Preliminary Analyses

Description of Sample Characteristics

Recruitment into the study, using physicians’ referrals took seven months.

Approximately 21% of those who were recruited (n=34) did not meet the inclusion

criteria regarding having sexual activity before surgery. Two female subjects (1.3%) had

lost a loved one within the past year and one (0.6%) was single; hence, these women

were sexually inactive. The other ten female subjects (29.4%) also reported not having

sexual activity before surgery. Almost 59% (n=20) of the males were sexually inactive

before surgery and one man experienced erectile dysfunction after transurethral resection

of the bladder (TURB) six months ago. Approximately 79% of those recruited (n=125)

met all inclusion criteria. However, of those who met all study criteria, five (4%) refused

to participate; one male participant stated that he did not want to be reminded of his

cancer diagnosis because it made him uncomfortable. The other man and three women

stated they did not want to participate in the study. Data collection ended with

recruitment of 120 subjects who met all study criteria and completed the study measures;

no one withdrew from the study (see Figure 4.1).

151
 Transurethral resection of bladder
Male (3%), n= 1
(61.8%)
n=21 Sexually inactive (58.8%), n= 20

Not meet (21.4%) Widow (5.9%), n= 2

n=34 Female
(38.2%) Single (2.9%), n= 1
n=13
Pre-op sexually inactive
(29.4%), n= 10

Female (2.4%), n= 3
Refused (4%)
n=5 Male (1.6%), n= 2
Meet (78.6%)
n=125 Female (25.6%), n= 32
Enrolled (96%)
n=120 Male (70.4%), n= 88

Figure 4.1. Distribution of the Sampling Recruitment

A convenience sample of 120 subjects from a Medical Center in Southern

Taiwan was interviewed and completed all the study questionnaires. With respect to the

demographic characteristics of the sample, the continuous variables were age (in years),

number of children, length of time since cancer diagnosis (in months / year), time since

operation (in months / years), and number of comorbid conditions. Categorical variables

were gender (female or male), marital status (never married, married, divorced, and

widowed), educational level (elementary, middle school, high school, undergraduate, and

graduate degree), employment status (retired, full-time, part-time, and others), religion

(Atheism, Buddhism, Catholicism, Christianity, Taoism, and other folk beliefs) , sexual

history (question #1 to #7, see Appendix D), stage of disease (Duke A, B1, B2, C1, and

C2), present surgery received (LAR or APR), presence of colostomy (yes or no), type of

treatment received (surgery, postoperative chemotherapy, and postoperative

152
chemotherapy and radiation), type of chemotherapy received, lubricant use for female

subjects (yes or no), Viagra use for male subjects (yes or no).

Age. Of the total respondents, 32 (26.7%) were female and 88 (73.3%) were male.

The age of the respondents ranged from 29 to 85 years, with a mean of 60.81 (SD = 9.98)

and a median of 59 years. In comparison with the population statistics described in 2005

by the government of Taiwan, this sample was fairly representative of the larger

population in terms of age (Taiwan Report, 2005). According to the Taiwan government,

the age range for the population (N= 4,047) was 20 to 85 years with less than 10%

ranging from 40 to 49 years, 18% ranging from 50 to 59 years, 27.2% ranging from 60 to

69 years, 28% ranging from 70 to 79 years, 13.5% were above age 80 and older, and

3.8% were below 40 years of age. In the study reported here, less than 1% of the

participants (n=1) ranged from 20 to 29 years of age, less than 10% (n=9) ranged from 40

to 49 years of age, and 27.5% (n=33) ranged from 60 to 69 years of age, which were

similar to the government study (27.2%). About 43% (n=51) ranged from 50 to 59 years

of age, 18% (n=22) ranged from 70 to 79 years of age. Only 3.3% (n=4) were above age

80 shown in Table 4.1.

Table 4.1. Comparison of Sample Age and Taiwan Government Study

Range 15-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89
Taiwan report .03 0.7 3.1 10 18 27.2 28 13.5
(%)
Present study 0 0.8 0 7.5 42.5 27.5 18.4 3.3
(%)
N =102 0 1 0 9 51 33 22 4

Marital status. The majority were married (95.8%) while a little more than 4%

were not currently married. Less than 2% (n=2, 1.7%) were never married, less than 2%

were divorced, and one person was widowed.

153
 Number of children. The range for number of children was 0 to 6 or more, with a

mean of 2.77 (SD=1.19); 4 (3.3%) participants did not have children.

Level of education. Level of education completed was not found to be normally

distributed. The largest categories were those who completed high school (36.7%) and

those who completed elementary school (30%), followed by those who completed

education beyond high school (24.1%). The category with the lowest percentage (9.2%)

was for those who completed middle school.

Employment status. About half of subjects were retired (50.8%), followed by full-

time workers (35.8%), part-time workers (9.2%), and 4.2% were housewives.

Religion. Ninety percent reported religious beliefs constituting Buddhism

(52.5%), Taoism and other folk beliefs (30%), Christianity and Catholicism (7.5%); 10%

of subjects reported themselves to be Atheists.

Time since cancer diagnosis. The length of time since cancer diagnosis ranged

from 3 to 180 months. The average length of time since cancer diagnosis was 36.61

months (SD = 38.36; median = 27.5). Over 33% (n=40) were diagnosed less than 1 year

ago. Thirty percent (n=36) were diagnosed with cancer between 2 and 3 years ago; nearly

22% (n=26) were diagnosed between 4 and 5 years ago, 5% (n=6) were diagnosed

between 6 and 7 years ago; and 3.3% (n=4) were diagnosed between 8 and 9 years ago.

Less than 7% (n=8) were diagnosed with cancer more than 9 years ago. The average

length of time since diagnosis was 3.16 years and the median was 3 years.

Time since operation. The length of time since their operation ranged from 3

to180 months. The average length of time since their operation was 36.39 months (SD =

38.46). Over 34% (n=41) were diagnosed less than 1 year ago. Thirty percent (n=36)

154
were diagnosed between 2 and 3 years ago; about 21% (n=25) were diagnosed between 4

and 5 years ago, 5% (n=6) were diagnosed between 6 and 7 years ago; and 3% (n=4)

were diagnosed between 8 and 9 years ago. Less than 7% (n=8) were diagnosed with

cancer more than 9 years ago.

Sexual history. On the items measuring sexual history, scores could range from 1

(not at all) to 5 (very much). Approximately 91 % (n=109) subjects reported that their

incisions did not make them uncomfortable at all during sexual activities (question #1);

about 81% (n=97) were not anxious at all when they think of sexual issue (question #2).

Only 9% (n=11) of the subjects, including both men and women, used medicine or other

substance to improve their sexual function (question #3). Among the male participants,

about 8% (n=7) were using Viagra (sildenafil) and 13% (n=4) of the female participants

were using a lubricant during sexual activity.

In terms of the importance of sexual life in general, before treatment and at

present (questions #4 to 6), 25% (n=30) of the subjects rated their sexual life in general

as not important at all, 12% (n=15) rated their sexual life before treatment as not

important at all and 27% (n=32) rated it as not important at all at present. Only 4% (n=5)

of the subjects viewed their sexual life in general as very important, nearly 6% (n=7) and

4% (n=5) of the subjects viewed their sexual life as very important before treatment and

at present, respectively. With respect to the importance of their sexual relationship with

their partners right now, nearly 26% (n=31) indicated it was not important at all, while

only 5% (n=6) rated it as very important.

155
 Stage of disease. In terms of the stage of the disease, 32% (n=39) of the 120

study participants were in stage A, 24 % (n=28) were in stage B1, 3% (n=4) were in stage

B2, 5% (n=6) were in stage C1, and 36% (n=43) were in stage C2 (see Table 4.2).

Type of treatment and surgery. As for the type of treatment received, 52% of the

study participants received surgery only, 37% (n=44) received surgery and postoperative

chemotherapy, and 11% (n=13) received surgery and both postoperative chemotherapy

and radiotherapy. As for the type of surgery they had, about 84% (n= 101) underwent a

low anterior resection (LAR) and 16% (n = 19) had an abdominoperineal resection (APR).

One forth (25%) of the study participants (n = 30) also had a colostomy performed.

Type of chemotherapy. With regard to the type of chemotherapy that the rectal

cancer patients received, 28% received chemotherapy with Five-Flurouracil and

Leucovorin, 12% received 5-Fluorouracil, Leucovorin and Oxaliplatin, and 8% received

5-Flurouracil, Leucovorin and Camptosar. The other 52% did not receive chemotherapy.

Comorbid conditions. Over half of the study participants (52%; n=62) reported

having no comorbid conditions. Over one third (35%, n=42) of them reported one

comorbid condition; 10% (n=12) had two comorbid conditions, and 3% (n=4) had three

comorbid conditions. The most frequently reported comorbid conditions were:

hypertension (31%; n=37) and diabetes mellitus (17%; n=20), followed by heart disease

(7.5%; n=9). The demographic characteristics of the sample are summarized in Table 4.2.

156
Table 4.2. Description of Characteristics of the Sample (N=120)
Continuous Variables M (SD) Range
(Min-Max)
Age (in year) 60.81 56 (29 – 85)
(9.98)
Number of children 2.77 6 (0 – 6)
(1.19)
Number of comorbid conditions .65 (.79) 3 (0 – 3)
Continuous Variables
N %
Educational Level
Completed elementary school 36 30.0
Completed middle school 11 9.2
Completed high school 44 36.7
Completed undergraduate degree 25 20.8
Completed graduate degree 4 3.3
Stage of Disease (in Duke staging system)
A (tumor penetrates into the mucosa of bowel wall) 39 32.5
B1 (tumor penetrates into, but not through the 28 23.5
muscular layer of the bowel wall)
B2 (tumor penetrates into and through the muscular 4 3.3
layer of the bowel wall)
C1 (tumor penetrates into, but not through the 6 5
muscular layer and spread into lymph nodes)
C2 (tumor penetrates into and through the muscular 43 35.8
layer of bowel wall and spread into lymph nodes)
Time since cancer diagnosis (year)
<1 40 33
2-3 36 30
4–5 26 22
>5 18 15
Time since operation (year)
<1 41 34
2-3 36 30
4–5 25 21
>5 18 15
Type of Treatment Received
Surgery only 63 52.5
Surgery plus chemotherapy 44 36.7
Surgery plus chemotherapy & radiatiotherapy 13 10.8

157
Table 4.2. (Continued)
Continuous Variables N %
Type of Chemotherapy
5 Fluorouracil+Leucovorin 33 27.5
5 Fluorouracil+Leucovorin+Camptosar 9 7.5
5 Fluorouracil+Leucovorin+Oxaliplatin 15 12.5
N/A 63 52.5
Categorical Variables N %

Gender
Female 32 26.7
Male 88 73.3
Marital Status
Never married 2 1.7
Married 115 95.8
Divorced 2 1.7
Widowed 1 0.8
Employment Status
Retired 61 50.8
Full-time 43 35.8
Part-time 11 9.2
Non-employee (housewife) 5 4.2
Religion
Atheism 12 10
Buddhism 63 52.5
Taoism and other folk beliefs 36 30.0
Catholicism and Christianity 9 7.5
Present Surgery Received
LAR 101 84.2
APR 19 15.8
Colostomy Received
No 90 75
Yes 30 25
Lubricant use (female)
No 28 87.5
Yes 4 12.5
Viagra (Sildenafil) use (male)
No 81 92
Yes 7 8

158
Relationships between Demographics and Cancer-Related Variables

Age and stage of disease. Because age was continuous measure/interval level data,

and stage of disease (tumor stage) was ordinal data, Spearman’s rho analysis was used.

No significant association was found between age and the stage of disease (rho= -.04,

p=.65) shown Table 4.3.

Age and type of treatment. Age was continuous data and type of treatment was

ordinal data. The types of cancer treatment included: surgery, surgery plus chemotherapy,

and surgery plus chemotherapy and radiotherapy. Therefore, Spearman’s rho analysis

was performed to see if there was a significant association between them. The results

revealed that age was significantly and negatively correlated with type of treatment

received (rho= -.20, p= .027), indicating that younger patients tended to have more types

of treatment, i.e., surgery plus chemotherapy and radiotherapy, while older patients

tended to receive fewer additive treatments as shown Table 4.3. Moreover, the type of

treatment received was significantly associated with stage of disease (rho= .81, p=.000).

Age and time since operation. Because both age and the time since operation were

interval level data, a Pearson’s product moment correlation analysis was used to

determine if a significant relationship existed between age and time since operation. Age

was found to be positively and significantly correlated with the length of time since

operation (r= .25, p= .006), indicating younger patients had a shorter length of time since

operation as shown Table 4.3.

Age and comorbid conditions. Because both age and the number of comobid

condition were interval level variables, a Pearson’s product moment correlation analysis

159
was used. There was no significant correlation found between age and number of

comorbid conditions (r= .13, p= .15) as shown Table 4.3.

Table 4.3. Intercorrelations Between Age and Cancer-Related Variables

Variables Stage of Type of Time since Comorbid
(N=120) disease treatment Operation Conditions
rho (p) rho (p) r (p) r (p)
Age -.04 -.20* .25** .13
(.65) (.027) (.006) (.15)
*p < .05; **p< .01
Note. Type of treatment: surgery, surgery plus chemotherapy, surgery plus chemotherapy
and radiatiotherapy
In summary, age was negatively associated with treatment type (p=.03) but

positively associated with the length of time since operation (p=.006). Thus, younger

patients tended to have more types of treatment and had a shorter length of time since

operation, while older patients tended to receive less types of treatment and had a longer

length of time since operation. There was no significant relationship found between age

and with number of comorbid conditions and stage of disease.

Gender and stage of disease. Because gender is dichotomous and stage of disease

(tumor stage) is an ordinal variable comprised of five stages, a Mann-Whitney U test was

used to examine the gender difference in the stage of disease. The findings indicated

there was no significant difference between men and women by stage of disease (U=

1251.0, p > .05). Females and males’ mean ranks were 65.41 and 58.72, respectively.

Gender and type of treatment. Because the type of treatment is ordinal measure

(i.e. surgery, surgery plus chemotherapy, and surgery plus chemotherapy and

radiotherapy), a Mann-Whitney U test was used to examine gender differences in the type

of cancer treatment. No significant gender difference by the type of treatment was found

(U = 1189.5, p > .05). Women’s mean rank was 67.33, while men’s mean rank was 58.02.

160
 Gender and time since operation. Because gender was a dichotomous variable

and time since operation was interval level data, an independent-samples t test comparing

the mean scores between men and women was used. A significant gender difference

(t(1,118) = -2.16, p = .03) was found. The men’s mean scores on the length of time since

operation was significantly higher (M=2.50, SD =1.49) than women’s mean scores

(M=1.88, SD =1.10), indicating the length of time since operation for rectal cancer was

longer for men than it was for women.

Gender and comorbid conditions. Because the number of comorbid conditions

was treated as an interval variable, an independent-samples t test was used to compare the

mean difference on number of comorbid conditions between males and females. There

was no significant mean difference on comorbid conditions between males and females

(t(1,118)= -.97, p= .33). The mean scores for men (M= .69, SD= .82) was not

significantly different from the women (M= .53, SD= .72).

In summary, a significant difference on time since operation was found between

men and women with the length of time since operation being longer for male rectal

cancer patients than for female rectal cancer patients. No significant gender differences

were found by stage of disease, type of treatment, or number of comorbid condition.

Description of Study Variables

The major study variables included three independent variables, namely,

perceived stress (operationalized by two indicators: cognitive appraisal of stress and

global stress), spirituality, resourcefulness, and one dependent variable, sexuality

(operationalized by three indicators: sexual function, sexual self-concept, and sexual

161
satisfaction, including communication and relationship. The measures of all study

variables were treated as interval level data in this study.

Missing Data

Very few cases were found to have missing data on a single item on the study

measures. The measure of Sexual Self-Schema for Males (SSSSM) had one piece of

missing data (.5 %) out of 120 cases and the measure of Cognitive Appraisal of Stress

Scale had one piece of missing data (.5 %). The ENRICH-communication measure had

two missing data items (1.0 %), and the measure of Resourcefulness had two missing

data items (1.0%). There were no missing data on the remaining study variables.

Therefore, mean substitution was used to replace the missing data described above.

Because there were so few missing data and because it was scattered randomly

throughout the data set, the generalizability of results was not expected to be affected

(Tabachinick & Fidell, 2001).

Study Variables

The independent variable, perceived stress was measured by the Perceived Stress

Scale (PSS-10) and the Primary Appraisal subscale of the Cognitive Appraisal of Stress

Scale. Spirituality was measured by the Body-Mind-Spirit Well Being Inventory-

Spirituality (BMSWBI-Sp). Resourcefulness was measured by the Resourcefulness Scale

(RS). The dependent variable, sexuality was measured by six measures: Sexual function,

was measured by the International Index of Erectile Function (IIEF) for men or the

Female Sexual Function Index (FSFI). Sexual self concept was measured by Sexual Self-

Schema Scale for males (SSSSM) / Sexual Self-Schema Scale for females (SSSSF).

Sexual satisfaction was measured by two approaches, ENRICH-Communication

162
(ENRICH-Co) and ENRICH- Sexual Relationship Scale (ENRICH-SRS). The

descriptive statistics (i.e., central tendency and variability) for all study variables are

presented in Table 4.4.

Table 4.4. Descriptive Statistics of Study Variables (N=120)

Variables Mean Median Possible Actual Skewness Kurtosis /
(SD) Range Range /Std. Error Std. Error
Cognitive 55.08 67.5 19-95 29-87 -.29 (.22) .10 (.44)
Appraisal of
(9.83)
Stress
Perceived Stress 9.72 11.0 0-40 0-24 .08 (.22) -.93 (.44)
(6.32)
Spirituality 85.56 89.0 0-130 51-100 -.79 (.22) -.04 (.44)
(12.64)
Resourcefulness 97.50 97.50 0-140 39-138 -.18 (.22) -.57 (.44)
(20.73)
Male Sexual 46.03 57.50 5-75 5-72 -.60 (.26) -1.37 (.51)
Function
(22.25)
(n=88)
Female Sexual 18.99 23.35 2-36 2-32.3 -.53 (.41) -1.31 (.81)
Function
(10.42)
(n=32)
Male Sexual 102.48 101.50 18-144 72-143 .37 (.26) .28 (.51)
Self-Concept
(13.65)
(n=88)
Female Sexual 54.34 54.50 -42-102 31-77 .14 (.41) -.89 (.81)
Self-Concept
(12.86)
(n=32)
Communication 35.37 36.0 10-50 11-48 -.83 (.22) .46 (.44)
(8.24)
Sexual 38.29 38.0 10-50 24-50 .10 (.22) -.94 (.44)
Relationship
(7.09)

Perceived stress. Perceived stress was measured by the Perceived Stress Scale

(PSS-10). The PSS-10 was used to assess global stress experienced by the rectal cancer

163
patients. The total sample mean on the PSS-10 was 9.72 (SD=6.32). Possible scores

ranged from 0 to 40 with higher scores indicating perception of greater stress. Less than

13% of the participants indicated they had been upset because of something that

happened unexpectedly. About 21% of the participants reported they felt nervous and

“stressed” fairly often or very often. Less than 10% of the participants felt they were

unable to control irritations or important things in their life or that they never felt that

things were going their way. Also, less than 10% reported that they could not cope with

all the things they had to do and fairly often felt that difficulties were piling up so much

that they could not overcome them. Approximately 14% reported feeling angry because

of things that happened outside of their control. In summary, the majority of the study

participants reported low levels of global stress. However, over one fifth of them felt

stressed and nervous, while only about 10% revealed their inability to face difficulties in

their life. The Cronbach’s alpha for the PSS-10 in this sample was .84.

In addition to PSS-10, the 19-item primary appraisal subscale of the Cognitive

Appraisal of Health Scale (CAHS) was used to measure the cognitive process of stress

appraisal. More specifically, these 19 items reflected stress appraisal as threat, challenge,

or harm/loss, as described within Folkman and Lazarus’ model of stress (Lazarus &

Folkman, 1984). The total sample mean on the 19-item cognitive appraisal of stress

items taken from the CAHS was 55.08 (SD=9.83) with possible scoring range from 19 to

95. The cognitive appraisal of stress scale comprised of three subscales, that is threat,

challenge, and harm/loss. Higher scores on each scale or item indicated greater agreement

with that form of appraisal. The internal reliability coefficient of these 19 items in this

sample was .79.

164
 The possible scores on the threat scale can range from 5-25; in this sample, the

mean was 10.81 (SD =4.31); one fifth (20%) of the participants agreed or strongly agreed

their current health condition was frightening to them, whereas 60% disagreed with that.

Thirteen percent of the participants agreed or strongly agreed and 80% disagreed that

things got worse because of their disease. Eighty percent of the participants disagreed or

strongly disagreed and only 10% agreed that their health conditions did not go well. In

summary, 20% assessed that the rectal cancer disease was frightening to them and 10%

agreed their disease did not progress well, and more than 10% agreed things got worse

because of their disease.

Possible scores on the challenge scale can range from 6-30; in this sample, the

mean was 24.18 (SD=3.35). Approximately 28% agreed or strongly agreed and 63%

disagreed that they felt a loss due to this disease. Thirty percent agreed or strongly agreed

and 60% disagreed that that they worried about what happened to them. Over 30% of the

participants disagreed or strongly disagreed and 48% agreed that they had no control over

what happened to them. About 16% of the participants disagreed or strongly disagreed

and 78% agreed or strongly agreed that their disease would not get them down.

Approximately 88% of the participants agreed or strongly agreed and less than 10%

disagreed that they could fight their disease in spite of difficulty. About 97% agreed that

they could handle their health condition. Moreover, About 93% agreed or strongly agreed

that their disease helped them learn more about themselves. Sixty-eight percent agreed or

strongly agreed and 20% disagreed that there was a lot they could do to overcome their

health condition. In summary, over 90% of the study participants reported they were able

to manage their disease, which helped them to learn more about themselves. About 30%

165
of them felt a sense of loss because of their disease; they worried about what would

happen to them and expressed feeling a lack of control over it.

Possible scores on Harm/ Loss scale can range from 8-40; in this sample, the

mean was 20.10 (SD=6.59). Approximately 62 % of the participants agreed or strongly

agreed that they felt hurt or harmed in some way by their current health condition. About

35% of the participants agreed or strongly agreed and over half (56%) disagreed or

strongly disagreed that their disease damaged their lives. Over 85% of the participants

disagreed or strongly disagreed that their relationships with their family and friends had

suffered, while only 7% agreed or strongly agreed with that. About 30% agreed or

strongly agreed and about 62% disagreed or strongly disagreed that they had not been

able to do what they wanted to do because of their disease. Over 75% disagreed or

strongly disagreed that they had lost interest in the things around them, while 15% of

them agreed or strongly agreed they had lost interest. More than one fifth (22%) agreed

or strongly agreed and 66% disagreed or strongly disagreed that they had to give up a

great deal because of their disease. Moreover, about 30% of the participants felt a sense

of loss over the things they could no longer do and 63% disagreed or strongly disagreed

with feeling a sense of loss.

Spirituality. Spirituality was measured by the 13-item BMSWBI-Spirituality,

which assesses the participants’ core values, philosophy, and meaning of life. The total

sample mean score on the BMSWBI-Spirituality was 85.56 (SD=12.64). The scores

ranged from 51 to 100 with higher total scores indicating better spirituality. The internal

reliability coefficient of the BMSWBI-Spirituality in this sample was .83.

166
 Approximately 83% of the participants disagreed that they lost direction of life or

did not know how to love themselves. Eighty percent of the participants disagreed that

they lacked vitality in life. Approximately 55% indicated they understood why

predicaments occurred, while about one third (31%) did not understand why they

encountered predicaments. About 75% of the participants felt a sense of calm and

harmony deep in their hearts and agreed that predicaments strengthened them, while 10%

of them did not feel peace and harmony in their mind. Moreover, about 80% agreed that

facing a predicament was a challenge and a learning opportunity and they were able to

manage it. About 70% of the participants disagreed with blaming heaven for being unfair

to them; less then 10% of the patients agreed to blaming heaven. Over 90 % of the

participants were grateful to people who had done things for them; they felt content with

whatever happened to them, were able to deal with difficulties, and were able to face life

as usual.

Resourcefulness. Resourcefulness was measured by Resourcefulness Scale (RS),

which included personal resourcefulness (self-help) and social resourcefulness (help-

seeking). The total sample mean on the resourcefulness scale was 97.51 (SD=20.73). The

scores ranged from 39 to 138 with higher scores reflecting greater resourcefulness. The

Cronbach’s alpha on the Resourcefulness in this sample was .88. The 120 subjects

reported high levels of resourcefulness, especially personal resourcefulness. Among the

items of tapping social resourcefulness (12-item), one third of 12 items of social

resourcefulness (RS) showed a low to moderate level of social resourcefulness, for

instance, they did not like to seek help from others in certain situations, e.g., when

lacking money or in expressing their feelings.

167
 Sexual function. Male sexual function was measured using a 15-item International

Index of Erectile Function (IIEF) in the 88 male study participants. The IIEF is

comprised of five domains: erectile function (EF, 6 items), orgasmic function (OF, 2

items), sexual desire (SD, 2 items), intercourse satisfaction (IS, 3 items), and overall

satisfaction (OS, 2 items). The total scores on the IIEF scale are unevenly distributed into

five domains. Six of the15 items represent the domain of EF, while the other domains

have two or three items as shown in Table 4.4. Moreover, the IIEF questionnaire has 10

items rated on a 6-point scale and five items rated on a 5-point scale. The possible total

scores on the IIEF ranged from 5 to 75 with a mean of 46.03 (SD=22.25). Cronbach’s

alpha was .97. Thirty-six percent (n=32) of the male participants had scores less than the

average of IIEF indicating more dysfunction, while more than half (64%) of them had

higher scores than the average, indicating less dysfunction.

Possible scores on the EF domain range from 1 to 30; in this sample, the mean of

19.85 (SD=11.05) indicated mild to moderate erectile dysfunction (Range of scores: 1-

10= severe erectile dysfunction, 11-16= moderate dysfunction, 17-21= mild to moderate

dysfunction, 22-25= mild dysfunction, 26-30= no dysfunction). The range for the

remaining domains, OF, SD, IS, and OS were 0-10, 2-10, 0-15, and 2-10, respectively.

Higher scores on each domain indicated less dysfunction.

Over 27% (n=24) of the men had scores less than 10, indicating severe erectile

dysfunction, 8% (n=7) had moderate dysfunction (scores 11-16), 4% (n=4) had mild to

moderate or mild (n=4) dysfunction with scores 17-21 and 22-25, respectively. Over 55%

(n=49) of the men reported no erectile dysfunction with scores 26-30. Approximately one

quarter (n=22, 25%) of the men indicated they had no sexual stimulation/intercourse

168
(orgasm function, OF) and did not attempt intercourse (IS) (n=23, 23.1%) in the past 4

weeks, while 62% (n=52) had higher scores than the average of 6.83 on the domain of

intercourse satisfaction. As for the domain of sexual desire (SD), 52% of the male

participants had scores less than the average of 6.44. For overall satisfaction (OS), 59%

(n=52) of the men had scores less than average of 6.47.

Table 4.5. International Index of Erectile Function and Score Distribution (N=88)
Domain (item) N % Mean Possible Skewness/ Alpha
(SD) range Kurtosis
Erectile Function (EF) 19.85 1-30 -.68/ -1.29 .97
(6) (11.05)
<10 24 27.3
11-16 7 7.9
17-21 4 4.5
22-25 4 4.5
26-30 49 55.6
Orgasmic Function 6.44 0-10 -.64/ -1.44 .98
(OF) (2) (4.32)
0 22 25
2-5 10 11.3
7-10 56 63.7
Sexual Desire (SD) (2) 6.44 2-10 -.17/ -.61 .79
2-6 46 52.3 (1.91)
7-10 42 47.7
Intercourse Satisfaction 6.44 0-15 -.44/ -1.28 .91
(IS) (3) (4.69)
0 23 23.1
2-7 13 14.7
8-15 52 62.2
Overall Satisfaction 6.47 2-10 -.59/-.01 .94
(OS) (2) (2.18)
2-7 52 59
8-10 36 40.9
IIEF Total Score (15) 46.03 5-72 -.59/-1.37 .82
< 47 32 36 (22.25)
49-72 56 64
Female sexual function was measured by the Female Sexual Function Index

(FSFI) for the 32 study participants who were women. The 19-item FSFI included six

domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. The items

comprising these subscales contributed almost equally to the total scale score as shown in

Table 4.6. The FSFI questionnaire contains 15 items that are rated on a 6-point scale and

169
four items that are rated on a 5-point scale. To determine the FSFI score, scores on the 6

domains are multiplied by a weighted score. Possible total scores ranged from 2 to 36; in

these women, the mean was 18.99 (SD=10.42). Higher scores reflected less sexual

dysfunction. The Cronbach’s alpha of the FSFI was .93.

Table 4.6. Female Sexual Function Index and Domain Score Distribution (N=32)
Domain (item)
Actual Skewness /
/Actual range N % Mean (SD) Alpha
range Kurtosis
Desire (2) 2.78 (1.11) 1.2-5.4 .39 / -.12 .79
1.20 – 2.40 13 40.6
3.00 - 3.60 15 46.9
4.20 - 5.40 4 12.5
Arousal (4) 2.45 (1.92) 0-5.4 -.14 / -1.40 .97
0.00 10 31.3
1.20 - 2.70 5 15.6
3.00 - 5.40 17 53.1
Lubrication (4) 3.19 (2.31) 0-6.0 -.51 / -.14 .97
0.00 10 31.3
3.00 1 3.1
3.30 - 6.00 21 65.6
Orgasm (3) 3.11 (2.30) 0-5.6 -.43 / 1.51 .97
0.00 10 31.3
2.00 - 2.80 2 6.2
3.60 3 9.4
4.00 - 4.40 7 21.9
5.20 - 5.60 10 31.3
Satisfaction (3) 3.92 (1.55) 0.8 -6 -.77 / -.21 .75
2.80 - 3.60 12 37.4
4.00 - 6.00 20 62.6
Pain (3) 3.54 (2.58) 0- 6 -.58 / -1.57 .98
0.00 10 31.3
1.60 1 3.1
4.00 - 6.00 21 65.6
FSFI Total Score 18.99 (10.42) 2.00-32.30 -.53 / -1.31 .93
(19)
< 10 10 31.2
11 – 20 3 9.3
21 – 30 14 43.5
31 – 32.5 5 15.5

170
 Forty percent (n=13) of the women reported a lower level of sexual desire than

the average (M=2.78, SD=1.11). Thirty-one percent (n=10) of them reported no sexual

activity when they were asked about arousal, lubrication, orgasm, and pain/discomfort;

thus, their FSFI scores were less than 10. Over one third (n=12, 37%) of the women

participants indicated a low level of sexual satisfaction shown in Table 4.6. However, in

comparison with the average score, more than half of the women indicated that they had

experienced or felt sexual desire (59 %), arousal (53%), lubrication (65%), orgasm (62%),

sexual satisfaction (62%), and never experienced pain or discomfort (65%) during sexual

activity in the past 4 weeks. Approximately 59% (n=20) of the women had FSFI scores

that exceeded the average of 18.99, indicating that they has lower sexual dysfunction.

Sexual self concept. Sexual self concept was measured by Sexual Self-Schema

Scale for Males (SSSSM) or Sexual Self-Schema Scale for Females (SSSSF). The SSSS-

M was used to assess the positive versus negative characteristics of a man’s self-image as

a sexual person (Anderson, et al., 1997). The SSSS-Male Scale is comprised of three

factors: passionate/loving (factor 1), powerful/aggressive (factor 2), and open-

minded/liberal (factor 3). Use of the total score is recommended (Andersen &

Cyranowski, 1994). The internal reliability coefficient for the total scale was .69 which is

close to the minimal requirement for reliability, i.e., .70 (Nunnally & Bernstein, 1994).

Among the 45 items constituting the total scale, 27 items, written in italics, were relevant

to a man’s self-image or description as a sexual person. Possible scores range from 72 to

143; in this sample, the mean was 102.48 (SD=13.65). Higher scores indicated greater

men’s self image as a sexual person. Fifty-three percent (n=47) of 88 male participants

had scores less than the average of 120, indicating they had a less positive perception of

171
themselves as a sexual person, while approximately 47% of the men had a more positive

perception of themselves as sexual person (Table 4.7).

Table 4.7. Sexual Self-Schema Scale-Male and Domain Score Distribution (N=88)
Domain/item Mean (SD) Skewness / Score N % Alpha
Kurtosis Range
Factor 1 (10) 41.74 (6.69) -.09/-.57 27 - 58

Factor 2 (13) 45.38 (7.56) .62/1.33 29 - 70

Factor 3 (4) 15.36 (4.09) .16/.02 5 - 24

SSSSM Total Score 102.48 .37/.28 72 - 143 .69

(27) (13.65)
72 - 102 47 53.2
103 - 143 41 46.6

Sexual Self-Schema Scale for Females (SSSSF) contains two positive factors and

one negative factor to assess the woman’s inclination to experience passionate/romantic

(factor 1), directness/openness (factor 2), and embarrassment or conservatism (factor 3).

The possible scores ranged from -42 to 102 with higher scores interpreted as positively

schematic and low scores negatively schematic. Use of the total score is recommended

(Andersen & Cyranowski, 1994). The internal reliability coefficient for the total scale

was .72. Among the 50 items, 26 written in italics were relevant to a woman’s self-image

description. The SSSSF total scale scores ranged from 31 to 77, with a mean of 54.34

(SD=12.86). An equal percentage (n=16, 50%) of the female participants had scores

lower than 54 and ranged from 55 to 77 (Table 4.8).

172
Table 4.8. Sexual Self-Schema Scale-Female and Domain Score Distribution (N=32)
Domain / items Mean (SD) Skewness / Score N % Alpha
Kurtosis Range
Factor 1 (10) 42.88 (7.81) -.14 / -.70 28 - 56

Factor 2 (9) 38.19 (6.84) .05 / -.94 26 - 51

Factor 3 (7) 26.72 (4.85) .30 / 1.66 14 - 40

Total Score (26) 54.34 (12.86) .14 / -.89 31 - 77 .73

<54 16 49.9
55 - 77 16 49.9

Sexual satisfaction. Sexual Satisfaction was measured using two instruments:

ENRICH-Communication (ENRICH-Co) and ENRICH- Sexual Relationship Scale

(ENRICH-SRS). The 10-item ENRICH-Communication scale was used to assess the

male and female participant’s feelings and attitudes toward communication in their

relationship. The range of scores is from 10 to 50, with higher scores indicating more

positive feelings about the quality and quantity of communication. In comparison with a

national survey of 21,501 married couples (N=43,002), the mean was 31.6 (SD=9.2) and

alpha reliability was .90 (Fowers & Olson, 1989), while the Cronbach’s alpha reliability

of ENRICH-Communication scale in this study was .86 and the mean was 35.4 (SD=8.2).

Approximately 27% of the study participants indicated they had very high positive

feelings (n=32) and high positive feelings (n=34, 28.4%) about the quality and quantity

of their communication, while over 20% of the participants had low positive (n=17,

14.2%) or very low positive (n=8, 6.6%) feelings about the quality and quantity of their

communication shown in Table 4.9.

173
Table 4.9. ENRICH-Communication Scale and Score Distribution (N=120)
Cutting points Possible Actual N % Mean (SD) Alpha
range range
Total Score 10 - 50 11 - 48 120 100 35.37 (8.24) .86
Very high 41 - 50 41 - 48 32 26.8
High 36 - 40 36 - 40 34 28.4
Moderate 29 - 35 30 - 35 29 24.1
Low 23 - 28 23 - 28 17 14.2
Very low 10 - 21 11 - 19 8 6.6

In addition to ENRICH-communication scale, sexual satisfaction was also

assessed by the ENRICH- Sexual Relationship Scale (ENRICH-SRS) in order to examine

the partner’s feelings related to the other’s affection and sexual relationship. The total

scores ranged from 10 to 50 with higher scores indicating greater satisfaction in

expressing affection and feelings about sexuality and lower scores reflecting greater

dissatisfaction in expressing affection and feelings about sexuality. In the national sample

of 21,501 married couples, the mean on the scale was 33.7 (SD=9.1) and internal

consistency was .88 (Fowers & Olson, 1989), while in the study reported here, the mean

was 38.29 (SD=7.09) and internal reliability coefficient was .81. Approximately 35%

(n=42) of the participants were very satisfied with their expression of affection and had

very positive feelings about sexuality; 28% (n=34) were satisfied with their expression of

affection and had a positive feelings about sexuality, 28% (n=33) were somewhat

satisfied with their expression of affection and had a few concerns about sexuality. Only

9% (n=11) of the participants were somewhat dissatisfied with their expression of

affection and had some concerns about sexuality in their life (Table 4.10).

174
Table 4.10. ENRICH-Sexual Relationship Scale and Score Distribution (N=120)
Cutting points Possible Actual N % Mean (SD) Alpha
range range
Total Score 10 - 50 24 - 50 120 100 38.29 (7.09) .81
Very high 41 - 50 41 - 50 42 34.9
High 36 - 40 36 - 40 34 28.3
Moderate 29 - 35 29 - 35 33 27.5
Low 23 - 28 24 - 28 11 9.1

Testing the Assumptions

Pearson’s correlations, Spearman’s rho, independent-samples t tests, and one-way

analysis of variance (ANOVA) were the statistical methods needed for addressing the

research questions posed in this study. Prior to inferential data analysis, testing

underlying assumptions was required in order to make accurate inferences about the

population. The primary assumptions for Pearson’s correlation and Spearman’s rho

included: 1) Normality, 2) Linearity, and 3) Homoscedasticity.

1) Normality. Normality was assessed by examining frequency distributions and

using exploratory analysis with SPSS, which provided graphical displays (histogram with

a superimposed normal curve, and P-P probability plots) and descriptive statistics (i.e.,

skewness and kurtosis values with standard errors) to insure adequate variation in the

variables, since lack of variance will weaken correlations with other variables.

The P-P probability plots were examined to determine whether non-normality

existed among the study variables. The scores on the independent variables and four of

six scales of dependent variable were nearly normal distributed. The P-P plots of the male

sexual function (n=88) and the female sexual function (n=32) showed some deviation

175
between the expected and the observed values. Although there was a gap between two of

the cases on the two variables, the male sexual function and the female sexual function,

the gap was not found for the residual normality, and none of the skew values were

greater than +/- 3. None of the kurtosis values were greater than 8. Thus, no evidence of

skewness and kurtosis was demonstrated in Table 4.2 (skewness = +/- 3, kurtosis < 8 - 20,

Kline, 1998). Furthermore, a sample size of 30 or more is considered sufficient to

overcome violation of this assumption (Daniel, 1995; Agresti & Finlay, 1997). In larger

sample sizes (i.e. 120), means scores should be considered as normally distributed,

according to the Central Limit Theorem; hence, the assumption of normality was met

(Tabachnick & Fidell, 2001).

2) Linearity. The assumption of linearity presumes that there is a linear

relationship between two variables (X and Y). Linearity was assessed through the

examination of the bivariate scatterplots (Tabachnick & Fidell, 2001). An approximate

straight line relationship was found among the scatterplots of all major study variables.

Linearity was also assessed using graphical displays (bivariate regression

scatterplots) and numeric tests (R squared option) to determine a linear relationship

between independent and dependent variables. Most of scatterplots were found to be

nearly linear; one pair of variables, the perceived stress and the communication, showed a

non-linear trend with R2 differences exceeding 2% while comparing the linear and

quadratic lines of best fit. Thus, the original independent variable and squared

independent variable were simultaneously used on partial regression plots to counter the

non-linear effect; the difference was less than 1% of additional explained variance, which

met the assumption of linearity.

176
 In addition, multicollinearity was examined to determine if there existed a linear

association between the dependent variable and independent variables. The numeric

statistic indicated there was no evidence of multicollinearity for all study variables. None

of them had values of tolerance equal or less than .20 (all tolerance values > .50) and

values of VIF (Variance Inflation of Factor) were larger than 10 (all VIF < 2) (Stevens,

1992).

3) Homosecedasticity. This means the residual variance of one variable is equal to

the residual variance of the other variable. This assumption was assessed by examining if

the differences between the Studentized Deleted Residuals (Y axis) and the Standard

Predicted value (X axis) scores form a relatively constant distribution around the

prediction line (i.e., constant error variance). If the data points reached a 3:1 ratio of

highest to lowest error variance scatter, a non-constant error variance would be indicated

(Fox, 1991). In this study, the assumption of homosecedasticity was not violated.

In addition, secondary assumptions for Pearson’s correlations and Spearman’s rho

analysis included:

1) Normality of residuals. Testing for this assumption required examination of

skew and kurtosis tests of SDR (i.e., normal errors). Normal errors were assessed using

numeric statistics and graphic outputs by plotting the probability plot (P-P) of

Studentized Deleted Residuals (SDR) under Regression. The residuals of independent

and dependent variables were normally-distributed. Two variables, the male sexual

function and the female sexual function were examined and the probability (P-P) plots of

regression SDR were showed the deviation of the “normal line” superimposed on the plot.

177
However, non-skew and non-kurtosis were demonstrated (skewness = +/-3, kurtosis < 8-

20, Kline, 1998). The assumption of normality of residuals was met.

2) Absence of influential cases. Unusual cases (i.e., outliers and influential cases)

were also identified before conducting the statistical analysis. Univariate outliers were

initially examined using SPSS Explore; one and four subjects/cases were considered as

possible outliers on the variables of age and time since operation, respectively. The

outlier(s) on age and time since operation were examined and revealed that it was the

youngest participant in the sample and the one with the longest time since operation,

respectively. Because they are probably the most interesting cases providing more

information of the sample, thus, these cases were kept in the data set. Moreover, three

scores (i.e., three ID cases) on the communication and one score (i.e., one ID case) on the

male sexual self-concept were considered as possible outliers on the variables

(communication and male sexual self-concept). Analysis for deletion of outliers and /or

variable transformation were/was conducted and the results were compared. Since the

findings were not found to be substantially different, these outliers were retained in the

data set.

To more precisely test for presence of no influential cases, examination of the

residuals (error variance) and related diagnostic statistics for multivariate outliers through

SPSS linear Regression were performed, including Cook’s Distance (≥ 1.0 indicates

outliers on X & Y axis), Mahalanobis Distance (outliers on independent variable, X axis),

Studentized Deleted Residuals (outliers on dependent variable, Y axis), SDFBETA (> 1

indicates outliers on X & Y), and the Covariate ratio (close to 1 is good).

178
 Cases were considered as possible outliers on the variables, communication, male

sexual self-concept, respectively. No differences were found in the graphical results upon

deletion of the suspected outliers. And none of the diagnostic statistics showed a Cook’s

D or SDFBETA greater than 1 or Covariate ratio close to 1. Therefore, the cases were

retained in the data set for further analysis. Moreover, the bias is generally less serious in

larger samples (i.e. 120) because of the increased likelihood of having a relatively higher

number of normal cases to offset the few deviant ones (Fox, 1991). Thus, the assumption

concerning the absence of influential cases was met.

Testing Assumptions for One-way ANOVA and Independent-sample t test

One-way analysis of variance (ANOVA) is a procedure that determines the

proportion of variability attributed to each of several components. It is used to compare

two or more means to see if there are any reliable differences among them (Tabachnick &

Fidell, 2001). Independent-samples t test is used to compare two group means. The

assumptions for a one-way ANOVA are generally identical to those for an independent-

samples t-test; these assumptions are: normality, linearity, proper levels of measurement,

existence of mutually exclusive groups, and homogeneity of variances. In addition to

testing of normality and linearity, which was discussed in the previous section of testing

assumptions for correlational analysis, the other required assumptions for one-way

ANOVA and independent-samples t test are addressed below:

1) Levels of measurement: The dependent variable, sexuality, included sexual

function, sexual self-concept, and sexual satisfaction (relationship and communication).

Each one was measured as a continuous variable. Although items were scaled on an

ordinal scale, because multiple items comprised each scale, it was treated as interval level

179
data. The independent variables in these analyses included education and religion; these

variables were categorical variables with more than two groups.

2) Existence of mutually exclusive groups: Analysis of variance requires a single

dependent variable and a single independent variable. As described above, the categorical

variables, which were the independent variables in these analyses, did not allow for

participants to have membership in more than a single category. Thus, this assumption

was met because observations within groups were independent of each other.

3) Homogeneity of variance. This assumption requires that equal variances exist

among the groups; this is determined by examining the non-significance of Levene’s test

for each ANOVA performed. The Levene’s test was found to be significant in the

analysis of erectile function by education and resourcefulness by stage of disease. Thus,

this assumption for homogeneity of variance was not met in those two cases. The Welch

F-ratio and the Brown-Forsythe F-ratio, more robust tests of equality of means, were used

instead (Fields, 2005).

Results of Research Questions

The purpose of this study was to examine the relationships between demographic

characteristics of Taiwanese rectal cancer patients undergoing cancer treatment and

cancer-related variables, perceived stress, spirituality, resourcefulness, and sexuality.

The study also explored relationships among perceived stress, spirituality,

resourcefulness, and sexuality among the study participants. Three major research

questions were addressed, the first two questions had 1 to 4 sub-questions related to the

major study variables.

180
Research Question 1. What are the differences in or relationships of major study

variables (perceived stress, spirituality, resourcefulness, and sexuality) in relation to the

demographic characteristics (i.e. age (A), gender (B), education (C), and religion (D) in

rectal cancer patients? (Q1A-Q4D)

Q1A - 4A: (Pearson’s correlations analysis)

1A: What is the relationship between age and perceived stress in rectal cancer patients?

2A: What is the relationship between age and spirituality in rectal cancer patients?

3A: What is the relationship between age and resourcefulness in rectal cancer patients?

4A: What is the relationship between age and sexuality in rectal cancer patients?

To answer the question 1A-4A, Pearson’s product moment correlations analysis

was used to determine if significant relationships existed between the age and each of the

major study variables. A bivariate correlation matrix is presented in Table 4.11. Age was

found to be negatively and significantly correlated with perceived global stress, (r = -.20,

p<.05) and the measures of sexual function in both males and females (r = -.24 and r = -

.36, p<.05, respectively). There were no significant correlations between age and

cognitive appraisal of stress, spirituality, resourcefulness, or the other four indicators of

sexuality. In summary, age had a negative relationship with perceived global stress,

indicating that older study participants reported lower global stress and younger

participants reported greater global stress. Age was not associated with cognitive

appraisal of stress, spirituality, resourcefulness, or sexuality. However, age was

negatively related with sexual function in both males and females, indicating older study

participants reported lower sexual function while younger participants reported better

sexual function.

181
 Table. 4.11. Pearson’s correlation coefficients between Age and Study Variables (Q1A-4A)

Cognitive Perceived Spirituality Resource- Sexual Satisfaction Male Male Female Female
Appraisal stress fulness Commun- Sexual sexual sexual sexual sexual
of stress (global) ication relationship self- function function self-
concept concept

(N = 120) (n = 88) (n = 32)

Age
-.12 -.20* .17 -.06 .002 -.08 .11 -.24* -.174 -.36*
* p <.05
182
Q1B - 4B: (independent-samples t test)

1B: Is there a significant gender difference in the perceived stress in rectal cancer patients?

2B: Is there a significant gender difference in the spirituality in rectal cancer patients?

3B: Is there a significant gender difference in the resourcefulness in rectal cancer patients?

4B: Is there a significant gender difference in the sexuality in rectal cancer patients?

Because gender is a dichotomous variable, an independent-samples t test was used

to determine if a mean difference existed between gender and 1) perceived stress, 2)

spirituality, 3) resourcefulness, and 4) sexuality (i.e., sexual function, sexual self-concept,

sexual satisfaction).

As shown in Table 4.12, a significant mean difference on perceived global stress

was found between males and females (t(1,118) = 2.30, p=.023). The mean scores on

perceived global stress for female participants was significantly higher (M=11.88,

SD=5.82) than the mean score for male participants (M=8.93, SD=6.34). Moreover, there

was a significant gender difference between the mean scores on resourcefulness (t(1,118)

=2.87, p=.005). More specifically, the mean score on the measure of resourcefulness in

females (M=106.25, SD=18.61) was higher than the mean score obtained for the males

(M=94.33, SD= 20.64). No gender differences were found on measures of cognitive

appraisal of stress, spirituality, or sexuality. In summary, the findings indicated that the

women perceived greater global stress but were more resourceful than the men.

183
Table 4.12. Comparison of Genders on Major Study Variables
Male Female Mean P
n = 88 n = 32 t
difference (2tailed)
Variable Mean SD Mean SD
Cognitive 54.89 10.00 55.62 9.46 .74 .36 .717
appraisal of
stress
Perceived stress 8.93 6.34 11.88 5.82 2.94 2.30* .023
(global)
Spirituality 86.45 12.11 83.09 13.91 -3.36 -1.29 .199

Resourcefulness 94.33 20.64 106.25 18.61 11.92 2.87** .005

Communication 35.92 7.97 33.84 8.88 -2.08 -1.22 .223

Sexual 38.58 7.06 37.50 7.21 -1.08 -.74 .463

relationship
*p<.05 ; **p<.01

Q1C - 4C: (one-way ANOVAs)

1C: Are there significant differences in perceived stress by level of education in rectal

cancer patients?

2C: Are there significant differences in spirituality by level of education in rectal cancer

patients?

3C: Are there significant differences in resourcefulness by level of education in rectal

cancer patients?

4C: Are there significant differences in sexuality by level of education in rectal cancer

patients?

Because categories of education constitute ordinal data, one-way ANOVAs were

conducted to determine if there were differences by educational level of the study

participants on 1) perceived stress, 2) spirituality, 3) resourcefulness, and 4) sexuality

(sexual function, sexual self-concept, sexual satisfaction).

There were no significant differences by educational level on perceived stress

(cognitive appraisal of stress, F(4,115)= .83, p= .51; global stress, F(4,115)=2.45, p= .05,

184
respectively). There were no significant mean differences by educational level found on

spirituality (F(4,115)=1.47, p= .22). However, the findings indicated that there was a

significant mean difference by educational level on resourcefulness (F(4,115)=5.36,

p=.001). The Scheffé and Bonferroni post hoc analyses showed that the study participants

who completed elementary school scored significantly lower than those who completed

middle school (mean difference = -22.33, p=.010) and those who completed high school

(mean difference = -18.15, p=.001). In other words, the study participants who completed

middle school (mean difference = 22.328, p=.010) and those who completed high school

(mean difference =18.146, p=.001) had significantly greater resourcefulness than those

with an elementary school education.

The results indicated a significant difference by educational level existed for

sexual relationship (F(4,115)=4.53, p=.002). Scheffé and Bonferroni post hoc tests were

conducted to determine where the differences in mean values were. Post hoc analysis of

the Bonferroni test revealed that the study participants who completed elementary school

scored significantly lower than those completing high school (mean difference= -5.40,

p=.004) and those with graduate education (mean difference = - 10.83, p=.022). These

findings were consistent with the mean plots presented in the study (Table 4.13). The

results of the Scheffé test showed that those who completed high school scored

significantly lower than those who completed elementary school (mean difference = -5.40,

p=.015). In other words, study participants who completed high school or completed a

graduate degree had significantly higher scores on sexual relationship than those who

completed elementary school. In summary, more highly educated rectal cancer patients

reported a greater sexual relationship.

185
 The findings showed no significant differences by educational level on

communication (F(4,115)=2.21, p=.07), female sexual self-concept (F(4,27)=.67, p=.621)

or female sexual function (F(4,27)=.68, p= .609). However, a significant difference by

educational level was found on male sexual self-concept (F(4,83)=3.07, p= .021). The

Bonferroni test in the post hoc analysis showed that male participants who completed an

elementary school education had significantly lower scores on male sexual self-concept

than those who completed graduate degrees (mean difference = -23.70, p= .030) and

those who completed an undergraduate degree (mean difference = -22.98, p= .043). The

results were consistent with the mean plots presented. In other words, male participants

who completed an elementary school education had a lower sexual self-concept than

those who completed higher education, such as an undergraduate degree and graduate

degree, respectively.

As for the differences by educational level on male sexual function, the Levene

test was significant, indicating that the assumption of homogeneity of variance was not

met (p=.000). Thus, the Welch and Brown-Forsythe tests, which reflect the F-ratio for

robust equality of means, were performed (Fields, 2005). Both the Welch (F=.000) and

the Brown-Forsythe tests were significant (F=.014) indicating that there were significant

differences by educational level on male sexual function.

In summary, the findings showed there were significant mean differences by

educational level on resourcefulness (p=.001), sexual relationship (p=.002), male sexual

self-concept (p=.021), and male sexual function (p=.000/.014). The study participants

who were more highly educated, were more resourceful and reported better sexual

relationships and male sexual self-concept and male sexual function.

186
Table 4.13. Comparison of Educational Levels on Major Study Variables
Welch/
School/Degree Elementary Middle High Undergrad Graduate
F Sig Brown-
N = 120 n = 36 n = 11 n = 44 n = 25 n=4 Forsythe
Variables M M M M M
(SD) (SD) (SD) (SD) (SD)
Cognitive 55.47 51.09 55.66 56.08 50.00 .83 .51
appraisal of (8.71) (10.36) (11.10) (8.14) (13.64)
stress
Perceived stress 11.67 9.27 8.18 10.64 4.50 2.45 .05
(global) (5.57) (6.60) (5.89) (7.18) (6.46)
Spirituality 82.25 82.64 88.59 85.84 88.25 1.47 .22
(10.64) (16.97) (11.28) (14.70) (14.06)
Resourcefulness 85.94 108.27 104.09 97.32 100.75 5.36 .001
(18.07) (20.74) (21.25) (17.66) (12.12)
Communication 32.83 38.09 36.84 34.28 41.25 2.21 .07
(7.74) (6.20) (8.96) (7.89) (4.99)
Sexual 34.92 38.45 40.32 38.32 45.75 4.53 .002
relationship (5.91) (6.86) (7.33) (6.76) (4.72)
N = 32
n=9 n=4 n = 13 n=5 n=1
Female sexual 50.33 54.25 58.62 50.40 55.00 .67 .62
self-concept (10.83) (16.40) (13.13) (14.59)
Female sexual 15.58 17.65 19.64 22.16 30.90 .68 .61
function (9.81) (13.40) (10.64) (9.86)
N = 88 n = 27 n = 7 n = 31 n = 20 n=3

Male sexual 98.63 104.14 105.55 99.35 122.33 3.07 .021

self-concept (13.96) (15.81) (11.28) (12.78) (17.67)
Male sexual 40.11 62.43 47.71 43.25 62.33 .000/
function (24.15) (6.50) (21.90) (22.20) (3.51) .014

Q1D – 4D: (one-way ANOVAs)

1D: Are there significant differences by religion on perceived stress in rectal cancer

patients?

2D: Are there significant differences by religion on spirituality in rectal cancer patients?

3D: Are there significant differences by religion on resourcefulness in rectal cancer

patients?

4D: Are there significant differences by religion on sexuality in rectal cancer patients?

187
 Because the identification of religion was put into four categories, one-way

ANOVAs were used to determine if there were differences by religion reported by the

study participants on 1) perceived stress (global stress and cognitive appraisal of stress), 2)

spirituality, 3) resourcefulness, and 4) sexuality (sexual function, sexual self-concept,

sexual satisfaction, i.e. communication and relationship).

The findings indicated there were no significant differences by religion found on

cognitive appraisal of stress (F(4,115)=.32, p=.81), and perceived global stress

(F(4,115)=9.75, p=6.63), respectively. Moreover, no significant differences by religion

were found on spirituality (F(4,115)=.47, p=.71), resourcefulness (F(4,115)= 1.49, p=.22),

communication (F(4,115)=.34, p= .80), sexual relationship (F(4,115)= .19, p=.90), male

sexual self-concept (F(4,83)= .87, p=.46), female sexual self-concept (F(4,27)=.67,

p=.52), male sexual function (F(4,83)= 1.30, p=.28), female sexual function (F(4,27)=.66,

p=.52). In summary, no significant differences by religion were found on any of the

major study variables, perceived stress (global stress and cognitive appraisal of stress),

spirituality, resourcefulness, and sexuality (sexual function - male and female, sexual

self-concept - male and female, sexual satisfaction, i.e. relationship and communication)

(Table 4.14).

188
Table 4.14. Comparison of Religion on Major Study Variables
Taoism & Catholicism
Groups Atheism Buddhism other &
F Sig
N = 120 n = 12 n = 63 beliefs Christianity
n = 36 n=9
M M M M
(SD) (SD) (SD) (SD)
Cognitive 52.83 55.06 55.42 56.89 .32 .81
appraisal of (8.83) (10.29) (10.67) (7.29)
stress
Perceived stress 9.75 9.35 10.22 10.22 .16 .92
(global) (6.63) (6.60) (5.76) (6.87)
Spirituality 88.33 85.44 84.17 88.22 .47 .71
(13.32) (13.28) (12.38) (8.23)
Resourcefulness 102.00 100.11 91.69 96.56 1.49 .22
(15.76) (21.19) (22.03) (14.55)
Communication 35.33 34.86 36.50 34.44 .34 .80
(8.75) (8.53) (7.86) (7.80)
Sexual 39.75 38.13 38.22 37.78 .19 .90
relationship (6.98) (6.72) (7.63) (8.45)
N = 32
n=0 n = 22 n=8 n=2
Female sexual 53.14 58.75 50.00 .67 .52
-
self-concept (11.21) (14.81) (26.87)
Female sexual - 18.20 22.35 14.35 .66 .52
function (10.93) (8.73) (12.94)
N = 88 n = 12 n = 41 n = 28 n=7

Male sexual 108.00 100.98 101.89 104.14 .87 .46

self-concept (11.77) (13.80) (14.59) (11.74)
Male sexual 35.67 49.83 45.11 45.29 1.30 .28
function (24.08) (21.19) (21.91) (25.36)
Research Question 2. What are the differences in or relationships of major study

variables (perceived stress, spirituality, resourcefulness, and sexuality in relation to the

cancer-related variables (i.e. stage of disease (E), type of treatment (F), time since

operation (G), and comorbid conditions (H)) in rectal cancer patients? (Q1E - Q4H)

Q1E – 4E: (Spearman’s rho analysis)

1E: What is the relationship between stage of disease and perceived stress in rectal cancer

patients?

189
2E: What is the relationship between stage of disease and spirituality in rectal cancer

patients?

3E: What is the relationship between stage of disease and resourcefulness in rectal cancer

patients?

4E: What is the relationship between stage of disease and sexuality in rectal cancer

patients?

Because stage of disease is considered as ordinal data and the major study

variables are continuous variables, Spearman’s rho was conducted to determine if there

were significant relationships between the stage of disease (A, B1, B2, C1, and C2) of the

study participants and each of the major study variables. A bivariate correlation matrix is

displayed in Table 4.15. The stage of disease (tumor stage) was found to be negatively

and significantly correlated with male sexual function (rho= -.24, p=.023) while no

significant correlations were found between stage of disease and perceived global stress

(rho= -.02, p=.87) and cognitive appraisal of stress (rho=.09, p=.35), spirituality

(rho= .07, p=.47), resourcefulness (rho= .09, p=.34), female sexual function (rho= -.31,

p=.09), sexual self-concept (males, rho= -.02, p=.88 and females, rho=.31, p=.09), and

communication (rho= .04, p=.69), and sexual relationship (rho= -.04, p=.65). In summary,

the findings indicated that in these rectal cancer participants, the stage of disease

diagnosed was negatively associated with male sexual function such that the higher tumor

stage was associated with male sexual dysfunction.

Q1F – 4F: (Spearman’s rho analysis)

1F: What is the relationship between type of treatment and perceived stress in rectal

cancer patients?

190
2F: What is the relationship between type of treatment and spirituality in rectal cancer

patients?

3F: What is the relationship between type of treatment and resourcefulness in rectal

cancer patients?

4F: What is the relationship between type of treatment and sexuality in rectal cancer

patients?

Because the type number of treatments received was viewed as ordinal data and

the major study variables as continuous data, Spearman’s rho was performed to answer

the questions 1F-4F to determine if significant relationships existed between cancer

treatment and each of the major study variables. Receiving surgery was coded as one type

of the treatment; receiving postoperative chemotherapy was coded as two types of the

treatment; receiving postoperative chemotherapy and radiation therapy was coded as

three types of the treatment to make it ordinal data. A bivariate correlation matrix is

presented in Table 4.16. Type of treatment was found to be negatively and significantly

correlated with male sexual function (rho= -.30, p=.005). There were no significant

correlations between cancer treatment and the other major study variables, namely

perceived stress (global stress and cognitive appraisal of stress), spirituality,

resourcefulness, female sexual function, sexual self-concept (males and females), and

sexual satisfaction (i.e., communication and sexual relationship). In summary, the

findings indicated that in these rectal cancer participants, cancer treatment was negatively

associated with male sexual function, such that the more treatment received, the worse

was men’s sexual function.

191
 Table 4.15. Intercorrelation Between Stage of Disease and Major Study Variables (Q1E-4E)

Cognitive Perceive Spirituality Resource- Sexual Satisfaction Male Male Female Female
appraisal d stress fulness Commun- Sexual sexual sexual sexual sexual
of stress (global) ication relationship self- function function self-
concept concept
N = 120 n = 88 n = 32
Stage of
Disease .09 -.02 .07 .09 .04 -.04 -.02 -.24* -.31 .31

Spearman’s rho was used, * p <.05

192

Table 4.16. Intercorrelations Between Type of Treatment and Major Study Variables (Q1F-4F)

Cognitive Perceived Spirituality Resource- Sexual Satisfaction Male Male Female Female
appraisal stress fulness Commun- Sexual sexual sexual sexual Sexual
of stress (global) ication relationship self- function function self-
concept concept
N = 120 n = 88 n = 32
Type of
.17 .12 -.10 .00 -.02 -.07 -.11 -.30** -.26 .20
Treatment
Spearman’s rho was used, * p <.05 **p<.01
Q1G – 4G: (Pearson’s correlations)

1G: What is the relationship between time since operation and perceived stress in rectal

cancer patients?

2G: What is the relationship between time since operation and spirituality in rectal cancer

patients?

3G: What is the relationship between time since operation and resourcefulness in rectal

cancer patients?

4G: What is the relationship between time since operation and sexuality in rectal cancer

patients?

To answer research questions 1G-4G, Pearson’s product moment correlations

were used to determine whether relationships existed between time since operation and

the major study variables (Table 4.17). Time since operation was found to be negatively

correlated with perceived global stress (r= -.21, p=.023). However, no significant

correlations were found between time since operation and cognitive appraisal of stress

(1G), spirituality (2G), resourcefulness (3G), sexual satisfaction (communication and

sexual relationship), sexual self-concept (males and females), and sexual function (males

and females) (4G).

In summary, the findings indicated that in these rectal cancer patients, the time

since their operation was associated with perceived global stress such that the longer it

was since their operation, the lower was their perceived global stress.

Q1H – 4H: (Pearson’s correlations analysis)

1H: What is the relationship between comorbid conditions and perceived stress in rectal

cancer patients?

193
2H: What is the relationship between comorbid conditions and spirituality in rectal cancer

patients?

3H: What is the relationship between comorbid conditions and resourcefulness in rectal

cancer patients?

4H: What is the relationship between comorbid conditions and sexuality in rectal cancer

patients?

Because the number of comorbid conditions is continuous data, Pearson’s product

moment correlation analysis was conducted to determine whether there were significant

relationships between the number of comorbid conditions and each of the major study

variables. The number of comorbid conditions was found to be negatively and

significantly correlated with resourcefulness (r= -.19, p=.04). There were no significant

correlations between the number of comorbid conditions and perceived stress (global

stress and cognitive appraisal of stress), spirituality, sexual satisfaction, sexual function

(males and females), and sexual self-concept (males and females). In summary, the

findings revealed that the number of comorbid conditions was negatively associated with

resourcefulness, indicating that greater comorbidity was associated with lower

resourcefulness (Table 4.18).

194
 Table. 4.17. Correlations between Time since Operation and Study Variables (Q1G - 4G)

Cognitive Perceived Spirituality Resource- Sexual Satisfaction Male Male Female Female
appraisal stress fulness Communi- Sexual Sexual sexual Sexual sexual
(global) cation relationship self- function self- function
concept concept
(N = 120) (n = 88) (n = 32)
Time
since
-.17 -.21* .11 .18 .12 .08 .14 .04 -.16 .10
operation

* p <.05
195

Table 4.18. Correlations between Comorbid Conditions and Study Variables (Q1H-4H)

Cognitive Perceived Spirituality Resource- Sexual Satisfaction Male Male Female Female
appraisal stress fulness Commun- Sexual Sexual sexual Sexual sexual
(global) ication relationship self- function self- function
concept concept
N = 120 n = 88 n = 32
Number of
cormobid .05 .18 -.10 -.19* -.13 -.13 .04 .10 -.26 -.21
condition
* p <.05

1
Research Question 3. What are the relationships between perceived stress and sexuality

(Q5), spirituality and sexuality (Q6), resourcefulness and sexuality (Q7), perceived stress

and spirituality (Q8), spirituality and resourcefulness (Q9), and perceived stress and

resourcefulness (Q10) in patients with rectal cancer?

To answer these questions, Pearson’s product moment correlations were

conducted to determine if significant relationships among all the major study variables.

A bivariate correlation matrix was shown in Table 4.19.

Q5. What are the relationships between perceived stress and sexuality?

Two indicators of perceived stress were examined in relation to sexuality in this

study: perceived global stress and cognitive appraisal of stress. Perceived global stress

was moderately but negatively correlated with the indicators of sexuality, including

communication (r= -.40, p<.001), sexual relationship (r= -.46, p<.001), male sexual self-

concept (r= -.35, p=.001), female sexual self-concept (r= -.54, p=.001) and male sexual

function (r= -.21, p=.048). Cognitive appraisal of stress was found to be negatively and

significantly correlated with communication (r= -.26, p=.004) (Table 4.19). The findings

indicated patients reporting greater perceived global stress, scored lower on

communication, sexual relationship (n=120), male sexual self concept (n=88), female

sexual self concept (n=32) and lower scored on male sexual function (n=88) (i.e., sexual

dysfunction). In addition, it was found that the higher the study participants scored on

cognitive appraisal of stress, the lower was their scores on communication with their

partners. In other words, male participants who perceived greater global stress had lower

sexual function, and both male and female participants who perceived greater global

stress reported lower sexual self-concepts and lower sexual satisfaction (Q5).

196
Q6. What are the relationships between sexuality and spirituality?

The findings indicated that spirituality was positively and significantly correlated

with communication (r= .47, p<.001), sexual relationship (r=.48, p<.001), male sexual

self-concept (r=.44, p=.000), and female sexual self-concept (r=.47, p=.007), indicating

that study participants who reported higher scores on the measure of spirituality had

higher scores on measures of sexual satisfaction and sexual self-concept (Q6)(Table 4.19).

Q7. What are the relationships between resourcefulness and sexuality?

Pearson’s correlational analysis showed that resourcefulness was significantly and

positively associated with communication (r=.22, p=.017), sexual relationship (r=.43,

p=.001), and sexual self-concept in males (r=.36, p=.001) and females (r=.50, p=.004).

The findings indicated that greater resourcefulness had higher scores on measures of

sexual satisfaction and sexual self-concept (Table 4.19).

Q8. What are the relationships between perceived stress and spirituality?

Pearson’s correlational analyses were conducted to examine relationships between

the two indicators of perceived stress (global stress and cognitive appraisal of stress) and

spirituality. Perceived global stress was found to be negatively and significantly

correlated with spirituality (r= -.54, p=.000). The findings showed that cognitive

appraisal of stress also had a significant and negative correlation with spirituality (r= -.37,

p=.000) (Table 4.19). The findings indicated that greater perceived stress, in terms of its

cognitive appraisal and global nature, was associated with lower spirituality in the study

participants. In other words, patients who perceived greater stress scored lower

spirituality.

Q9. What are the relationships between perceived stress and resourcefulness?

197
 Pearson’s correlational analyses were conducted to examine relationships between

the two indicators of perceived stress (global stress and cognitive appraisal of stress) and

resourcefulness. The results showed that perceived global stress was negatively and

significantly correlated with resourcefulness (r= -.32, p=.000); however, there was no

association between cognitive appraisal of stress and resourcefulness (r= -.10, p=.291)

(Table 4.19). The findings showed that study participants who reported lower perceived

global stress also reported greater resourcefulness, however their resourcefulness was

unrelated to their cognitive appraisal of stress.

Q10. What are the relationships between spirituality and resourcefulness?

Pearson’s correlational analysis was conducted and the findings showed that

spirituality was positively and significantly correlated with resourcefulness (r= .32,

p=.000) (Table 4.19), indicating that the study participants who reported greater

spirituality also had greater resourcefulness.

Additional Analyses of Major Study Variables

Pearson’s product moment correlational analysis determined the strength and

direction of the correlation between the two indicators of perceived stress: cognitive

appraisal of stress and perceived global stress (Table 4.19). The findings showed that

study participants with greater cognitive appraisal of stress also reported greater feelings

of global stress (r= .46, p=.000).

In addition, communication between partners was found to be positively

associated with sexual self-concept in males (r= .38, p=.000) and females (r= .48,

p=.000), while sexual relationship was found to be positively correlated with male sexual

self-concept (r= .44, p=.000) and female sexual self-concept (r= .63, p=.000) (Table

198
4.19). Moreover, there was a significant correlation between communication and sexual

relationship (r= .68, p=.000). This indicated that higher scores on the measures of

communication and sexual relationship were strongly associated with sexual self-

concepts. In summary, having a more positive sexual self-concepts was associated with

greater sexual satisfaction.

Table. 4.19. Correlations Matrix of Major Study Variables (N=120) (Q5-10)

1 2 3 4 5 6 7 8 9 10
1.Cognitive 1.00
appraisal of
stress
2. Perceived .46*** 1.00
stress (global)
3.Spirituality -.37*** -.54*** 1.00

4. Resourceful- -.01 -.32*** .32*** 1.00

ness
5. Commun- -.26** -.39*** .47*** .22** 1.00
ication
6. Sexual -.01 -.46*** .48*** .43*** .68***1.00
relationship
7. Male sexual .02 -.35*** .44*** .36*** .38*** .44***1.00
self-concept
8. Female sexual -.07 -.54*** .47** .50** .48** .63*** - 1.00
self-concept
9. Male sexual -.22* -.21* .13 -.02 .15 .17 .17 - 1.00
function
10. Female sexual -.45** -.15 .02 .08 .27 .19 - .14 - 1.00
function
* p <.05, **p <.01, ***p<.001
1. Cognitive appraisal of stress; 2. Perceived stress (global); 3. Spirituality;
4. Resourcefulness; 5. Communication; 6. Sexual relationship; 7. Male sexual self-
concept; 8. Female sexual self-concept; 9. Male sexual function; 10. Female sexual
function.

199
Additional Analyses of Cancer-related Variables and Major Study Variables

In terms of the presence of a colostomy in the rectal cancer patients, a

dichotomous variable (present or not present) was examined in relation to the other major

study variables. An independent-samples t test was therefore used to determine if a mean

difference existed between patients with colostomy and those without a colostomy

performed on 1) perceived global stress and cognitive appraisal of stress, 2) spirituality, 3)

resourcefulness, and 4) sexuality indicators. The results showed a significant mean

difference on perceived global stress between patients with a colostomy and those

without a colostomy (t(1,118)= -2.58, p= .011). The mean score on perceived global

stress for persons who had colostomy was significantly higher (M= 12.23, SD =5.20)

than those who did not have a colostomy. Also, a significant mean difference was found

between those with and those without a colostomy on cognitive appraisal of stress

(t(1,118)= -2.44, p= .016). The mean score on the measure of cognitive appraisal of

stress in those with a colostomy (M=58.80, SD=8.54) was higher than those who had no

colostomy. In addition, a significant mean difference was found between those with and

those without a colostomy was found on female sexual function (t(1,30) = 2.394,

p= .023). The mean score on female sexual function in women with a colostomy was

lower (M= 8.13, SD=10.27) than women without a colostomy (M= 20.55, SD=9.64).

Similarly, there was a significant mean score difference on male sexual function (IIEF)

(t(1,86)= 2.76, p= .007) between men with a colostomy and those without a colostomy.

Men who had a colostomy had lower mean scores on male sexual function (M= 36.31,

SD= 24.24) than those without a colostomy (M= 50.11, SD=20.20). No mean score

differences were found on spirituality, resourcefulness, sexual self-concept, or sexual

200
satisfaction (i.e., communication and sexual relationship) in males and females between

two groups as shown in Table 4.20.

Table 4.20. Comparison of Colostomy versus No Colostomy on Major Study Variables

Groups Colostomy No colostomy
n = 30 n = 90
Variable Mean SD Mean SD df t P
(2tailed)
Cognitive appraisal 58.80 8.54 53.84 9.96 118 -2.44 .016*
of stress
Perceived stress 12.23 5.20 8.88 6.46 118 -2.58 .011*
(global)
Spirituality 81.77 12.81 86.82 12.40 118 1.92 .058

Resourcefulness 93.53 23.44 98.83 19.71 118 1.22 .23

Communication 35.53 7.40 35.31 8.54 118 -.13 .899

Sexual relationship 37.43 6.61 38.58 7.25 118 .76 .446

n = 26 n = 62
Male sexual self- 98.62 12.44 104.10 13.89 86 1.74 .086
concept
Male sexual function 36.31 24.24 50.11 20.19 86 2.75 .007**

n=4 n = 28
Female sexual 61.00 10.95 53.39 12.99 30 -1.11 .275
self-concept
Female sexual 8.13 10.27 20.55 9.64 30 2.39 .023*
function
*p<.05; **p<.01

For the analysis between length of time since cancer diagnosis and the major

study variables, three categories were created: <12 months (<1year), 13-60 months (1-5

years), > 61 months (>5 years)). One-way ANOVAs were performed to determine if

there were differences by the three categories of time since cancer diagnosis on 1)

perceived stress and cognitive appraisal, 2) spirituality, 3) resourcefulness, and 4)

sexuality indicators. The findings indicated that there were no significant differences by

time since cancer diagnosis for any of the major study variables as shown in Table 4.21.

201
Table 4.21. Comparison by Length of Time since Diagnosis of Major Study Variables
Groups < 1 year 1 – 5 years > 5 years
N = 120 n = 40 n = 62 n = 18
df F Sig
M M M
(SD) (SD) (SD)
Cognitive appraisal of 55.00 55.89 52.50 2,117 .83 .44
stress (9.32) (9.52) (11.93)
Perceived stress (global) 9.33 10.74 7.06 2,117 2.56 .08
(6.15) (6.14) (6.74)
Spirituality 88.13 83.06 88.44 2,117 2.57 .08
(11.84) (13.17) (11.32)
Resourcefulness 98.60 94.60 105.11 2,117 1.91 .15
(23.02) (19.84) (16.90)
Communication 36.88 34.11 36.33 2,117 1.53 .22
(7.02) (8.06) (10.78)
Sexual relationship 39.67 36.97 39.78 2,117 2.29 .11
(6.65) (7.36) (6.53)
N = 32 n = 15 n = 15 n=2
Female sexual self- 59.80 49.93 46.50 2,29 2.93 .07
concept (11.05) (13.12) (12.02)
Female sexual function 16.61 21.95 14.70 2,29 1.18 .32
(11.89) (8.51) (10.89)
N = 88 n = 25 n = 47 n = 16
Male sexual self- 102.24 102.66 102.31 2,85 .01 .99
concept (12.83) (14.64) (12.64)
Male sexual function 48.64 45.57 43.31 2,85 .30 .74
(22.65) (21.82) (22.25)
*p<.05, **p<.01

Additional Analyses of Gender difference on Major Study Variables

Separate Pearson’s product moment correlational analyses were examined for

men and women to determine the relationships on perceived stress (global and cognitive

appraisal stress), spirituality, and resourcefulness and dependent variable (sexuality). The

results indicated that perceived global stress was negatively correlated with male sexual

function (r= -.21, p=.048), sexual self-concept in males (r = -.35, p=.001) and females

(r= -.54, p=.001), communication (males, r = -.35, p=.001; females, r=-.50, p=.001), and

sexual relationship in males (r= -.44, p=.000) and in females (r=-.50, p=.004), and

202
communication in both sexes (r=-.39, p=.000) and sexual self-concept (r= -.46, p=.000)

in both sexes as demonstrated in Table 4.22.

The findings also indicated that cognitive appraisal of stress (an indicator of stress)

was negatively associated with sexual function in males (r= -.22, p=.036) and in females

(r= -.45, p=.01), communication in males (r= -.30, p=.004), and in both sexes (r= -.26,

p=.001) shown in Table 4.22.

Table. 4.22. Gender Differences on Perceived Stress and Sexuality

Variables Total (N =120) Men (n = 88) Women (n =32)
r (p) r (p) r (p)
Perceived Stress & Sexuality
Sexual function (M/F) -.21* (.048) -.15 (.40 )
Sexual self-concept (M/F) -.35***(.001) -.54***(.001)
Communication -.39***(.000) -.35***(.001) -.50** (.004)
Sexual relationship -.46***(.000) -.44***(.000) -.50** (.004)
Cognitive Appraisal of Stress &
Sexuality
Sexual function (M/F) -.22* (.036) -.45** (.01 )
Sexual self-concept (M/F) -.02 (.882) -.22 (.224)
Communication -.26**(.001) -.304**(.004) -.13 (.477)
Sexual relationship -.01 (.91) -.10 (.338) -.06 (.736)
* p <.05, **p <.01, ***p<.001

In order to determine if there were significant relationships between spirituality

and sexuality for men and women separately, Pearson’s product moment correlation

analysis was conducted. Spirituality had a significant positive correlation with sexual

self-concept in males (r =.44, p=.000), in females (r =.47, p=.007), communication in

males (r =.46, p=.000), communication in females (r= .47, p=.007), communication in

both sexes (r=.47, p=.000), sexual relationship in males (r= .47, p=.000), sexual

relationship in females (r= .48, p=.005) and sexual relationship in both genders (r =.48,

p=.000) as shown in Table 4.23.

203
Table. 4.23. Gender Differences on Spirituality and Sexuality
Variables Total (N =120) Men (n = 88) Women (n =32)
r (p) r (p) r (p)
Spirituality & Sexuality
Sexual function (M/F) .13 (.219) .02 (.896)
Sexual self-concept (M/F) .44***(.000) .47**(.007)
Communication .47***(.000) .46***(.000) .47**(.007)
Sexual relationship .48***(.000) .47***(.000) .48**(.005)
* p <.05, **p <.01, ***p<.001
Pearson’s product moment correlation analysis was used to determine the strength

and direction between resourcefulness and sexuality in males and females. The findings

revealed that resourcefulness was positively correlated with sexual self-concept in males

(r=.36, p=.001), and in females (r =.50, p=.004), communication in females (r=.43,

p=.015) and in both sexes (r=.02, p=.01), sexual relationship in males (r =.49, p=.000), in

females (r=.42, p=.017), and in both genders (r=.04, p=.000). However, resourcefulness

was not associated with communication in males (r=.20, p=.066) as shown in Table 4.24.

Table 4.24. Gender Differences on Resourcefulness and Sexuality

Variables Total (N =120) Men (n = 88) Women (n =32)
r (p) r (p) r (p)
Resourcefulness & Sexuality
Sexual function (M/F) -.02 (.861) .08 (.677)
Sexual self-concept (M/F) .36***(.001) .50**(.004)
Communication .02** (.01) .20 (.066) .43* (.015)
Sexual relationship .04***(.000) .49***(.000) .42* (.017)
* p <.05, **p <.01, ***p<.001
Summary of Research Findings

Using statistical procedures to address the research questions, which included

Pearson’s product moment correlation, Spearman’s rho, independent-samples t test, and

one-way ANOVAs, key findings for each of the research questions are highlighted below:

204
Demographic Data Findings

Age. Age had a negative correlation with perceived global stress (r=-.20, p< .05),

and sexual function in both men and women. Gender differences were found on

perceived global stress and on resourcefulness (t(1,118 ) = 2.30, p < .05) and t(1,118)

=2.87, p < .01, respectively. Significant difference by educational level were found on

measures of resourcefulness (F(4,115) = 5.36, p=.001), sexual relationship (F(4,115) =

4.53, p= .002), male sexual self-concept (F(4,83) = 3.07, p=.021), and male sexual

function (Welch (F= .000) and Brown-Forsythe tests (F= .014)), while the level of

significance was set at p = .05. The findings indicated the highly educated rectal cancer

patients reported more resourcefulness and greater sexual relationship, and male sexual

self-concept and sexual function. There were no significant differences by religion on the

major study variables, perceived stress, spirituality, resourcefulness or sexuality.

Cancer-Related Variables Findings

Stage of disease. Stage of disease (tumor stage) was found to be negatively and

correlated with sexual function in the male rectal cancer patients (rho= -.24, p=.023),

indicating higher it was the tumor stage, the worse was the male sexual function.

Significant difference was found by cancer treatment on the measure of male sexual

function (rho= -.29, p=.006), indicating the more treatment the male patients received,

the worse sexual function they had. In these rectal cancer patients, the time since their

operation was significantly associated with perceived global stress (r= -.21, p< .05) such

that the longer it was since their operation, the lower was their perceived stress. No

significant correlation was found between the number of comorbid conditions and

sexuality, perceived global stress, cognitive appraisal of stress, and spirituality. There

205
was a negative correlation between the number of comorbid conditions and

resourcefulness (r= -.19, p=.04). The findings indicated that study participants who had a

greater number of comorbid conditions had lower resourcefulness.

Significant Differences or Relationships among Major Study Variables

With respect to the relationships among study variables, the research findings

showed that rectal cancer patients had lower sexual self-concepts and lower sexual

satisfaction while they perceived higher global stress (r= -.35, p=.001 (male); r= -.54,

p=.001 (female), and r= -.40, p< .001 (communication); r= -.46, p< .001 (sexual

relationship), respectively). In the male rectal cancer patients, lower sexual function was

associated with greater perceived global stress (r= -.21, p=.048) (Q5). The findings also

showed that greater spirituality in both men and women was associated with greater

sexual satisfaction (r=.47 (communication); r=.48 (sexual relationship), p< .001,

respectively) and more positive sexual self-concept (r=.44, p=.000 (male); r=.47, p=.007

(female)) (Q6). Further, the findings indicated that greater resourcefulness was related to

greater sexual satisfaction (r=.22, p=.017 (communication); r=.43, p=.001(sexual

relationship)) and more positive sexual self-concept (r= .36, p=.001 (male); r= .50,

p=.004 (female), respectively) (Q7). The findings indicated that greater cognitive

appraisal of stress and perceived global stress were associated with lower spirituality (r=

-.37, p=.000 and r= -.54, p=.000, respectively) (Q8). Moreover, lower resourcefulness

was associated with greater perceived global stress (r= -.32, p=.000) (Q9). In addition, in

the rectal cancer patients, greater spirituality was associated with greater resourcefulness

(r= .32, p=.000) (Q10).

206
Additional Findings

Major study variables. Additional findings using Pearson’s product moment

correlations indicated that greater cognitive appraisal of stress was associated with

greater perceived global stress (r= .46, p=.000). Moreover, communication between

partners had a positive and association with sexual self-concept in males (r= .38, p=.000)

and females (r= .48, p=.000), while sexual relationship was found to have a positive

correlation with male sexual-self concept (r= .44, p=.000) and female sexual-self concept

(r= .63, p=.000). Moreover, there was a positive correlation between communication and

sexual relationship (r= .68, p=.000). The findings thus indicated that the rectal cancer

patients who reported better communication or sexual relationship had more positive

sexual self-concepts. In summary, the findings showed that better sexual self-concept was

related to greater sexual satisfaction (Figure. 4.2; Table 4. 19).

Demographic and cancer-related variables. There was a negative association

between age and type of treatment received (p=.03) and a positive correlation between

age and time since operation (p=.006) (Table 4.3), indicating young age patients received

more types of treatment and had a shorter length of time since their operation, while older

patients likely received less types of treatment and had a longer length of time since their

operation. In addition, the number of types of cancer treatments received was positively

correlated with patient’s stage of disease (p=.000), indicating that patients with a higher

stage of disease received more types of cancer treatment. However, age was not related to

the number of comorbid conditions (Table 4.3). With respect to the time since operation,

the findings showed that there were significant differences by length of time since

207
operation between genders (p=.03), with the men reporting a longer time since their

operation than the women rectal cancer patients (Table 4.25).

Gender differences on major study variables. In men, perceived global stress was

negatively associated with sexual function (p=.048), sexual self-concept (p=.001),

communication in males (p=.001), and sexual relationship (p=.000). In women,

perceived global stress was negatively associated with sexual self-concept (p=.001),

communication (p=.004), and sexual relationship (p=.004). The findings revealed that

men who had low scores on sexual function, sexual self-concept, communication, or

sexual relationship, were found to have high scores on perceived global stress. In addition,

women who had low scores on sexual self-concept, communication, or sexual

relationship, were found to have high scores on perceived global stress (Table 4.23, 4.25).

Cognitive appraisal of stress had a negative correlation with male sexual function

(p=.036) and female sexual function (p=.01), communication (total, p=.001) and

communication (males, p=.004), indicating that low sexual function in both men and

women and low scores on communication for the total sample and the men, were

associated with higher scores on cognitive appraisal of stress (Table 4.23, 4.25).

Spirituality was positively correlated with male sexual self-concept (p=.000),

female sexual self-concept (p=.007), communication (total sample, p=.000; males,

p=.000; and females, p=.007), sexual relationship (total sample, p=.000; males, p=.000;

females, p=.005). These results showed that persons with a lower sexual self-concept,

low communication, and less satisfactory sexual relationship in both genders were low in

spirituality (Table 4. 24, 4.25).

208
 Resourcefulness was also positively related with male sexual self-concept

(p=.001), female sexual self-concept (p=.004), communication (total sample, p=.01 and

in females, p=.015), sexual relationship (total sample, p=.000; males, p=.000; females,

p=.017). These results showed that persons with a lower sexual self-concept, low

communication, and less satisfactory sexual relationship were low in resourcefulness

(Table 4. 25).

Cancer-related and major study variables. There was a significant difference

between persons with and persons without a colostomy on perceived stress (global,

p=.011; cognitive appraisal nature, p=.016). The mean scores (i.e., global and cognitive

appraisal of stress) for the persons with a colostomy were higher than the mean scores of

those without a colostomy. Moreover, significant differences on sexual function in both

the men and the women who had a colostomy versus those who did not (males, p=.007;

females, p=.023). In the men and the women, mean scores on sexual function were lower

for those with a colostomy in comparison with those who had no colostomy (Table 4.20,

Table 4.25).

Based on the significantly statistical findings of the study, the associations

between concerning scores on the major study variables and respondent characteristics

were summarized and demonstrated in Table 4.25.

Consideration of Bonferroni Correction

In this descriptive study, there is a need to interpret all of the findings with

caution because of the number of statistical tests that were required for examining the

relationships between the demographic and cancer-related variables and the four major

study outcomes (perceived stress, spirituality, resourcefulness, and sexuality).

209
Considering the chance of type I error that may occur when conducting multiple

statistical tests, a Bonferroni correction may be applied, which involves dividing the

desired level of significance (p = .05) by the total number of statistical tests that were

performed (n = 139). Applying this formula (.05 divided by 139 tests), the new level of

significance would be p < .0003. This level of significance would be required to

determine findings of definitive significance, while those results found to be significant at

p = .05 through p = .0003, would be identified as those approaching significance or

showing trends toward significance and worthy of further examination in future studies.

This is especially true for the analysis conducted for the demographic and cancer-related

variables.

However, highly significant relationships (i.e. p < .0003) were found among

demographic and cancer-related variables and some of the major study variables. For

example, greater perceived global stress was correlated with lower spirituality (r= -.54,

p=.000), lower resourcefulness (r= -.32, p=.000) and less communication (r= -.39,

p=.000) and greater cognitive appraisal of stress was correlated with lower spirituality (r=

-.37, p=.000). However, lower spirituality was correlated with less positive male sexual

self-concept (r= .44, p=.000), lower resourcefulness (r= .32, p=.000), less communication

in males (p=.000) and in the total sample (p=.000), and less satisfying sexual relationship

in males (p=.000) and in the total sample (p=.000). Lower resourcefulness was correlated

with less satisfying sexual relationship in males (p=.000) and in the total sample (p=.000).

In addition, the higher stage of disease was correlated with a greater number of cancer

treatments.

210
 As for the additional analysis, cognitive appraisal of stress was significantly

correlated with perceived global stress (r= .39, p=.000), communication and sexual

relationship were correlated (r= .68, p=.000) and both communication and sexual

relationship were associated with sexual self-concept in the women (r= .48, p=.000 and

r= .63, p=.000, respectively) and the men (r= .38, p=.000 and r= .44, p=.000,

respectively).

211
Table 4.25. Associations Between Concerning Scores on Major Study Variables and
Respondent Characteristics
Scores on Major Study Variables
High Perceived Global Stress
High Cognitive Appraisal Stress
Low Resourcefulness
Low Spirituality
Low Communication
Low Sexual relationship
Low Sexual self-concept
Low Sexual function
Respondent Characteristics
Young age
Women
Colostomy performed
Shorter length of time since operation
Low male sexual function
Low sexual self-concept (men/women)
Low communication (men/women/both)
Low sexual relationship (men/women/both)
Colostomy performed
Low communication (men/both)
Low sexual function (men/women)
Men
More comorbid conditions
High global stress
Low education
Low spirituality
Low communication (women/both)
Low sexual relationship (men/women/both)
Low sexual self-concept (men/women)
High perceived stress (global & cognitive)
Low resourcefulness
Low communication (men/women/both)
Low sexual relationship (men/women/both)
Low sexual self-concept (men/women)
High perceived stress (global & cognitive)
Low sexual self-concept
High perceived stress (global)
Low education
Low sexual self-concept
Low communication
High perceived stress (global)
Low communication
Low sexual relationship
Low education (men)
Old age
Low education (men)
Colostomy performed
Higher stage of disease
More types of treatment (men)
High perceived stress (global) (men)
212
 Stage of
Disease
rho= -.24
rho= .81
rho= -.29
Type of Male sexual function
r= -.24
Treatme r= -.36 Female sexual function

rho= -.20 r= -.37 Spirituality

r= -.19
Age Cognitive Communication
r=-.22
appraisal of stress r=-.45 Male sexual function
r= -.20
Female sexual function
Colostomy r= -.32 Resourcefulness
r=.46
r= -.39 Communication
r= .25 r= -.46 Sexual relationship
Perceived
stress r= -.35
Male sexual self-concept
r= -.21 r= -.54 Female sexual self-concept
r= -.54
r= -.21 Male sexual function
Time since
operation r=.47 Communication
Spirituality r=.48 Sexual relationship
r=.44
Male sexual self-concept
r=.32 r=.47 Female sexual self-concept

r=.22 Communication
r= -.19 Sexual relationship
Resource- r=.43
Comorbid Male sexual self-concept
fulness
condition r=.36
r=.50 Female sexual self-concept
r=.38 Male sexual self-concept
Commun-
ication r=.48
Female sexual self-concept
r=.68
r=.63 Female Sexual self-concept
Sexual r=.44
relationship
Male sexual self-concept
Education
Male sexual function
Figure 4.2. Relationships among Demographic and Cancer-related and Study Variables

213
 CHAPTER V: SUMMARY and DISCUSSION

Introduction

This chapter provides a discussion of the research findings in light of theoretical

and empirical literature. In addition, study limitations and the influence of cultural issues

and impact of instrument translation are addressed. The implications for theory

development, future research, clinical practice, health policy, and nursing education, and

recommendations for future research and knowledge development will be discussed.

Summary

This descriptive and exploratory study was the first step to examine relationships

among major study variables that included perceived stress, spirituality, resourcefulness,

and sexuality in Taiwanese adults with rectal cancer who were undergoing cancer

treatment and to explore relationships among demographic and cancer-related variables,

perceived stress, spirituality, resourcefulness, and sexuality. Neuman Systems Model

(Neuman, 1995), Lazarus’s (1984) stress and coping theory, and Zauszniewski’s (2006)

mid-range theory of resourcefulness provided the theoretical frameworks to guide the

study. In Neuman’s Model, the wellness-illness continuum implies harmony or

disharmony. The environment is a source of stressors and resources. The person is

viewed as a wholistic, open system, composed of physiological, psychological, socio-

cultural, developmental, and spiritual dimensions, which interact with his/her

environmental stressors through an interactive adjustment process that causes varying

degrees of harmony, stability, and balance. The goal of nursing in Neuman’s Model is to

facilitate optimum wellness through primary (identification of stressors), secondary

214
(treatment of symptoms following stress reaction), or tertiary prevention (adapting,

reeducating, or maintaining the possible wellness state).

Stress appraisal, through the process of cognitive appraisal for the situation

(primary appraisal) in Lazarus’s Stress Transaction Model, plays a significant role in

determining whether a situation is threatening, harmful, or challenging. Meaning and

significance of the stressful event to the person (appraisal) is a key component in the

identification of coping strategies. As a result, a status of well-being, social function, and

somatic health is attained. Two coping resources, self-help and help-seeking strategies,

which have been identified in the mid-range theory of resourcefulness, have been found

to have a significant effect on the person’s adjustment to illness.

This study involved a sample of 120 rectal cancer adults ranging from 29 to 85

years of age, who were recruited through physician’s referral in a Medical Center in

southern Taiwan. This sample included 32 women and 88 men. The sample size was

determined by power analysis for statistical tests needed for the study: Pearson’s product

moment correlations, Spearman’s rho correlation, one-way ANOVAs, and independent-

samples t test.

Sexuality, a major focus of the study, is a sensitive area for all persons. Structured

face-to-face interviews were conducted by the investigator or an experienced, well-

trained research assistant in a private room. In order to minimize each participant’s

discomfort from possible embarrassment, eight instruments were administered in the

following order to broach the topic gradually: Perceived Stress Scale (PSS-10), Cognitive

Appraisal of Health Scale (CAHS), Resourcefulness Scale (RS), Body-Mind-Spirit Well

Being Inventory- Spirituality (BMSWBI-Sp), Sexual Self-Schema Scale-female (SSSS-

215
F)/ Sexual Self-Schema Scale-male(SSSS-M), Enriching, Nurturing Relationship,

Communication, Happy Scale - Communication (ENRICH-Co), Nurturing Relationship,

Communication, Happy Scale – sexual relationship scale (ENRICH-SRS), International

Index of Erectile Function (IIEF)/ Female Sexual Function Index (FSFI). Demographic

data and cancer-related information were also collected.

Pertinent findings

Analyses of sample characteristics showed that about 27% (n=32) were women

and 73% (n=88) were men, with a mean age of 61 years. Ninety-six percent of the study

participants were married and had an average of three children, while 4% were not

married. Sixty-seven of the patients completed high school or elementary educational

levels. Ninety percent of the rectal cancer patients had religious beliefs. About 55% were

retired or non-employed. Only 9% of the patients used a substance or lubricant to

improve their sexual function during sexual activities, while women (13%) were more

likely to use lubricants than men (8%) were.

Statistical analyses of cancer-related data revealed that the average length of time

since cancer diagnosis was 36 months, which was nearly the same as the length of time

since their operation. Thirty-two percent of the patients were diagnosed with cancer in

Duke A, 24% were in Duke B1, 3% were in Duke B2, 5% were in Duke C1, and 36%

were in Duke C2. Over half (52%) of the rectal cancer patients had surgery treatment

only, 37% received surgery plus postoperative chemotherapy, and 11% received surgery

plus postoperative chemotherapy and radiotherapy. The majority of the patients (84%)

underwent a low anterior resection (LAR) and 25% of the patients had a colostomy

performed.

216
 Discussion

Research Question 1. What are the differences in or relationships of major study

variables (perceived stress, spirituality, resourcefulness, and sexuality) in relation to the

demographic characteristics (i.e. age (A), gender (B), education (C), and religion (D)) in

rectal cancer patients? (Q1A-Q4D)

Relationships/Differences of Demographic Characteristics on Major Study Variables

Relationships between age and perceived global stress. As expected, age was

found to be negatively correlated with perceived global stress (1A), indicating that older

participants reported lower global stress and younger patients reported greater perceived

global stress. The findings were consistent with Rong (2000) who reported that elderly

subjects tended to have low stress, high resourcefulness, and high adaptive functioning.

The results of this correlational analysis also support Neuman’s systems model (1995),

which says that age-related developmental processes interact with the person’s

environmental stressors, which include intrapersonal (i.e., cancer or reaction of cancer

treatment), interpersonal (i.e, role expectation, communication), and extrapersonal

stressors (i.e, time since diagnosis), throughout the adjustment process. According to

Lazarus and Folkman’s (1981) transaction model, cognitive appraisal depends on the

person’s subjective interpretation of a transaction (i.e., bidirectional relationship of the

person affects the environment) and therefore influences his/her perception of the

stressors. This, in turn, affects the degrees of harmony and stability in the person -

environment interaction.

Relationships between age and cognitive appraisal of stress. The second indicator

of perceived stress was cognitive appraisal of stress. No correlation was found between

217
age and cognitive appraisal of stress. This was unexpected, however, similar findings

that showed no correlation between age and cognitive appraisal of stress were found in

two studies (Herzer, Zakowski, Flanigan, & Johnson, 2006; Laubmeier et al. 2004).

Those studies differed from the current study in that they focused on threat appraisal

rather than the cognitive appraisal of stress that includes threat, challenge, and harm/loss

as defined by Lazaurs and Folkman’s theory of cognitive appraisal of stress. In addition,

the samples in those two studies involved cancer survivors, but did not focus specifically

on rectal cancer patients. Accordingly, the current findings are only partially consistent

with the findings of previous studies.

The results from this study reported here were not consistent with Bowman and

colleagues’ (2003) study, which reported that age was negatively correlated with stress

appraisal, indicating that younger cancer survivors, including 30% of colorectal cancer

patients, reported more stressful appraisal. This study showed no association between age

and cognitive appraisal of stress. The discrepancy between the findings from the

Bowman et al’s (2003) study and the study reported here may be related to differences in

the measurement of stress appraisal between the two samples.

The incongruent results that were found between the two indicators of perceived

stress may have been related to measurement error. Although the Chinese translation of

the PSS has been used in Taiwanese people and does appear to measure the perceived

degree to which environmental demands exceed one’s ability to cope, the measure of the

second indicator, cognitive appraisal of stress, was translated into Chinese for the first

time for this study; it is used to measure the threat, challenge, and harm/loss dimensions

of stress appraisal.

218
 During the data collection on the measure of cognitive appraisal of stress, the

research assistant/researcher consistently used the term “this health condition” instead of

using the word “cancer.” Participants could have different interpretations concerning

what was meant by “this health condition.” Thus, it is very possible that the measure

may have captured perceived response to a specific stressor (this health condition) other

than cancer. Alternative explanations may be the homogeneity or size of the sample,

both of which may affect the significance of the findings. Future studies of larger

samples and consistent use of phrasing on study questionnaires, i.e. specific referral to

cancer, are needed to reduce ambiguities in interpretation.

Relationships between age and resourcefulness. Age was not associated with

resourcefulness in the present study. This finding is consistent with the study by

Zauszniewski and colleagues (2005), which found that age was not a significant predictor

of resourcefulness in African American caregivers and noncaregivers. However,

according to Zauszniewski’s (2006) resourcefulness theory, age is an intrinsic factor that

may influence the process regulating cognition (process regulator), and then, in turn,

affect resourcefulness (personal and social). The sample in the study reported here was

recruited from a single medical center and may have been too homogeneous in terms of

age to obtain significant results. Future studies should focus on recruitment of rectal

cancer patients with a wider age range.

Relationships between age and spirituality. Age was not associated with

spirituality in the present study. According to Neuman’s (1995) model, age is related to

developmental processes, while spirituality is integrated within one’s physiological,

psychological, sociocultural, and developmental variables. The spiritual dimension

219
influences and is also influenced by all other variables. Because age was associated with

perceived stress, the interrelationships of spirituality, stressors, and reactions to stressors

are seen as a means for strengthening the spiritual nature of the person. The mean score

on the Body-Mind-Spirit Well-Being Index-Spirituality subscale was 85.56 and ranged

from 51 to 100, indicating that the majority of the participants had a high level of

spirituality (i.e., meaning in life). One explanation for this finding may be related to the

length of time since their diagnosis or operation (mean=36 months). Perhaps over time,

the participants were better able to adopt a positive attitude in relation to their stressful

situation, while going through the adjustment process.

Relationships between age and sexuality. The correlation matrix indicated that

age was negatively related with sexual function in both males and females (4A),

indicating older rectal cancer study participants reported lower sexual function while

younger participants reported better sexual function. The negative relationship found

between age and sexual function in both gender groups was partially consistent with

Lindau and colleagues (2007) and Brecher’s (1984) studies, which found that sexuality or

sexual activity declined with advancing age and illness. However, Lindau and colleagues

(2007) focused on a sample of Americans ranging from 57 to 85 years in age (Lindau et

al. 2007), whereas the age ranges of the sample in the study reported here were from 29

to 85 years. In contrast with the study reported here, Schmidt and colleagues (2005b)

found that for male rectal cancer patients, impaired sexuality was independent of age.

Gender differences on perceived global stress. The findings from the present

study indicated there was a significant gender difference on perceived global stress (1B);

female patients reported higher perceived global stress than male patients. This finding is

220
consistent with conclusions drawn by Graupe and colleagues (1997), who concluded that

female colorectal cancer patients are special risk group with a high level of psychological

strain. This finding is also consistent with a study conducted by Northouse and colleagues

(2000), which found that female colon cancer and their spouses reported high emotional

distress or concurrent stress. Perceived stress depends a great extent upon how the person

conceptualizes stress. There are wide individual differences in the perception of what is

stressful and when it is stressful (Eisdofer et al. 1981).

Gender differences on resourcefulness. The study findings indicated a gender

difference in relation to resourcefulness, with females reporting greater resourcefulness

than the male study participants (3B). A gender difference on resourcefulness was also

found in the study by Zauszniewski and Chung (2001), which showed a gender difference

on resourcefulness with women found to be more resourceful than men. However,

another study contradicts this finding and reported no difference between elderly men and

women on resourcefulness (Bekhet & Zauszniewski, 2008). In comparison to the study

reported here, the sample characteristics in Zauszniewski and Chung’s (2001) study (i.e,

women with diabetes) and Bekhet and Zauszniewski’s (2008) study (relocated elders)

differed from those in the present study (rectal cancer adults). In addition, both previous

studies measured only personal resourcefulness, while the study reported here measured

both personal and social resourcefulness skills.

The results are consistent with Zauszniewski’s Resourcefulness theory, which

suggests that gender is an intrinsic factor that may influence process regulators, which

may include cognitions (i.e. cognitive appraisal) and the person’s self-control skills and

help-seeking behaviors, which constitute resourcefulness.

221
 Educational level and major study variables. The findings showed there were

significant differences by educational level on resourcefulness (p=.001) (3C), sexual

relationship (p=.002), male sexual self-concept (p=.21), and male sexual function

(F=.000/F=.014) (4C), indicating that more highly educated rectal cancer patients

reported greater sexual relationship (satisfaction), better sexual self-concept in men, and

better sexual function. The study participants who were more highly educated, were more

resourceful (4C).

As for the significant differences by educational level on resourcefulness, the

findings of this study are consistent with the findings reported by previous studies where

persons with higher educational levels were more highly resourceful than those with less

education (Bekhet & Zauszniewski, 2008). However, the sample characteristics in Bekhet

and Zauszniewski’s (2008) study differed from the sample in the present study. In the

study reported here, the participants were Taiwanese rectal cancer adults (aged 29 to 85),

while in Bekhet and Zauszniewski’s (2008) study, they were American elders (aged 65 to

95), many of whom had chronic conditions, and who recently relocated to retirement

communities.

A significant difference by education level on sexual self-concept was found in

men. A similar significant difference by education level was also reported in other studies,

which showed that increasing education was associated with better relocation adjustment

(Bekhet & Zauszniewski, 2008) and better adaptation (Rong, 2000); both relocation

adjustment and adaptation may be strongly tied to one’s self concept.

This finding is also partially consistent with a study conducted by Ustundag and

colleagues (2007), which showed a significant difference between self-esteem scores and

222
educational status (p< .05) and highly educated patients had higher scores on self-esteem.

Sexual self-concept comprises self-esteem, role performance and self-expectations. The

results from the study reported here highlighted sexual self-concept in both genders.

These findings may also reflect the ancient Chinese belief “Knowledge is extremely

important above everything else.” Since ancient times, sex discrimination has been an

existing phenomenon in the Chinese society; men have had more opportunities than

women to receive education or higher education. Receiving a higher education is an

honor for the person and also for his family, which in turn, elevates one’s self esteem,

and, therefore contribute to increasing one’s sexual self-concept. Thus, the cultural effect

may provide an explanation for the relationship between educational level and sexual

self-concept in this study.

As for the significant differences that were found on sexual relationship by

educational level, no studies were found to support this finding. However, the association

between sexual relationship and education may be related to the association found

between sexual relationship and sexual self-concept. In Chinese culture, receiving a

higher education is believed to elevate one’s self-esteem, and therefore, one’s self-

concept, which in turn, may influence one’s sexual relationship.

With regard to the educational difference on male sexual function, very few

empirical studies were found in support of this finding. One explanation could be that in

traditional Chinese society, men have more opportunities for receiving education, which

provides them more available resources for problem-solving, such as sexual problems;

knowledge concerning how to manage sexual problems may positively affect their sexual

function.

223
Research Question 2. What are the differences in or relationships of major study

variables (perceived stress, spirituality, resourcefulness, and sexuality (i.e., sexual

satisfaction) in relation to the cancer-related variables (i.e. stage of disease (E), type of

treatment (F), time since operation (G), and comorbid condition (H)) in rectal cancer

patients? (Q1E - Q4H)

Relationships / Differences on Major Study Variables in Cancer-related Variables

Relationships between stage of disease and sexuality. The findings indicated that

the stage of disease was negatively associated with male sexual function such that higher

tumor stage (i.e., advanced cancer) was associated with greater male sexual dysfunction

(Q4E). Very few empirical studies have reported differences in sexuality at the various

stages of disease in rectal cancer patients. The findings are consistent with a study

conducted by Morino and colleagues (2009), who reported that the advancement of

tumors significantly predicted impaired sexual function in male rectal cancer patients

undergoing surgery (Morino et al. 2009).

Relationships between type of cancer treatment and sexuality. The findings from

the study reported here indicated that type of treatment (i.e., surgery, surgery plus

chemotherapy, and surgery plus chemotherapy and radiotherapy) was negatively

associated with males’ sexual function in that the more treatment received, the worse was

their sexual function (Q4F). These findings were similar to the studies conducted by

Ameda and colleagues (2005) and by Morino and colleagues (2009), who found that two

factors - types of surgery (i.e., APR or LAR) and adjuvant or neoadjuvant treatment were

identified as significant predictors of poor postoperative sexual function (Ameda et al.

2005; Morino et al. 2009). Other studies, however, had findings that were inconsistent

224
with these findings that suggested that the type of surgery had an effect on sexual

function of both genders (Ness et al. 1998; Chatwin et al. 2002; Camilleri-Brennan &

Steele, 2001; Hendren et al. 2005; Schmidt, Bestmann, Küchler, Longo, et al. 2005b;

Schmidt, Bestmann, Küchler, & Kremer, 2005a; Asoglu et al. 2009) or that radiation was

negatively associated with sexual function in both men and women (Temple et al. 2003).

Basically, these studies focused on the effects of cancer treatment (i.e., surgery or

adjuvant therapy or neoadjuvant) on sexual function rather than on the types of cancer

treatment as in the study reported here. Future research may focus on the relationship or

differences of individual treatment on outcomes that include sexuality.

Relationships between time since operation and perceived global stress. The

findings indicated that time since the study participant’s operation was associated with

perceived global stress such that the shorter it was since their operation, the higher was

their perceived global stress (1G). This may indicate that over time, the patients may have

developed cope strategies and may have adapted to having had the operation.

The positive correlation between time since operation and perceived global stress

is consistent with the study conducted by Bekhet & Zauszniewski (2008), which reported

that time since relocation had a positive association with relocation adjustment (Bekhet,

2007). Both studies illustrate the effects of coping with stress over time. However, in

studies that specifically examined time since diagnosis in cancer patients, Laubmeier and

colleagues (2004) and Herzer and colleagues (2006) found no significant correlation

between time since diagnosis and threat appraisal in cancer patients. Since the length of

time since operation was similar to the length of time since diagnosis in the present study,

the findings were consistent with those reported by Laubmeier and colleagues (2004) and

225
Herzer and colleagues (2006). However, the study by Herzer and colleagues (2006)

focused on persons with multiple types of cancer rather than rectal cancer as in this study

(1G).

Relationships between comorbid conditions and resourcefulness. The number of

comorbid conditions was found to be negatively associated with resourcefulness,

indicating that greater comorbidity was associated with lower resourcefulness (3H).

These findings are consistent with the study conducted by Tithiphontumrong’s (2005)

study, which found that elders with fewer chronic conditions had greater personal

resourcefulness. However, the sample characteristics of the study reported here were

different from those of the other study (Tithiphontumrong, 2005). The Resourcefulness

scale scores for this sample ranged from 39 to 138 with a mean of 97.51 and a standard

deviation of 20.73, which reflected high levels of resourcefulness. The participants in this

study scored above the average score on the resourcefulness scale, especially personal

resourcefulness but low to moderate levels on social resourcefulness. The findings

indicate that the participants did not tend to seek help from others. One possible

explanation for why a greater number of chronic conditions were associated with lower

resourcefulness may be that the study participants did not seek help for treatment

illnesses, which then became chronic over time. This may be especially true in this study,

which involved a younger population on average than the study conducted by

Tithiphontumrong (2005). This finding is consistent with Zauszniewski’s (2006) mid-

range theory of resourcefulness, which conceptualizes that comorbid conditions are

intrinsic factors that may affect self-control behavior and help-seeking ability, that

constitute personal and social resourcefulness.

226
 Relationship among the Main Study Variables

Research Question 3. What are the relationships between perceived stress and sexuality

(Q5), spirituality and sexuality (Q6), resourcefulness and sexuality (Q7), perceived stress

and spirituality (Q8), spirituality and resourcefulness (Q9), and perceived stress and

resourcefulness (Q10) in patients with rectal cancer?

Relationship between perceived stress and sexuality (Q5)

In the study reported here, perceived global stress was negatively associated with

the indicators of sexuality, including sexual satisfaction (communication and sexual

relationship), sexual self-concept (male and female), and male sexual function. These

findings from the present study are consistent with those of Kreitler and colleagues (2007)

who reported a significant main effect of perceived stress on quality of life, which was

operationalized to include sexuality, family functioning, negative emotions, body image,

self-image, sense of control, sense of coping, and meaningfulness in cancer patients with

mixed diagnoses (Kreitler, Peleg, & Ehrenfield, 2007). Their sample age (ranging 18 to

78 years) is similar to the sample in the current study, however, only about 30% and 12%

of 60 cancer patients had colon cancer or rectal cancer, respectively.

One of the indicators of perceived stress in the present study, cognitive appraisal

of stress, was found to be negatively and significantly associated with communication.

The results of the present study are partially consistent with the other studies, which have

reported that greater harm/loss appraisal was related to or explained lower body pain and

role limitations (Ahmad, 2000), lower self-assessed health and increased depressive

symptoms (Keister, 2004). Other studies found a significant relationship between

cognitive appraisal and social constraints (Herzer et al. 2006). Herzer and colleagues

227
(2006) indicated that the cancer patients’ threat appraisal predicted their perception of

social constraints (i.e., perceived inadequacy of social support from spouse resulting in

inadequate couple communication).

Cognitive appraisal of stress in the current study did not specifically measure

either harm/loss or threat appraisal; it also measured challenge appraisal. If the study

reported here involved measures of harm/loss, threat, and challenge appraisal individually,

the sample size would be insufficient to detect significant results. Increasing the sample

size should be considered in designing future studies to examine the three types of

cognitive appraisal separately.

The present findings also support Neuman’s systems model (1995), which states

that an open client system actively interacts with environmental stressors, so that while

the person is invaded by particular stressors (i.e., cancer and its treatment), the stability

factors (defense lines), such as coping abilities, problem-solving abilities defend against

the stressors to retain the system’s stability, and a reaction to stressors takes place (i.e.,

changes in sexual function, sexual self-concept, and sexual satisfaction).

Relationship between spirituality and sexuality (Q6)

The findings from this study showed that spirituality was positively and

significantly associated with sexual satisfaction (i.e., communication and sexual

relationship), and sexual self-concept (males and females) (Q6), which indicated that

spirituality and sexuality are closely related (Helminiak, 1998). No other studies were

found that specifically examined the relationship between spirituality and sexuality in

persons with rectal cancer. Anderson and Cole (1978) found that sexual activity enhanced

handicapped people’s self-esteem, which fostered their spiritual growth and development.

228
However, because the two samples are very different and the measures were dissimilar,

the findings from the two studies may not be comparable.

In a study of psychosocial needs among cancer patients, Mclllmurray and

colleagues (2003) reported that 83% of cancer patients who had a religious faith in

general were less reliant on health professionals, had less need for information, and had

less need for help (possibly reflecting less social resourcefulness) with their sexuality

than those who said they had no religious faith (Mclllmurray et al. 2003). This study

indicates an association between spirituality and sexuality. However, the operational

definition for spirituality in the present study reflected meaning in life rather than

religious faith.

In another study, Kim and Seidlitz (2002) reported that the spirituality was not

associated with stress in college students. But spirituality moderated / buffered the effect

of stress on negative affect and physical adjustment and was directly related to

adjustment and negative affect (Kim & Seidlitz, 2002). Although the findings may not

directly support the present study, several studies were found that describe spirituality

viewed as coping mechanism (Feher & Maly, 1999; Lamdan et al. 1997).

Relationship between resourcefulness and sexuality (Q7)

The findings reported here indicated that resourcefulness was positively and

significantly associated with sexual satisfaction (i.e., communication and sexual

relationship), and sexual self-concept (males and females) (Q7). No studies were found

that have examined resourcefulness and sexual satisfaction or sexual self-concept in

rectal cancer patients. However, the results from this study may be consistent with a

study conducted by Pedro (2001) that showed an inverse correlation between learned

229
resourcefulness and health-related quality of life (HRQL) in long-term cancer survivors

(Pedro, 2001) and a study by Lai (2005) that persons with greater positive beliefs, which

included a positive view of oneself, has greater resourcefulness and better adaptive

functioning. However, the studies by Pedro (2001) and Lai (2005) only measured

personal resourcefulness skills, while the study reported here conceptualized

resourcefulness as consisting of both personal and social dimensions. This finding is

partially consistent with Zauszniewski’s (2007) study, which showed that teaching

resourcefulness skills to elders resourcefulness improved their functioning and quality of

life.

This finding is also consistent with resourcefulness theory (Zauszniewski, 2006),

in that resourcefulness is viewed as intervening factor for coping with stressful situation

(i.e., cancer and treatment) between process regulators (i.e., primary and secondary

appraisal)) and quality of life outcomes (i.e., indicators of sexuality).

Relationship between perceived stress and spirituality (Q8)

The findings of the present study indicated that perceived stress, conceptualized

as cognitive appraisal and global stress, was negatively associated with spirituality (Q8).

The findings in the present study were opposite to other studies done on spirituality and

health perception and health impairment in the older adults with rheumatoid arthritis

(Potter & Zauszniewski, 2000). Spirituality was found to have a significant impact on the

health perception of the older adults with rheumatoid arthritis (Potter & Zauszniewski,

2000). However, in the study reported here, spirituality was not conceptualized as both

religiosity and existential well-being (sense of life purpose and satisfaction) as it was in

the study by Potter and Zauszniewski (2000).

230
 Spirituality can be viewed as an emotion-focused coping strategy. The findings

from the present study support the interrelationships of the person’s spirituality, stressors

(cancer and cancer treatment), and reactions to stressors (i.e., indicators of sexuality) in

the Neuman Systems Model (1995), but not in the negative direction, as found in this

study. One explanation could be that measure of spirituality (BMSWI-Sp) was

developed in Hong Kong (Chinese), but this study was the first time it was used in the

Taiwanese population. Even though the pilot test showed there was no problem in

understanding the items, the items are scored on a 10-point scale with response ranks

from 0 (not at all) to 10 (very much),which makes it possible for patient’s to tend to use

extreme scores or scores all in the middle of the scale for all items. Such response biases

can produce scores that may distort the data. Another explanation involves cultural

differences in the interpretation of items on the scale; the scale was developed in Hong

Kong and may not reflect the meaning in life for Taiwanese people.

According to Neuman’s systems model (1995), intrapersonal stressors (i.e.,

cancer treatment), interpersonal stressors (role expectation or communication patterns),

and other factors, such as time of stressor occurrence (e.g., time since their diagnosis/

operation, past and present condition of the patient, nature and intensity of the stressor)

may affect the person’s coping, and therefore, influence their perceptions. Future research

could consider examination of the relationship between perceived stress and spirituality

while controlling for cancer-related variables as covariates.

Relationship between perceived stress and resourcefulness (Q9)

The results from this study showed that perceived global stress was negatively

and significantly associated with resourcefulness (Q9). Rong’s (2005) study showed that

231
there was an association found between learned resourcefulness and perceived stress,

which was similar to the findings from the study reported here. However, Rong’s study

only focused on learned resourcefulness, whereas the current study focused on both

learned resourcefulness (i.e. personal resourcefulness) and social resourcefulness. The

sample recruited in the present study was also Taiwanese, however the ages of

participants in the current study had a wider distribution. Rong (2005) also found learned

resourcefulness (i.e., personal resourcefulness) had a potential moderating effect on the

relationship between perceived stress and adaptive functioning in Taiwanese elders.

However, the study reported here was the first attempt to examine the relationships

among these variables in persons with rectal cancer. Thus, future research might test the

moderating or mediating effect of resourcefulness on the relationships between perceived

stress and sexuality. In addition, the findings reported here indicated that cognitive

appraisal of stress was not associated with resourcefulness (Q9). These findings are

partially consistent with Neuman’s systems model (1995), in which an open client system

actively interacts with his/her environmental stressors (i.e., intra- inter-, or extrapersonal

stressors). According to Zauszniewski’s resourcefulness theory (2006), perceived stress

would be conceptualized as an intrinsic factor that influences process regulators (i.e.

cognitive appraisal), and self-control behavior/cognitive-behavioral skills (i.e., personal

and social resourcefulness). Thus, the relationship between global stress and

resourcefulness found in this study is consistent with Zauszniewski’s (2006)

resourcefulness theory, but the lack of association between cognitive appraisal and

resourcefulness is not.

232
 The findings of the present study also reflect a Chinese idiom, which suggests that

“Relying upon oneself is better than relying upon others.” This may explicitly indicate

the characteristics of Taiwanese persons who tend to be self-reliant, which may have

been reflected in their low to moderate scores on the social resourcefulness items of the

Resourcefulness Scale.

Relationship between spirituality and resourcefulness (Q10)

Vey little empirical evidence was found to support the findings of the present

study in regard to the positive association between spirituality and resourcefulness (Q10).

Potter and Zauszniewski (2000) reported that spirituality and resourcefulness were

significantly associated in persons with rheumatoid arthritis. However, resourcefulness in

the Potter and Zauszniewski (2000) study was measured only as personal and not social

resourcefulness. Thus, the relationship between resourcefulness and spirituality found in

that study was not the same as in the present study, which also captured the social (help-

seeking) dimension of resourcefulness. In addition, the two studies differed in the way

that spirituality was conceptualized. In the Potter and Zauszniewski (2000) study, it was

conceptualized as religiosity, which was not true for the study reported here. Finally, the

samples in the two studies differed. Whereas the Potter and Zauszniewski (2000) study

included persons with rheumatoid arthritis, this study focused on persons with colorectal

cancer. Since spirituality of often considered a dimension of quality of life, the study

findings may be considered as supportive of Zauszniewski’s (2006) resourcefulness

theory, which suggests a positive association between resourcefulness and quality of life.

Additional Analyses

233
 Major study variables. The findings from the current study showed that cognitive

appraisal of stress was positively associated with perceived global stress. Similarly,

Golden-Kreutz and colleagues’ (2005) study showed that cancer-related traumatic stress

symptoms were significantly associated with perceived global stress (r= .62, p< .001) in

breast cancer patients. This association reflects the positive association between intrinsic

factors (i.e. perceived global stress) and process regulators (i.e. cognitive appraisal)

suggested by Zauszniewski’s (2006) resourcefulness theory.

In addition, the communication that takes place between partners was positively

related with the sexual self-concept of both the men and women who participated in the

study, while their satisfaction with their sexual relationship was positively associated

with their sexual self-concepts. This showed that sexual satisfaction was positively

associated with sexual self-concept. In addition, communication was found to be

positively and significantly associated with sexual relationship.

Self-concept is composed of body image, role performance, self-expectancy, and

self-esteem/worth. Sexual self-concept is a core component of one’s sexuality (Anderson,

1999). The finding from the present study showed that sexual satisfaction (i.e.,

communication and sexual relationship) was positively associated with the sexual self-

concept, which is consistent with findings from a study by Menard and Offman (2009)

that found strong correlations among sexual self-esteem, sexual assertiveness, and sexual

satisfaction (Menard & Offman, 2009). The findings from the present study are partially

consistent with other research in which the body image, sexual self-esteem, sexual

satisfaction and life satisfaction of women with physical disabilities were found to be

significantly lower than those in women without disabilities (Victor, Ilana, & Daniela,

234
2009). In addition, Victor and colleagues (2009) found that sexual satisfaction was a

major factor in explaining the variance in life satisfaction in both groups of women

(disabled and non-disabled), and the relationships between sexual satisfaction and life

satisfaction were bidirectional.

The findings reported here are partially consistent with the study conducted by

Holmes (2003), which reported that women who received transplants had poorer sexual

health, poorer body image, loss of sexual interest, decreased sexual satisfaction and more

ongoing sexual problems than those in a group of healthy women (Holmes, 2003). The

findings of the present study are also consistent with Beckham and Godding’s (1990)

study, which found that a patient’s perceptions of sexual satisfaction may depend on

factors other than frequency of intercourse and the definitions of satisfaction may differ

between and within individuals over time (Beckham & Godding, 1990). Although the

findings from these two studies involved women who were not rectal cancer patients, the

findings were similar to the present study in terms of various indicators of sexuality. The

similarity of the findings across studies may be related to the seriousness or chronicity of

the illness. Therefore, a longitudinal study may be helpful for exploring/ determining

changes in sexual satisfaction or sexual self-concept over time.

Further investigations should include the exploration of the effect of sexual

satisfaction and/or sexual self-concept on quality of life. A qualitative research study

focusing on the exploration of lived experiences on their sexual problems including views

of self-concept, couple relationship, communication, and sexual satisfaction is needed.

Sexual self-concept, including body image and one’s role performance, may change over

235
time. Therefore, prospective longitudinal studies to examine the effects of role function

and body image changes on sexual satisfaction are needed.

The findings indicated that there was a positive correlation between

communication and sexual self-concept in males and females. Therefore, better

communication between partners was related to more positive sexual self-concepts.

Illness can induce a threat to one’s self-concept (such as loss of control and

autonomy, one’s self-image changes), threat to one’s emotional equilibrium, and threat to

permanent physical changes (Cohen & Lazarus, 1979). Anderson and Cole (1978)

indicated that frank discussion of sexuality was important for the self-esteem and

psychological well-being of handicapped people, which may reflect the relationship

between communication with their partners and sexual self-concept in the study reported

here. Kralik and colleagues (2001) study showed that changes in body image,

communicating sexuality, and meeting the needs of others were three concerns of women

who live with chronic illness. The findings from this study are partially consistent with

the study conducted by Weber (2001), which reported that most dyadic logs for the

longer term survivors of prostate cancer (support partners) revealed that the most frequent

topics of discussions were about incontinence and erectile dysfunction. This reflects the

relationships between communication with partners, sexual self-concept and sexual

relationship. However, these two samples can not be comparable since the participants in

Weber’s (2001) study were all men with prostate cancer.

One example of the relationship between communication and sexual self-concept

was that of an employed female participant in the present study who was accompanied by

her husband to the data collection interview. She honestly revealed that in order to meet

236
her husband’s needs, she has been using the lubricant during sexual activities for a while.

“It works well.” She added. However, before she was leaving the room, she turned to the

researcher and spoke softly, “Please do not let my husband know the substance, I don’t

want him feel bad.” She gave a kindly reminder. Obviously, there was no communication

between the couple regarding this sexual issue from this woman’s confession. It is not

difficult to imagine that she must be experiencing considerable stress in using the

lubricant with caution each time.

The results of the study reported here showed there was a positive correlation

between communication and sexual relationship. In other words, a better sexual

relationship was associated with a more positive sexual self-concept. These findings

were partially consistent with a study of survivors of mixed cancers conducted by Schag

and colleagues (1994), which found that patients with colon and prostate cancer had

fewer problems with communication with their partner than did those with lung cancer

(Schag, Ganz, Wing, Sim, & Lee, 1994). Badr and Taylor’s (2006) found that persons

with lung cancer talked with their partners about their relationships and reported fewer

constraints and better communication about cancer. These findings indicated the

importance of communication within the couple’s relationship (Badr & Taylor, 2006). In

addition, in a qualitative study of palliative cancer patients that included colon cancer

patients who underwent cancer treatment (i.e., surgery and chemotherapy / and radiation),

the major themes included expression of sexuality, discussing sexuality, and quality of

life (Lemieux, 2004). Takahashi and Kai (2005) identified long-term outcomes of the

relationship with breast cancer women’s partners as an emerging theme. They also

reported that one of the factors influencing the women after treatment for breast cancer

237
was the importance of the sexual relationship with her partner (Takahashi & Kai, 2005).

These themes from previous studies reflected the association of the communication

between partners and sexuality in their lives.

The findings from the present study were not consistent with the findings from a

study conducted by Molassiotis and colleagues (2000) that found that the sexual

relationship among women with gynecological cancer was moderately influenced by low

sexual function. Sexuality, defined as the frequency of sexual activity, followed by sexual

pleasure and satisfaction with or interest in sex, was most impaired (Molassiotis et al.,

2000). However, the age range in the present study was greater than the age range in the

study by Malassiotis and colleagues (2000), which was from 29 to 75. In addition, the

study by Malassiotis and colleagues focused only on women (gynecological cancer),

while the study reported here focused on both men and women with rectal cancer.

Therefore, the two study samples differed and may not be comparable.

One example of the relationship between communication and sexual relationship

is a male participant who indicated that a discouraging word from one’s spouse is enough

to destroy the other’s self-esteem, and, in turn, it destroys the sexual relationships

between the partners. In fact, in Chinese culture, using a negative word such as “useless”

especially on men’s sexuality could interpret a negative meaning on male’s sexual

function.

Another example of the relationship between sexual satisfaction and

communication is one man who came alone to the data collection interview. He was able

to answer the questionnaire items initially until he turned to the measure of

communication between partners. The researcher noticed that tears were running in his

238
eyes, and immediately passed tissue papers to him and kindly reminded that he may

discontinue to answer questionnaire items anytime if he was uncomfortable answering

them. The man refused the request and responded to the researcher “It has nothing to do

with the questionnaire items, it is between me and my wife that I need to deal with.”

Then he was looking down the table. The researcher offered a cup of water to the man

and suggested that maybe he needs a break. The men nodded his head. About 10 minutes

later, the man turned to the researcher and said that he is able to continue the

questionnaire items. Future research should include respondents’ feelings and thoughts

regarding answering the questionnaire items.

However, unexpectedly, the results from this study showed that sexual function in

males and females was not significantly correlated with either sexual self-concept in

males and females or sexual satisfaction (i.e., communication and sexual relationship).

These findings contradict the findings published by Bultler and colleagues (1998), who

reported that sexual satisfaction and intimate feelings were related to changes in female

sexual function with their partners (Bultler et al. 1998) and the findings published by

Anderson and colleagues (1997, 1999), who indicated that gynecological cancer patients’

sexual self-schema accounted for 34% of the variance in predicting current sexual

responsiveness and behavior after controlling the type of cancer and its treatment

(Anderson et al. 1997, 1999). Moreover, the findings from the present study are

inconsistent with those of Butler and colleagues (1998), who reported that sexual

functioning contributed to one’s view of self as a sexual being in women with

gynecological cancer and findings from Yurek’s (1997) study that found that women with

breast cancer who had a negative sexual self-schema reported greater distress in sexually-

239
relevant situations than women without breast cancer. In addition, the findings from the

study by Yurek (1997) indicated that sexual self-schema contributed 55% in the

frequency of sexually intimate behaviors following breast cancer surgery. These three

studies focused on gynecological or breast cancer patients rather than rectal cancer

patients of both genders, as the study reported here has done. Moreover, sexual

satisfaction (communication and sexual relationship) in the present study did not reflect

the frequency of sexual behaviors/responses or the level of distress in sexually-relevant

situations. Thus, these findings may not be comparable.

The non-significant findings of the relationship between sexual function and

sexual self-concept and sexual satisfaction can be attributed to several reasons: First,

although sexual problems may be substantial, for the sake of saving face, the study

participants were very likely not to honestly respond to the questionnaire items during the

face-to-face interviews. Secondly, discussing sensitive issues, i.e. sexuality may be

embarrassing or uncomfortable to discuss those feelings or experiences, especially for

people who live in the traditional conservative Chinese society, for whom it is possible to

choose not to face the problem honestly. Thirdly, they assume that sexuality is a personal

and private matter between their partners, so it should not be revealed to others.

These explanations can be supported by the information from the descriptive data

provided here. For example, approximately 21% (n =34) of the subjects who were

recruited did not meet the inclusion criteria due to sexually inactivity before surgery.

Eighty-eight percent of subjects including men and women responded “No sexual life”

“Nothing much to say about it.” It is likely that this topic made them uncomfortable to

speak of or to participate the study. ‘No sexual life’ does not necessarily reflect real

240
problems for them. The descriptive data also demonstrated an increased percentage (12%

vs. 27%) for rating one’s sexual life before and after treatment as “not importance at all.”

About 26% reported their sexual relationship with partners at present as “not important at

all” which is consistent with their attitudes toward their sexual life after treatment. Over

27% of the men had severe erectile dysfunction and 31% of the women reported no

sexual activity in the last 4 weeks while they were interviewed. Over 37% of the women

participants indicated a low level of sexual satisfaction. Over 20% of the participants had

low or very low positive feelings about the quality and quantity of their communication

and about 9 % were somewhat dissatisfied with their expression of affection and had a

few concerns about sexuality.

In fact, during the data collection interviews, about 30% of participants did not

hesitate to participate in this study. One male participant even indicated “This is an

important problem, however, people never discuss it with others even among cancer

patients.” A highly educated young woman who earned a master’s degree supported the

study and recommended that something like individual’s feelings, thoughts and

perceptions needs to be explored in addition to the survey. “I am looking forward to

seeing the results of this study.” She added.

Demographic and cancer-related variables. The findings from the present study

showed that age was negatively associated with the type of treatment received; younger

patients received more types of treatment while older patients received less types of

treatment. Similarly, Cree and colleagues’ (2009) study of rectal cancer patients showed

that the decrease of adjuvant treatment associated with increasing age was marked

(p< .001), ranging from about 70 % in those aged < 65 years to about 30% in those aged

241
> / = 75 years (Cree et al. 2009). However, although cancer treatment brings about

physiological and psychosocial changes in all age groups, elderly persons often

experience unique alterations that may lead to significant complications or sequelae. A

few of the more common problems faced by elders include: preexisting disease, sensory

changes, altered mobility, lack of social support, and alterations in cognitive function

(Robbins, 1989). Since receiving more types of treatment can place an increased burden

on elderly persons, combinations of chemotherapy, surgery, and radiation may not be

used as frequently in elders as they are in younger patients.

The results also revealed that age was positively associated with time since

operation; younger patients have shorter length of time since their operation, while older

patients had a longer time since their operation. Thus, the younger patients sampled in

this study had their surgery more recently than the elderly study participants. Surgery as

a form of cancer treatment is more commonly done in younger adults who may not be at

the same risk for complications that more elderly persons may experience because of

their advanced age.

The findings also showed that the type of treatment received was positively

associated with the stage of the cancer that was diagnosed in the rectal cancer patients.

This finding was expected since cancer treatment is commonly dependent on the stage of

the disease process. The results from this study were consistent with those of Cree and

colleagues’ (2009), who reported that patients with stage III rectal cancer were more

likely to receive adjuvant treatment than stage II patients (Cree et al. 2009). In addition, a

significant gender difference was found in the length of time since operation with the

men reporting a longer time since their operation than the women patients. This may

242
suggest that the men were diagnosed with rectal cancer at an earlier age and therefore had

surgery sooner than the women.

Cancer-related and major study variables. A significant difference was found

between persons with colostomy and without colostomy on perceived global stress, and

cognitive appraisal of stress. Also, there were significant differences on sexual function

in both genders.

Very few recent studies in regard to colostomy and perceived stress were found.

The results of the present study are consistent with the study conducted by Beckham and

Godding (1990), which provided empirical evidence that body image affects the sexual

functioning of cancer patients and by Monga (2002) who found that patients with a

colostomy face changes in body image in relation to their colostomy, which may affect

sexual enjoyment (Monga, 2002). The finding from the present study is partially

consistent with Ofman and Auchincloss’s (1992) study that showed that many persons

with a colostomy have difficulty adjusting to the odor and dealing with cleanliness, and

fear stool leakage, which may reflect the effect of colostomy on body image, and in turn,

its affects on sexual self-concept.

The results of the study reported here focused on perceived stress, in terms of

cognitive appraisal and global stress, and sexual functioning of rectal cancer patients,

including persons with a colostomy and persons without a colostomy. Future research

should address the relationship or effects of surgical disfigurement on sexual adjustment

or the impact of having a colostomy on indicators of sexuality while controlling other

relevant demographic or cancer-related variables as covariates.

243
 Limitations

The interpretation of the findings from the study is limited by sampling and

methodological factors. First, the generalizability of the findings is limited because of

the use of a convenience sample. However, because this study was descriptive and

exploratory and the first to examine relationships among perceived stress, resourcefulness,

spirituality, and sexuality in Taiwanese rectal cancer patients who are difficult to identify

and recruit, study participants were enrolled in the study as they presented at the medical

centers that served as research sites. Recruiting the study participants in this way

provided a sample of rectal cancer patients who are currently being treated or monitored.

Second, interpretation of the findings is limited by the cross-sectional design used

in this study. Thus, it was not possible to observe changes in perceived stress,

resourcefulness, spirituality, or sexuality over time or to establish any causal relationships

among the study variables. However, the purpose of this study was to examine

relationships among demographic and cancer-related variables and the major study

variables at a single point in time and not to examine causal relationships.

Third, the sample recruited from the medical center was mostly males (73%) and

the ratio of males to females was almost 3:1. This can be explained by the fact that the

medical center that served as a recruitment site was a veteran hospital in the past.

However, considering the challenges encountered in recruiting the study participants, the

length of time since cancer diagnosis ranged from one to ten years. Less than 7% (n=8) of

the study participants were diagnosed with cancer over nine years ago. Thus, the study

participants who had a longer time since being diagnosed with cancer may have adapted

over time to their diagnosis and treatment.

244
 Fourth, the data were collected during face-to-face interviews with the study

participants during which the study questionnaires were completed. Although the use of

face-to-face interviews was successful in minimizing the amount of missing data, it is

possible that the data collector may have introduced a bias. It is possible that the data

collector may have influenced how participants responded to questionnaire items.

However, introduction of bias was minimized as much as possible by the extensive

training of the data collector, who was taught how to elicit item responses in a neutral and

consistent manner.

Finally, it is important to note that all the findings from this descriptive study

must be interpreted with caution because of the total number of statistical tests that were

needed (n = 139) to address the research questions and the possibility that some of the

findings may been significant by chance. The use of the Bonferroni correction procedure,

which would require applying a more stringent alpha level of significance (i.e. p < .0003)

would suggest that many of the findings may not be significant. However, the findings

obtained at p =.05 through p =.0003 are worthy of further examination in future research.

Influence of Cultural Issues

Sexuality involves an interaction of culture and society, while culture affects

people’s sexual expressions and behaviors. Today, in sexual liberal societies, despite the

impact of Western culture on people’s thinking toward sexuality, traditional Chinese

sexual beliefs still have an impact on contemporary Taiwanese societies. Heritage derived

from Confucian philosophy continues to have a substantial impact on sexuality among

Taiwanese persons.

245
 In addition to the standard treatment regimens for cancer patients, alternative

forms of therapy, such as specific food therapy (e.g., high protein food, organic food) or

Chinese medicine, are also used for cancer patients. These alternative treatments are

believed to help Taiwanese persons with cancer to recuperate from their illness. For

sexual problems that may be encountered, certain specific Chinese herbs are

recommended to improve sexual function in men.

Women in Chinese traditional society tend to be submissive and passive in

sexuality. Lieh-Mak and Ng (1981) described how men seek help for their sexual

problems (Lieh-Mak & Ng, 1981). However, among Taiwanese women, findings from

the present study indicated that the rate of using lubricant for women during their sexual

activity was higher than the rate of using Viagra for men with sexual problems (13% vs.

8%). Thus, the present study showed that women sought help more frequently for sexual

problems than did the men who participated in the study. However, besides the methods

mentioned in this study (i.e. lubricants for women and Viagra for men), other Chinese

traditional methods include the use of herbs, nutritious foods, and sex aids (Tang et al.

1996) were not found. The use of these methods should be investigated in future research

with rectal cancer patients.

Impact of Instrument Translation

When health disparity research involves non-English-speaking persons,

instrument translation is a major method to understand health phenomena among

different cultures of people (Willgerodt, Kataoka-Yahiro, & Ceria, 2005). Careful

selection and judgment of instruments was used in designing the present study in order to

obtain reliable and valid data as well as to ensure cultural relevance. Among the eight

246
instruments used in this study (PSS, CAHS, RSS-10, BMSWBI-SP, SSSS-F/SSSS-M,

ENRICH-Co, ENRICH-SRS, IIEF/FSFI), only three (PSS-10, BMSWBI-Sp, and IIEF)

had been translated previously into Chinese (target language). Of these three measures,

the PSS-10 and IIEF were psychometrically tested in the Taiwanese population, however,

the BMSWBI-Sp was tested in Hong Kong, where the Chinese language is also spoken.

The goal of instrument translation is to achieve meaning/semantic and content

equivalence of the measure to ensure its cultural appropriateness (Brislin, 1970; Cause,

Coronado, & Watson, 1998). The translation method described by Brislin (1970) was

adopted for this study. The iterative process of translation-back translation and pilot

testing in the Taiwanese population were completed prior to the study (Werner &

Campbell, 1970). That is, item meanings for the Taiwanese version were similar to the

original English version and the items had cultural relevance for the Taiwanese culture.

As a result, the data collection interviews in the final study went fairly smoothly and

there was little difficulty in obtaining responses to the items from the study participants.

Very few of the questionnaire items needed clarification during the pilot testing.

For example, study participants asked for clarification on the resourcefulness scale item

that asked about borrowing money, because this is not acceptable in the Taiwanese

culture. During the interview, many of the patients responded to this item by saying that

it won’t never happen in their lives, because they spend money based on how much they

earn.

Most of the eight translated instruments had acceptable estimates of reliability and

validity. However, the scales measuring sexual self-schema for males and females had

lower internal consistency estimates -- .69 and .70, respectively. With regard to these

247
measures, 27 out of 45 terms in the male version and 26 out of 50 terms in the female

version of the scale were used to describe sexual self-image.

Additionally, in the scale measuring sexual function in men (male sexual

function), 6 of the 15 items reflect erectile function, while 19 items of scale measuring

sexual function in women (female sexual function) are evenly distributed across several

domains. Moreover, male and female versions of these scales are scored differently. For

example, items constituting the female version have assigned weights that are applied in

computing the total score; the items are not weighted in the male version of the sexual

function scale.

Implications

The findings from this study of perceived stress, resourcefulness, spirituality and

sexuality in Taiwanese persons with rectal cancer have implications for theory

development, clinical practice, health policy, and nursing education.

Theory Development

The findings from this study support the three theories on which it was based. The

results from this study have important implications for holistic nursing theory

development. It provides a comprehensive understanding of the phenomenon in

Taiwanese persons through the exploration of relationships among the major study

variables, demographics, and cancer-related variables.

The findings support Neuman’s system model in the light of the four meta-

paradigm concepts of nursing. The findings of this study contribute to the expanding of

the nursing knowledge through filling the gaps that existed in the empirical literature. The

248
results specifically support the two major concepts, stress and the reaction to stressors,

which exist within the client (person) system in Neuman Systems Model.

According to the Neuman systems model (1995), intrapersonal stressor (i.e.,

cancer treatment), interpersonal stressors (role expectation or communication patterns),

other factors (e.g., time since their diagnosis/ operation, nature and intensity of the

stressor) may affect the person’s coping (flexible line of defense and resistance), and

therefore, it will influence the person’s stability/wellness. Neuman indicated that stressors

can have a positive or negative outcome, such as low sexual function or high sexual

satisfaction in this study. The findings from this study support the goal of nursing to

facilitate optimum wellness through primary (when stressor are identified), secondary

(treatment of symptom, such as use of lubricant), and tertiary prevention (coping, or

maintaining). The significant findings from this study support the interrelationships

among spirituality, resourcefulness, stressors (cancer treatment), and reaction to stress

(indicators of sexuality) as articulated within the Neuman Systems Model.

The results also support Lazarus and Folkman’s (1984) stress and coping theory

in that when individuals encounter stressful situations, such as cancer and its treatment,

one’s cognitive processes determine both the perception of stress and one’s emotional

reaction through primary and seconday appraisal. The findings demonstrate that

perceived stress has its influences/associations on other major study variables (i.e.,

indicators of sexuality) and demographic and cancer-related variables.

The findings provide support for the mid-range theory of resourcefulness

(Zauszniewski, 2006). Both self-help (personal resourcefulness) and help-seeking

behaviors (e.g., social resourcefulness) were measured in this study and found to be

249
associated with intrinsic factors (i.e., perceived stress, number of comorbid conditions,

education), and quality of life (i.e. sexual satisfaction). Although the findings showed a

low to moderate level of social resourcefulness due to participants’ dislike of seeking

help from others in certain situations, this finding remaining consistent with

resourcefulness theory. Contrary to what would be expected according to resourcefulness

theory, cognitive appraisal was not found to be associated with resourcefulness,

indicating that cognitive appraisal may not function as a process regulator in mediating or

moderating the effects of intrinsic and extrinsic factors on resourcefulness.

Thus, this study extended the body of knowledge of the phenomena explicated

within the Neuman Systems Model, Lazarus’s Stress and Coping theory, and the mid-

range theory of resourcefulness.

Clinical Practice

In this study, an individual’s perceptions were of paramount importance in

determining whether or not cancer treatments were perceived as stressful. From the

findings, perceived stress (i.e., cancer treatment) was found to be associated with many

variables, including demographic variables (gender), cancer-related variables (time since

operation, colostomy performance), cognitive appraisal of stress, spirituality,

resourcefulness, and indicators of sexuality (communication, sexual relationship, sexual

self-concept and sexual function in males). According to Neuman (1995), individuals

actively interact with environmental stressors (i.e., intra-, inter-, extrapersonal stressor)

that influence their reaction to stressors. Stressful events could eventually become

overwhelming. Thus, assessing stress and observing its impact on indicators of sexuality,

and on spirituality and resourcefulness are important for coping.

250
 The results of the study showed that the patient’s perceptions of sexual

satisfaction depended on factors, such as sexual self-concept, spirituality and

resourcefulness other than frequency of intercourse. However, because definitions of

satisfaction may differ between and within individuals over time, it is important for

health care professionals to find out what the patient wants in terms of satisfaction. At the

same time, identifying variations due to the myths related to sexuality is needed, such as

1) participants fear that disease can be transmitted to the partner; 2) intercourse is the

only way to have sex; 3) sex without orgasm is not good sex; 4) intimacy is necessary

related to intercourse or orgasm; 5) sexual encounters must usually or always result in

orgasm.

The study findings showed communication between partners (couple

communication) is a crucial element on their sexual relationship, which may directly or

indirectly affect one’s sexual self-concept and sexual satisfaction for both men and

women. Chapman (2001) emphasizes that any attempt to understand communication

patterns must be rooted in an understanding of the relationship between the client and his

or her significant others. Communication barriers can create additional problem in couple

relationship already stressed by illness. Understanding the distinctive conversation

patterns between genders and enhancing the couple growth starts with/through

listening/debriefing conversation between couples. As a health care professional who

deals with sexually related issues for rectal cancer patients, nurses should listen and

provide support and encouragement.

In this study, spirituality and resourcefulness are significantly and positively

associated and are also correlated with same outcome variables, that is, sexual

251
satisfaction (i.e., communication and sexual relationship) and sexual self-concept.

According to the findings, participants tend to rely on self-help skills (i.e., personal

resourcefulness) to deal with problems. Teaching patients include why, when and where

to seek help from others either formal or informal is necessary. Because it is

characteristic of Taiwanese people to be self-reliant, teaching resourcefulness skills,

especially the help-seeking skills constituting social resourcefulness, is essential so that

they may learn to rely on family/ friends, exchange ideas with others, and seek

professional or expert help when they encounter stressful situations.

The importance of the associations among spirituality, perceived stress, and

indicators of sexuality (i.e., reaction of stress) were shown in the study’s findings. Thus,

the findings suggest the potential examination of interventions to enhance or promote

spirituality in order to reduce stress or improve sexuality.

The relationship between spirituality and resourcefulness and indicators of

sexuality (sexual satisfaction and sexual self-concept) should be tested to determine the

existence of moderating or mediating effect, which in turn, may lead to the development

of interventions that can enable rectal cancer patients to effectively use spiritual

interventions and helping seeking to regain stability or harmonious health.

Health promotion programs for rectal cancer long-term survivors should

incorporate significant findings from the study presented here, including those derived

from scores on measures of demographic and cancer-related variables and perceived

stress, spirituality, resourcefulnesss, and indicators of sexuality, into the creation of an

assessment tool for screening persons at risk for high perceived stress, low spirituality,

low resourcefulness and low scores of indicators of sexuality satisfaction (i.e. low

252
communication and low sexual relationship), low sexual self-concept, and low sexual

function.

Moreover, establishing a standard assessment of sexual health status before and

after operation for rectal cancer patients is essential for advanced nursing practice. In

addition to demographic data (i.e, age, gender, education, number of children, number of

comorbid conditions) and cancer-related data (i.e., time since operation/diagnosis, stage

of disease, type of treatment, colostomy performance, types of therapy), a sexual history

might be included in an assessment as follows: 1) How important would you rate your

sexual function? 2) How would you rate yourself as sexual being? 3) How would you rate

your sexual relationship? 4) Have you taken/used medicine or substance to improve your

sexual function? 5) Have you taken Chinese medicine/hurb to improve sexual function? 6)

Have you talked about your problems with your partner? 7) Do you feel an inner need to

talk about your feelings? 8) When you are having problems, is talking about them

important to make things right again? 9) Do you like to keep problem with you?

A clinical pathway for screening the high risk rectal cancer patients and partners

should be established. It should include available resources, treatment, sexual counseling

for subjects at risk for experiencing sexual dysfunction, such as those with rectal cancer.

In addition, for the cancer patients to meet the goal of sexual health indicated by WHO

(1975), strategies should be established to help them successfully cope with anxiety and

fear while facing their sexual problems.

Health Policy

According to the Taiwan government report (Taiwan Report, 2005) and supported

by the findings from this study, the prevalence of rectal cancer is increasing in younger

253
persons. Moreover, the survival rate is improving over time. As a result, the number of

younger aged survivors is expected to increase. For these individuals, sexual issues

following cancer treatments will become more prominent and significant, particularly for

those in the reproductive years of life. Future health policy should address the

establishment of a sperm or ovary bank for persons who are at risk of infertility after

surgery or adjuvant therapy. Pre- or postoperative sexual assessment, sexual counseling

and couples therapy should be provided as needed under the national medical insurance

system.

Nursing Education

Establishing a nonjudgmental and positive attitude toward sexuality is important

for all health care professionals. Before dealing with sexual issues in their patients, health

care professionals need to be aware of the uniqueness and the multidimensionality of

sexuality for each individual. Health care professionals need to assess their own beliefs,

attitudes, and values toward sexuality through self-reflection and self-awareness. Thus, a

curriculum related to sexuality or sexual health must be developed within nursing

programs; these might include seminars on sexual issue as well as in-service program for

nurses in practice. Helminiak (1989) indicated that one who is uncomfortable with their

own sexuality may be uncomfortable with their own body, which may also influence their

self-esteem. However, one who is able to accept his or her own sexuality is better able to

accept the meaning and significance of their patient’s sexual problems. Therefore, he or

she will be better able to deal with their cancer patient’s sexual problems in a positive and

supportive manner.

254
 The findings from this study will be disseminated through continuing education

programs to nurses working at the research sites where study participants were recruited.

The program will also address clarification of misconceptions concerning sexuality in the

Chinese culture and questions about preoperative concerns of cancer patients and how the

nurses might answer them. Such programs should also be expanded to include all health

care professionals since obtaining non-judgmental communicative skills related to sexual

issues are important for all who provide care.

Recommendations

Future Research

The present study was the first step to explore sexuality holistically. The findings

provided a significant foundation for future research to further examine relationships

among demographic, cancer-related variables, perceived stress (global and health-

specified stress), spirituality, resourcefulness, and indicators of sexuality in this

population. This study provided evidence for the reliability of translated measurements.

Future studies may further focus on experimental design, secondary analyses, model

testing, mediating or moderating effects testing, and qualitative research including both

genders of patients with rectal cancer and their partners.

Several recommendations for research can be made given the findings of this

descriptive correlational study of Taiwanese colorectal cancer patients. These

recommendations include the following:

First of all, for the future research and knowledge development, an adequate

sample size of women study participants is needed for making comparisons with men on

perceived stress, resourcefulness, spirituality, and sexuality as well as comparing them on

255
other demographic characteristics and cancer-related variables. To achieve this,

recruitment from additional medical centers that serve more women with rectal cancer in

Taiwan would be essential. Since men and women may differ on cancer-related and

other variables of interest, a comparative study is needed to identify important differences

that may suggest different interventions to promote sexual health for men and women.

Second, because sexual satisfaction and sexual self-concept are so highly

integrated in and perhaps dependent upon one’s relationship with a sexual partner,

research that includes the rectal cancer patient and his or her partner would be

informative. Inclusion of the partner would provide another perspective and additional

information about the dyadic communication and relationship. The results from such a

study may inform future intervention research for persons with rectal cancer and their

partners.

Third, because the findings suggested that spirituality and resourcefulness were

associated with perceived stress and certain indicators of sexuality and that perceived

stress was related to indicators of sexuality, it is possible that the effects of perceived

stress on sexuality indicators may be mediated or moderated by either spirituality or

resourcefulness. Therefore, future research should test for these effects. Such studies

should be planned to control for potentially confounding demographic and cancer-related

variables, as identified within this study. However, a study of this kind would require a

sufficient sample of persons with rectal cancer would need to be obtained so that

sufficient power to detect significant effects would be attained. The findings from a

study of mediating and moderating effects would inform the future development and

256
testing of interventions that promote spirituality or resourcefulness in order to enhance

the sexuality of rectal cancer patients.

Fourth, the study presented here does not provide information about changes on

cancer-related variables, perceived stress, resourcefulness, spirituality, or sexuality over

time. A longitudinal study with perhaps three measurement points (pre-operative, 3-

month postoperative, 6-month postoperative) may be conducted to examine changes on

the cancer-related or other major study variables over time.

Fifth, a qualitative study of the sexuality among Taiwanese rectal cancer patients

and their partners might be conducted based on phenomenology theory to assess the

meaning of sexuality and the lived experience of having cancer and treatment relevant to

their culture.

Sixth, secondary analysis of the scoring of the measure used for male sexual

functioning to examine differences between the use of weighted and unweighted scores is

needed for evaluation of the usefulness of this measure for future research.

Seventh, secondary analysis of the two subscales of the resourcefulness measure

may be examined in relation to the other major study variables, demographics, and

cancer-related variables in order to determine whether both dimensions of

resourcefulness are important for Taiwanese people facing stressful situations, such as a

serious medical illness like cancer.

Lastly, future research should examine the interrelationships among the major

study variables (perceived stress, spirituality, resourcefulness) and interpersonal (such as,

body image changes, bowel movement disturbance) and extrapersonal factors, as

identified within the context of Neuman’s Model, and their effects on sexuality.

257
Plan for Dissemination

Considering the importance of the findings on contemporary advanced nursing

practice and nursing research, the results need to be disseminated not only to health care

professionals including researchers, faculty, student nurses, but also to people in clinical

practice, such as nurses, physicians, and patients. Dissemination of the findings can be

accomplished by giving a presentation in conference, seminars, having an open forum,

posting flyers and publishing in journals or newsletters.

258
 APPENDIX A
Data Collector Manual

A. Contacting the subjects

1. Obtain the list of eligible subjects through physicians’ referral with patients’
permission
2. Complete data collection instrument form including inclusion and exclusion
criteria
3. Contact patients who will come to OPD follow-up visit in the near future based on
the list
4. Introduce the study on the phone and set up an interview time
5. Make a reminder phone call one week before the interview
6. Further explain study purpose at OPD interview time
7. Obtain informed consent
8. Complete questionnaires in a private room
9. Return questionnaires in anonymous with envelop provided
10. Give a $100 Taiwanese Dollar worth of gift card
11. Observe and ask about any discomfort regarding the questionnaires completion

B. Content of introducing the study: the way you --

1. Presenting the study: includes
- the purposes of the study – examine the associations among demographic
and cancer-related variables, perceived stress, spirituality, and
resourcefulness, and sexuality in Taiwanese rectal cancer patients.
- confidentiality of the results
- the voluntary nature of the study
- the researcher is the only person who will use the results

2. Asking the questions

- exactly the way they are written, with no variation or wording changes
- details regarding the specific question

3. Probing the incomplete answers

- in nondirective ways (i.e., do not push the respondent and increase the
likelihood of any one answer over another)
- A standard probe: repeating the question

4. Recording the answers

- For closed-response questions, the interviewer records an answer only
when the respondent actually chooses one
- For an open-ended question, interviewer records exactly in the words that
the respondent uses

5. Interpersonal relations
- To behave as a professional, not to communicate any judgments on
answers that respondents give

259
 APPENDIX B
Data Collection Instrument

Study #___________ Date: / /

Study Title: Perceived stress, spirituality, resourcefulness and sexuality in patients with
rectal cancer undergoing cancer treatments
Investigator: Tsay-Yi Au, R.N., PhD candidate at Case Western Reserve University

SAMPLE SELECTION

Exclusion criteria: patients who have

1) a prior history of sexual dysfunction

2) a prior history of any type of cancer

Inclusion criteria: patients who have

1) a confirmed diagnosis of rectal cancer classified as Duke A to C

2) no previous cancer diagnoses

3) receiving either LAR or APR

4) receiving or not receiving adjuvant treatment (e.g., radiation, chemotherapy)

5) receiving post-surgery follow-up regularly over three months

6) either male or female who is making a regular follow-up visit

7) a history of sexual activities (i.e., individual participates in a sexual relationship

producing human sexual response cycle) with his/her sexual partner

8) age 20 years old and older

REASON FOR REFUSAL ___________________________________________

INSTRUCTIONS TO DATA COLLECTOR:

1. Eligible subjects must marked “YES” for all items of inclusion criteria and
marked “NO” for all items of exclusion criteria
2. If possible, collect the demographic characteristics of subjects who refuse this
participation.

260
 APPENDIX C
DEMOGRAPHIC INFORMATION

Study #: ___________ Date: / /____

Please take time to fill out the box of the following items to the best of your ability.
Thank you very much for providing related information.

1. Gender 1 □ Male 2 □ Female

2. Marital status 1 □ Never married 2 □ Married

3 □ Divorced 4 □ Separated
5 □ Widowed 6 □ Other (specify) _________

3. Age ________ years

4. Number of children 1 □ One 2 □ Two

3 □ Three 4 □ Four
5 □ Five 6 □ Other (adopted)

5. Education 1 □ Completed elementary school

2 □ Completed middle school
3 □ Completed high school
4 □ Completed undergraduate degree
5 □ Completed graduate degree
6 □ Other (specify) _________________

6. Employment status (check one)

1 □ Retired 2 □ Full-time job
3 □ Part-time job 4 □ Other (specify) _________________

7. Religion (preferred) check one

0 □ Atheist 1 □ Buddhism
2 □ Taoist 3 □ Catholic
4 □ Islamic 5 □ Christian
6 □ Other (specify) _________________

8. Sexual history questions (please circle one)

8.1. How uncomfortable is your incision during sexual activities?

0 □ Not at all 1 □ A little bit
2 □ Somewhat 3 □ Quit a bit
4 □ Very much

261
8.2. How anxious are you when you think of sexual issue?
0 □ Not at all 1 □ A little bit
2 □ Somewhat 3 □ Quit a bit
4 □ Very much

8.3. Have you taken medicine for improving sexual function?

0 □ No 1 □ Yes
If yes，Please specify？______________________________________

8.4. How important is your sexual life in general?

0 □ Not at all 1 □ A little bit
2 □ Somewhat 3 □ Quit a bit
4 □ Very much

8.5. How important is your sexual life before treatment?

0 □ Not at all 1 □ A little bit
2 □ Somewhat 3 □ Quit a bit
4 □ Very much

8.6. How important would you rate your sexual aspect now?
0 □ Not at all 1 □ A little bit
2 □ Somewhat 3 □ Quit a bit
4 □ Very much

8.7. How important is your sexual relationship with your partner right now?
0 □ Not at all 1 □ A little bit
2 □ Somewhat 3 □ Quit a bit
4 □ Very much

Medical Data (by data collector)

9. Length of being diagnosed of cancer (months) ______

10. What kind of surgery do you receive (Present surgery received)?

1 □ Low anterior resection (LAR)
2 □ Abdominoperineal resection (APR)

11. Times since operation (months)?

1 □ 0~6 months 2 □ 7~12 months
3 □ 13~18 months 4 □ 19~24 months
5 □ 25~30 months 6 □ 31~36 months
7 □ 37~42 months 8 □ 43~48 months

262
12. Colostomy received? 0 □ No 1 □ Yes

13. Type of treatment received:

0 □ No adjuvant treatment
1 □ Surgery
2 □ Postoperative chemotherapy
3 □ Postoperative radiation _______________________________
4 □ Postoperative chemo- and radiation therapy_________________

14. Stage of Disease (Tumor stage) 1 □ A 2 □ B1 3 □ B2

4 □ C1 5 □ C2

15. Comorbidity of Illness (numbers and specify):

0 □ No 1 □ One
2 □ Two 3 □ Three
4 □ Four 5 □ Five
Please specify ___________________________

Thank you for completing this questionnaire.

263
 APPENDIX D

Sexual History Questions #1-7

1. How uncomfortable is your incision during sexual activities?

2. How anxious are you when you think of sexual issue?
3. Have you taken medicine for improving sexual function?
4. How important is your sexual life in general?
5. How important is your sexual life before treatment?
6. How important would you rate your sexual aspect now?
7. How important is your sexual relationship with your partner right now?

264
APPENDIX E

265
266
267
268
 BIBLIOGRAPHY

Agresti, A. & Finlay, B. (1997). Statistical methods for the social sciences (3rd ed.). NJ:
Prentice Hall, Inc.

Ahmad, M. M. (2005). Psychometric evaluation of the cognitive appraisal of health scale

with patients with prostate cancer. Journal of Advanced Nursing, 49(1), 78-86.

Ahmad, M. M. (2000). A correlational study of cognitive appraisal, coping strategies and

health status in prostate cancer patients. Doctoral dissertation, Case Western
Reserve University, Cleveland.

Allal, A. S., Sprangers, M. A. G., Laurence, F., Reymond, M. A., & Kurtz, J. M. (1999).
Assessment of long-term quality of life in patients with anal carcinomas treated
by radiotherapy with or without chemotherapy. British Journal of Cancer, 80(10),
1588-1594.

Allal, A. S., Gervaz, P., Gertsch, P., Bernier, J., Roth, A. D., Morel, P., et al. (2005).
Assessment of quality of life in patients with rectal cancer treated by preoperative
radiotherapy: A longitudinal prospective study. International Journal of
Radiation Oncology, Biology, Physics, 61(4), 1129-1135.

Allen, M. E. (1987). A holistic view of sexuality and the aged. Holistic Nursing Practice,
1(4), 76-83.

Allport, G. W., & Ross, J. M. (1967). Personal religious orientation and prejudice.
Journal of Personality and Social Psychology, 5, 432-443.

Ameda, K., Kakizaki, H., Koyanagi, T., Hirakawa, K., Kusumi, T., & Hosokawa, M.
(2005). The long-term voiding function and sexual function after pelvic nerve-
sparing radical surgery for rectal cancer. International Journal of Urology, 12,
256-263.

American Cancer Society. (2002). Cancer Facts & Figures –2002. American Cancer
Society: Atlanta.

Ammerman, C. (1990). Spiritual dimension of human sexuality. Journal of Religious

Gerontology, 7, 83-97.

Ananth, H., Jones, L., King, M., & Tookman, A. (2003). The impact of cancer on sexual
function: A controlled study. Palliative Medicine, 17, 202-205.

Anderson, B. (1993). Predicting sexual and psychologic morbidity and improving the
quality of life for women with gynecologic cancer. Cancer, 17, 1678-1690.

269
Andersen, B. L., & Cyranowski, J. M. (1994). Women’s sexual self-schema. Journal of
Personality Social Psychology, 67, 1079-1100.

Anderson, B. L., Cyranowski, J. M., & Espindle, D. (1999). Men’s sexual self-schema.
Journal of Personality and Social Psychology, 76(4), 645-661.

Anderson, P. B., & Morgan, M. (1994). Spirituality and sexuality: The healthy
connection. Journal of Religion and Health, 33, 115-121.

Andersen, B.L., & ven der Does, J. (1994). Sexual morbidity following gynecologic
cancer: An international problem. International Journal of Gynecologic Cancer, 4,
225-240.

Anderson, B. L., Anderson, B., & deProsse, C. (1989). Controlled prospective

longitudinal study of women with cancer: I. Psychological outcomes. Journal of
Consulting and Clinical Psychology, 57, 683-691.

Anderson, B. L., Woods, X. A., & Copeland, L. J. (1997). Sexual self-schema and sexual
Morbidity among gynecologic cancer survivors. Journal of Counsulting &
Clinical Psychology, 65(2), 221-229.

Andersen, B. L. (1999). Surviving cancer: The importance of sexual self-concept.

Medical and Pediatric Oncology, 33, 15-23.

Anderson, T. P., & Cole, T. M. (1978). Sexual counseling of the physically

disabled. Postgraduate Medicine, 58, 117-123.

Andersen, B. L. & Cyranowski, J. M. (1994). Women’s sexual self-schema. Journal of

Personality and Social Psychology, 67(6), 1079-1100.

Anllo, L. M. (2000). Sexual life after breast cancer. Journal of Sex & Marital Therapy,
26(3), 241-248.

Arveux, I., Boutron, M. C., Mrini, E. I., Arveux, A., & Liabeuf, A. (1997). Colon cancer
In the elderly: Evidence for major improvements in health care survival. British
Journal of Cancer, 76, 903-967.

Astin, J. A. (1997). Stress reduction through mindfulness meditation: Effects on

psychological symptomatology, sense of control and spiritual experiences.
Psychotherapy and Psychosomatics, 66(2), 97-106.

Asoglu, O., Matlim, T., Karanlik, H., Atar, M., Muslumanoglu, M., Kapran, Y., et al.
(2009). Impact of laparoscopic surgery on bladder and sexual function after total
mesorectal excision for rectal cancer. Surgical Endoscopy, 23, 296-303.

Auchincloss, S. (1991). Sexual dysfunction after cancer treatment. Journal of

270
 Psychosocial Oncology, 9(1), 23-42.

Badr, H. C., & Taylor, C. L. (2006). Social constraints and spousal communication in
lung cancer. Psycho-oncology, 15, 673-683.

Baider, L., Andritsch, E., Goldzweig, G., Uziely, B., Ever-Hadani, P., Hofman, G., et al.
(2004). Changes in psychological distress of women with breast cancer in long-
term remission and their husbands. Pschosomatics, 45(1), 58-68.

Baider, L., Kaufman, B., Peretz, T., Manor, O., Ever-Hadani, P., Kaplan, De-Nour, A.
(1996). Mutuality of fate: adaptation and psychological distress in cancer patients
and their partners. In L. Baider, C. L. Copper, A. Kaplan De-Nour (Eds.), Cancer
and the family (pp.173-187). Chichester: Wiley.

Bailey, C., Corner, J., Addington-Hall, J., Kumar, D., Nelson, M., & Haviland, J. (2003).
Treatment decisions in older patients with colorectal cancer: The role of age and
Multidimensional function. European Journal of Cancer Care, 12, 257-262.

Balslev, I., & Harling, H. (1983). Sexual dysfunction following operation of carcinoma of
the rectum. Diseases of the Colon & Rectum, 26, 785-788.

Banks, R. (1980). Health and the spiritual dimensions: Relationships and implications for
professional preparation programs. The Journal of School Health, 50, 195.

Becker, N., Muscat, J. E., & Wynder, E. L. (2001). Cancer morbidity in the United States
and Germany. Journal of Cancer Research Clinical Oncology, 127, 293-300.

Beckham, J. C., & Godding, P. R. (1990). Sexual dysfunction in cancer patients. Journal
of Psychosocial Oncology, 8(1), 1-16.

Bekhet, A. K., & Zauszniewski, J. A. (2008). Milieu Change and Relocation Adjustment
in Elders. Western Journal of Nursing Research, 31(1), 113-129.

Bekkers, M. J. T. M., van Knippenberg, F. C. E., van Dulmen, A. M., van den Borne, H.
W., & van Berge Henegouwen, G. P. (1997). Survival and psychosocial
adjustment to stoma surgery and nonstoma bowel resection: A 4-year follow-up.
Journal of Psychosomatic Research, 42(3), 235-244.

Belcher, A. E., Dettmore, D., & Holzemer, S. P. (1989). Spirituality and sense of well-
being in persons with AIDS. Holistic Nursing Practice, 3(4), 16-25.

Bjorck, J. P., Hopp, D. P., & Jones, L. W. (1999). Prostate cancer and emotional
functioning: Effects of mental adjustment, optimism and appraisal. Journal of
Psychosocial Oncology, 17, 71-85.

Bowman, K. F., Deimling, G. T., Smerglia, V., Sage, P., & Kahana, B. (2003). Appraisal

271
 of the cancer experience by older long-term survivors. Psycho-Oncology, 12, 226-
238.

Bowen-Reid, T. L., & Harrell, J. P. (2002). Racist experiences and health outcomes: An
examination of spirituality as a buffer. Journal of Black Psychology, 28(1), 18-36.

Braden, C. J. (1990). A test of the self-help model: Learned response to chronic illness
experience. Nursing Research, 39(1), 42-47.

Brallier, L. W. (1982). Transition and transformation: Successfully managing stress (Ed.),

Los Altos, CA: National Nursing Review.

Brecher, E. M. (1984). Love, sex, and aging: A consumer’s union report. Boston: Little,
Brown, & Company.

Brennan, M. (2004). Research: Spirituality and religiousness predict adaptation to vision

loss in middle-aged and older adults. The International Journal for the
Psychology of Religion, 14(3), 193-214.

Brislin, R. W. (1970). Back-translation for cross-cultural research. Journal of Cross-

cultural Psychology, 1, 185-216.

Browne, M. W., & Cudeck, R. (1989). Single sample cross-validation indices for
covariance structures. Multivariate Behavioral Research, 24, 445-455.

Butler, M. H., Dahlin, S. K., & Fife, S. T. (2002). Languaging factors affecting client’s
acceptance of forgiveness intervention in marital therapy. Journal of Marital
Family Therapy, 28(3), 285-298.

Bulter, R. N., & Lewis, M. I. (1993). Love and sex after 60. New York: Ballantine Books.

Burbie, G. E., & Polinsky, M. I. (1992). Intimacy and sexuality after cancer treatment:
Restoring a sense of wholeness. Journal of Psychosocial Oncology, 10(1), 19-33.

Burnard, P. (1988). The spiritual needs of atheists and agnostics. Professional Nurse, 4,
130-132.

Burkhardt, M. A. (1994). Becoming and connecting: Elements of spirituality for women.

Holistic Nursing Practice, 8, 12-21.

Burns, N., & Grove, S. K. (1997). The practice of nursing research: Conduct, critique,
and utilization (3rd ed.). Philadelphia: W. B. Saunders.

Burns, N., & Grove, S. K. (2001). The practice of nursing research: Conduct, critique,
and utilization (4th ed.). Philadelphia: W. B. Saunders.

272
Burkhardt, M. A. (1989). Spirituality: An analysis of a concept. Holistic Nursing Practice,
3(3), 69-76.

Butler, L., Banfield, V., Sveinsen, T., & Allen, K. (1998). Conceptualizing sexual health
in cancer care. Western Journal of Nursing Research, 20, 683-705.

Caldwell, R. S. (2003). An exploration of the unique experience of survivors of

gynecological cancer: Sexuality and body image. Unpublished doctoral
dissertation, Institute of Transpersonal Psychology.

Camilleri-Brennan, J., & Steele, R. J. C. (2001). Prospective analysis of quality of life

and survival following mesorectal excision for rectal cancer. British Journal of
Surgery, 88(12), 1617-1622.

Cause, A. M., Coronado, N., & Watson, J. (1998). Conceptual, methodological, and
statistical issues in culturally competent research. In M. Hernandez, & M. R.
Isaacs (Ed.), Promoting cultural competence in children’s mental health
services (pp. 305-331). Boltimore, MD: Paul H. Brookes Publishing Co.

Carson, V. B. (Ed.). (1989). Spiritual dimensions of nursing practice. Philadelphia: W.

B. Saunders Company.

Catania, J. A., Gibson, D. R., Chitwood, D. D., & Coates, T. J. (1990). Methodological
problems in AIDS behavioral research: Influences on measurement error and
participation bias in studies of sexual behavior. Psychological Bulletin, 108, 339-
362.

Catterall, R. A., Cox, M., Greet, B., Sankey, J., & Griffiths, G. (1998). Spiritual care: The
assessment and audit of spiritual care. International Journal of Palliative Nursing,
4(4), 162-168.

Cawley, N. (1997). An exploration of the concept of spirituality. International Journal of

Palliative Nursing, 3, 31-36.

Chan, C. L. W., Ng, S. M., Ho, R. T. H., & Chow, A. Y. M. (2006). East meets West:
Applying Eastern spirituality in clinical practice. Journal of Clinical Nursing, 15,
822-832.

Chapman, M. (2001). Theoretical orientation: Family systems and psychodynamics. In L.

Berg-Cross (2nd ed.), Couple therapy (pp.279). New York: The Haworth Clinical
Practice Press.

Chavez-Garcia, C., & Helminiak, D. A. (1985). Sexuality and spirituality: Friends, not
foes. Journal of Pastoral Care, 39, 151-163.

273
Chatwin, N. A. M., Ribordy, M., & Givel, J. C. (2002). Clinical outcomes and quality of
life after low anterior resection for rectal cancer. European Journal of Surgery,
168, 297-301.

Chiu, L. (2001). Spiritual resources of Chinese immigrants with breast cancer in the USA.
International Journal of Nursing Studies, 38(2), 175-184.

Christmeyer, C., Catanzareti, M., Langford, A., & Reitz, J. (1988). Bridging the gap:
Theory to practice – part I: clinical applications. Nursing Management, 19(5), 42-
50.

Chorost, M. I., Weber, T. K., Lee, R. J., Rodriguez-Bigas, M. A., & Petrelli, N. J. (2000).
Sexual dysfunction, informed consent and multimodality therapy for rectal cancer.
The American Journal of Surgery, 179, 271-274.

Clark, J. C. (1993). Psychosocial responses of the patient: Altered sexual health. In S. I.

Grownwald, M. H. Frogge, M. Goodman, & C. H. Yarbro (3rd ed.), Cancer
nursing principles and practice (pp. 449-467). Boston: Jones & Bartlett.

Cohen, S., Kessler, R. C., & Gordon, L. U. (1995). Strategies for measuring stress in
studies of psychiatric and physical disorders. In S. Cohen, R. C. Kessler, & L. U.
Gordon (Ed.), A guide for health and social scientists (pp. 3). New York: Oxford
University Press.

Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis.
Psychological Bulletin, 98, 310-57.

Cohn, F., & Lazarus, R. S. (1979). Coping with the stress of illness. In G. C. Stone, F.
Cohn., N. Adler, et al. (Ed.), Health psychology: A handbook (pp. 217-254).
Washington: Jossey- Bass.

Cohen, S., Tyrrell, D. A., & Smith, A. P. (1993). Negative life events, perceived stress,
negative addict, and susceptibility to the common cold. Journal of Personality
and Social Psychology, 64(1), 131-140.

Cohen, S., & Williamson, G. M. (1988). Perceived stress in a probability sample of the
United States. In S. Spacapan, & S. Oskamp (Eds.), The social psychology of
health (pp. 31-67). Newbury Park, CA: SAGE Publications.

Cohen, J. (1965). Some statistical issues in psychological research. In B. B. Wolman

(Ed.), Handbook of clinical psychology (pp. 95-121). New York: McGraw-Hill.

Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress.
Journal of Health and Social Behavior, 24, 385-396.

274
Cohen, S. (1986). Contrasting the Hassles Scale and the Perceived Stress Scale: Who’s
really measuring appraised stress? American Psychologist, 41, 716-718.

Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). New
Jersey: Hillsdale.

Cohen, J. (1990). Things I have learned (so far). American Psychologist, 45, 1304-1312.

Cohen, J. (1992). A power primer. Psychological Bulletin, 112(1), 155-159.

Cohen, J., & Cohen, P. (1983). Applied multiple regression/correlation analysis for the
behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates.

Cole, S. (1999). Assessment of differential item functioning in the Perceived Stress

Scale-10. Journal of Epidemiology and Community Health, 53, 319-320.

Coll, R. (1989). Toward a holistic approach to human sexuality. Religious Education, 84,
262-272.

Corrigan, P., McCorrde, B., Schell, B., & Kdder, K. (2003). Religion and spirituality in
the lives of people with serious mental illness. Manuscript submitted for
publication.

Cornu, A. (1957). The origins of Marxist thought (pp.12-17). Springfield, IL: Thomas.

Coyne, J. C., Aldwin, C., & Lazarus, R. (1981). Depression and coping in stressful
episodes. Journal of Abnormal Psychiatry, 122, 47-51.

Cree, M., Tonita, J., Turner, D., Nugent, Z., Alvi, R., Barss, R., et al. (2009). Comparison
of treatment received versus long-standing guidelines for stage III colon and stage
II/III rectal cancer patients diagnosed in Alberta, Saskatchewan, and Manitoba in
2004. Clinical Colorectal Cancer, 8(3), 141-5.

Curran, M. C. (1999). Sexual self-schema and sexual functioning in women diagnosed

with breast cancer. Unpublished master’s thesis, York University, Toronto.

Cyranowski, J. M., Aarestad, S. L., & Anderson, B. L. (1999). The role of sexual self-
schema in a diathesis-stress model of sexual dysfunction. Applied & Preventive
Psychology, 8(3), 217-228.

Dailey, D. (1984). Does renal failure mean sexual failure. The Renal Family, 6, 2-4.

Daniel, W. W. (1995). Biostatistics: A foundation for analysis in the health sciences (6th
ed.). New York: Willey.

David, J. R., & Duda, F. C. (1977). Christian perspectives on the treatment of sexual

275
 dysfunction. Journal of Psychology and Theology, 5, 332-336.

de Chardin, P. T. (1955). The phenomenon of man. London: Collins.

Denney, N. W., & Quadagno, D. (1992). Human sexuality. St. Louis: C.V. Mosby.

Derogatis, L. R., & Coons, H. L. (1993). Self-report measures of stress. In L. Goldberger,

& S. Breznitz (2nd ed.), Handbook of stress: Theoretical and clinical aspects (pp.
200-203). New York: The free press.

Derogatis, L. R., & Melisaratos, N. (1979). The DSFI: A multidimensional measure of

sexual functioning. Journal of Sex and Marital Therapy, 5, 244-281.

Derogatis, L. R., & Kourlesis, S. M. (1981). An approach to evaluation of sexual

problems in cancer patient. CA: A Cancer Journal for Clinicians, 31, 46-50.

Dirksen, S. R. (2000). Predicting well-being among breast cancer survivors. Journal of

Advanced Nursing, 32(4), 937-943.

Dossey, B. M., & Guzzetta, C. E. (2000). Holistic nursing practice. In B. M. Dossey, L.

Keegan, & C. E. Guzzetta (Eds.), Holistic nursing: A handbook for practice (pp.
5-26). Rockville, MD: Aspen.

Driever, M. (1984). Theory of self-concept. In C. Roy (Ed.), Introduction to nursing: An

Adaptation model (pp. 169-191). Englewood Cliffs, NJ: Prentice-Hall.

Dunn, K. M., Croft, P. R., & Hackett, G. I. (1998). Sexual problems: A study of the
prevalence and need for health care in the general population. Family Practice, 15,
519-524.

Dunkel-Schetter, C., Feinstein, L., Taylor, S. E., & Falke, R. (1992). Patterns of coping
with cancer and their correlates. Health Psychology, 11(2), 79-87.

Dyson, L., Cobb, M., & Forman, D. (1997). The meaning of spirituality: A literature
review. Journal of Advanced Nursing, 26, 1183-1188.

Edelson, M. (1970). Sociotherapy and psychotherapy (pp.225-231). Chicago: University

of Chicago Press.

Eisdofer, C., Cohen, D., Kleinman, A., & Maxim, P. (Ed.). (1981). Models for clinical
psychopathology. New York: Spectrum Publications.

Ellison, C. (1983). Spiritual well-being: Conceptualization and measurement. Journal of

Psychology and Theology, 11, 330.

Emblen, J. D. (1992). Religion and spirituality defined according to current use in

nursing literature. Journal of Professional Nursing, 8(1), 41-47.

276
Enker, W. E. (1992). Potency, cure, and local control in the operative treatment of rectal
cancer. Archives of Surgery, 127, 1396-402.

Erwin, D. O., Spatz, T. S., & Turturro, C. L. (1992). Development of an African-

American role model intervention to increase breast self-examination and
mammography. Journal of Cancer Education, 7, 311-319.

Fallowfield, L. (1992). The quality of life: Sexual function and body image following
cancer therapy. Cancer Topics, 9, 20-21.

Fawcett, J. (1989). Analysis and evaluation of conceptual models of nursing (2nd ed.).
Philadelphia: D. A. Davis.

Feher, S., & Maly, R. (1999). Coping with breast cancer in later life: The role of religious
faith. Psycho-Oncology, 8(5), 408-416.

Fehring, R. J., Miller, J. F., & Shaw, C. (1997). Spiritual well-being, religiosity, hope,
depression, and other mood states in elderly people coping with cancer. Oncology
of Nursing Forum, 24(4), 663-671.

Feher, S., & Maly, R. (1999). Coping with breast cancer in later life: The role of religious
faith. Psycho-Oncology, 8(5), 408-416.

Ferlay, J., Bray, F., Pisani, P., & Parkin, D. M. (2001). GLOBOCAN 2000-Cancer
incidence, mortality and prevalence worldwide, Version 1.0. IARC CancerBase
No. 5, Lyon: IARC Press.

Ferrell, B., Smith, S., Ervin, K., Itano, J., & Melancon, D. (2003). A qualitative analysis
of social concerns of women with ovarian cancer. Psycho-Oncology, 12, 647-663.

Ferrell, B., Smith, S., Cullinane, C., & Melancon, C. (2003a). Psychological well being
and quality of life in ovarian cancer survivors. Cancer, 98, 1061-1071.

Ferrell, B., Smith, S., Cullinane, C., & Melancon, C. (2003b). Symptom concerns of
women with ovarian cancer. Journal of Pain and Symptom Management, 25(6),
528-538.

Ferrell, B. R., Smith, S. L., Juarez, G., & Melancon, C. (2003). Meaning of illness and
spirituality in ovarian cancer survivors. Oncology of Nursing Forum, 30(2), 249-
257.

Fingerman, K., Gallagher-Thompson, D., Lovett, S., & Rose, J. (1996). Internal
resourcefulness, task demands, coping and dysphoric affect among caregivers of
the frail elderly. International Journal of Aging and Human Development, 42,
229-248.

277
Fields, A. (2005). Discovering statistics using SPSS. London: Sage.

Fisher, S. (1986). Stress and strategy. London: Lawrence Erlbaum Associates.

Folkman, S., Lazarus, R. S., Gruen, R. J., & DeLongis, A. (1986). Appraisal, coping,
health status, and psychological symptoms. Journal of Personality and Social
Psychology, 50(3), 571-579.

Folkman, S., & Lazarus, R. S. (1980). An analysis of coping in a middle-aged community

sample. Journal of Health and Social Behavior, 21, 219-239.

Folkman, S., & Lazarus, R. R. (1988). Coping as a mediator of emotion. Journal of

Personality and Social Psychology, 54, 466-475(a).

Folkman, S., & Greer, S. (2000). Promoting psychological well-being in the face of
serious illness: When theory, research and practice inform each other.
Psychooncology, 9, 11-19.

Fowers, B. J., & Olson, D. H. (1989). ENRICH marital inventory: A discriminant

validity and cross-validity assessment. Journal of Marital and Family Therapy,
15(1), 65-79.

Fowler, F. J. (1993). Survey research methods (2nd ed.). (pp. 105-107). Newbury Park,
CA: Sage publications, Inc.

Fox, J. (1991). Regression diagnostics. (Series Ed.), Qquantitative applications in the

social sciences (No. 79). Newbury Park, CA: Sage.

Frankl, V. (1952). The Doctor and the Soul. New York: Bantam Books.

Frankl, V. (1963). Man’s search for meaning. New York: Pocket Books.

Frankl, V. (1985). Man’s search for meaning. New York: Washington Square Press.

Frank-Stromborg, M., & Olsen, S. J. (2004). Instruments for clinical health-care

research (3rd ed.). Massachusetts: John & Bartlett Publishers, Inc.

Frari, B. D., & Tschmelitsch, J. (2002). Quality of life following rectal cancer resection:
Pros and cons of sphincter preservation. Clinics in Colon and Rectal Surgery,
15(1), 87-92.

Fryback, P. B., & Reinert, B. R. (1999). Spirituality and people with potentially fatal
diagnoses. Nursing Forum, 34(1), 13-22.

Fulton, R. A. (1995). The spiritual variable. In B. Neuman (3rd ed.), The Neuman Systems
Model (pp. 77-91). Norwalk, CT: Appleton & Lange.

278
Gall, T. L. (2000). Integrating religious resources within a general model of stress and
coping: Long-term adjustment to breast cancer. Journal of Religion and Health,
39(2), 167-182.

Gallagher, C. A. (1985). Matrimonial spirituality: A prophetic voice in the church.

Studies in Formative Spirituality, 6, 201-214.

Ganz, P. A. (1990). Current issues in cancer rehabilitation. Cancer, 65, 742-751.

Gibbs, H. W., & Achterberg-Lawlis, J. (1978). Spiritual values and death anxiety:
Implications for counseling with terminal cancer patients. Journal of Counseling
Psychology, 25, 563-569.

Germer, V. (1996). Psychiatric patients’ experience of spirituality in a group setting.

Image: Journal of Nursing Scholarship, 28(3), 279.

Genia, V., & Shaw, D. G. (1991). Religion, intrinsic-extrinsic orientation, and depression.
Review of Religious, 32, 274-283.

Gifford, B. C. J. (1987). Self-Help as a learned response to chronic illness experience: A

test of four alternative theories (adaptation, helplessness, resourcefulness).
(Doctoral dissertation, The University of Arizona, 1986). Dissertation Abstracts.

Glaser, R., Kiecolt-Glaser, J., Marucha, P., MacCallum, R., Laskowski, B., & Malarkey,
W. (1999). Stress-related changes in pro-inflammatory cytokine production in
wounds. Archives of General Psychiatry, 56, 450-456.

Glasgow, M., Halfin, V., & Althausen, A. F. (1987). Sexual response and cancer. CA: A
Cancer Journal for Clinicians, 37, 322-333.

Goldberg, L. R. (1992). The development of markers for the Big-Five factor structure.
Psychological Assessment, 4, 26-42.

Golden-Kreutz, D. M., Browne, M. W., Frierson, G. M., & Andersen, B. L. (2004).

Assessing stress in cancer patients: A second-order factor analysis model for the
perceived stress scale. Assessment, 11(3), 216-223.

Golden-Kreutz, D. M., Thornton, L. M., Gregorio, S. W., Frierson, G. M., Jim, H. S.,
Carpenter, K. M., et al. (2005). Traumatic stress, perceived global stress, and life
events: Prospectively predicting quality of life in breast cancer patients. Health
Psychology, 24(3), 288-296.

Goldfried, M. R. (1980). Psychotherapy as coping skills training. In M. J. Mahoney (Ed.),

Psychotherapy process: Current issues and future directions (pp. 89-119). New
York: Plenum Press.

279
Gloeckner, M. R. & Startling, J. R. (1982). Providing sexual information to ostomy
patients. Diseases of the Colon & Rectum, 25, 575-579.

Goodwin, L. D. (1984). The use of power estimation in nursing research. Nursing

Research, 33, 118-120.

Gonzalez, E. W. (1997). Resourcefulness, appraisals, and coping efforts of family

caregivers. Issues in Mental Health Nursing, 18, 209-227.

Gotay, C. C. (1984). The experience of cancer during early and advanced stages: The
views of patients and their mates. Social Science & Medicine, 18(7), 605-613.

Graupe, F., Hansen, O., Bracht, B., & Stock, W. (1997). Psychologic strain of patients in
a follow-up program after curative research of colorectal carcinoma. Psychosocial
Oncology, 15, S63.

Greeno, E. W. (2006). Understanding your prognosis. In B. Levin, T. Ades, D. Brooks, C.

H. Crane, P. M. Hoff, P. J. Limburg, & D. A. Rothenberger (Ed.), American
Cancer Society’s: Complete guide to colorectal cancer (pp. 93). Atlanta:
American Cancer Society.

Guren, M. G., Eriksen, M. T., Wiig, J. N., Carlsen, E., Nesbakken, A., Sigurdsson, H. K.,
et al. (2005). Quality of life and functional outcome following anterior or
abdominoperineal resection for rectal cancer. European Journal of Surgical
Oncology, 31, 735-742.

Hafen, B. Q., Kauen, K. J., Frandsen, K. J., & Smith, L. (1996). The healing power of
spirituality. Spirituality and Health, 4, 377-399.

Hart, S. L. (1997). Radical cystectomy for bladder cancer: Functional limitations,

appraisals, and emotional distress. Unpublished doctoral dissertation, University
of Southern California.

Harrison, J. (1993). Spirituality and nursing practice. Journal of Clinical Nursing, 2, 211-
217.

Hasse, J. E., Britt, T., Coward, D. D., Leidy, N. K., & Penn, P. E. (1992). Simultaneous
concept analysis of spiritual perspective, hope, acceptance, and self-transcendence.
IMAGE, 24(2), 141-147.

Havenga, K., Enker, W. E., Norstein, J., Moriya, Y., Heald, R. J., van houwelingen, H. C.,
et al. (1999). Improved survival and local control after total mesorectal excision
or D3 lymphadenectomy in the treatment of primary rectal cancer: An
international analysis of 1411 patients. European Journal of Surgery and
Oncology, 25, 368-374.

280
Havenga, K., Maas, C. P., DeRuiter, M. C., Welvaart, K., & Trimbos, J. B. (2000).
Avoiding long-term disturbance to bladder and sexual function in pelvic surgery,
particularly with rectal cancer. Seminars in Surgical Oncology, 18, 235-243.

Havenga, K., Enker, W. E., McDermott, K., Cohen, A. M., Minsky, B. D., & Guillem, J.
(1996). Male and female sexual and urinary function after total mesorectal
excision with autonomic nerve preservation for carcinoma of the rectum. Journal
of American Colon Surgery, 182, 495-502.

Heald, R. J., & Ryall, R. D. (1986). Recurrence and survival after total mesorectal
excision for rectal cancer. Lancet, 28, 1479-1482.

Heald, R. J. (1988). The “holy plane” of rectal surgery. Journal of the Royal Society of
Medicine, 81, 503-508.

Helminiak, D. A. (1987). Spiritual Development: An interdisciplinary study. Chicago:

Loyola University Press.

Helminiak, D. A. (1998). Sexuality and spirituality: A humanist account. Pastoral

Psychology, 47(2), 119-125.

Hendren, S. K., O’Connor, B. I., Liu, M., Asano, T., Cohen, Z., Swallow, C. J., et al.
(2005). Prevalence of male and female sexual dysfunction is high following
surgery for rectal cancer. Annals of Surgery, 242(2), 212-223.

Heriot, C. S. (1992). Spirituality and aging. Holistic Nursing Practice, 7(1), 22-31.

Heriot, A. G., Tekkis, P. P., Fazio, V. W., Neary, P., & Lavery, I. C. (2005). Adjuvant
radiotherapy is associated with increased sexual dysfunction in male patients
undergoing resection for rectal cancer. Annals of Surgery, 242(2), 502-510.

Herzer, M., Zakowski, S. G., Flanigan, R., & Johnson, P. (2006). The relationship
between threat appraisal and social constraints in cancer survivors and their
spouses. Journal of Behavioral Medicine, 29(6), 549-560.

Hiatt, J. F. (1986). Spirituality, medicine, and healing. Southern Medical Journal, 79(6),
736-743.

Highfield, M. F., & Carson, C. (1983). Spiritual needs of patients: Are they recognized?
Cancer Nursing, (June), 187-192.

Ho, R. T. H., Chan, C. L. W., & Ho, S.M. Y. (2004). Emotional control in Chinese
female cancer surviviors. Psycho-Oncology, 13, 808-817.

Holmes, W. (2003). Sexual health of women following hematopoietic stem cell

transplantation. Unpublished doctoral dissertations, The University of

281
 Connecticut, Connecticut.

Howden, J. (1992). Development and psychometric characteristics of the Spirituality

Assessment Scale. Unpublished doctoral dissertation, Texas Women’s University,
Denton, TX.

Hsiao, C. P., & Dai, Y. C. B. S. (2001). Health care demands of cancer patients receiving
chemotherapy and its related factor. Unpublished master thesis, National Taiwan
University, Taipei, Taiwan.

Hungelmann, J., Kenkel-Rossi, E., Klassen, L., & Stollenwerk, R. M. (1989).

Development of the JAREL spiritual well-being scale. In R. M. Carroll-Johnson
(Ed.), Classification of nursing diagnoses: Proceedings of the eighth conference
of the North American Nursing Diagnosis (pp.393-398). Philadelphia: Lippincott.

Hunter, M. S., Grunfeld, E. A., & Ramirez, A. J. (2003). Help-seeking intention for
breast-cancer symptoms: A comparison of the self-regulation model and the
theory of planned behavior. British Journal of Health Psychology, 8, 319-333.

Hurny, C., & Holland, J. C. (1985). Ostomies in cancer patients. CA: A Cancer Journal
for Clinicians,35, 170-183.

Jayne, D.G., Brown, J.M., Thorpe, H., Walker, J., Quirke, P., & Guillou, P.J. (2005).
Bladder and sexual function following resection for rectal cancer in a randomized
clinical trial of laparoscopic versus open technique. British Journal of Surgery, 92,
1124-1132.

Jenks, J. M., Morin, K. H., & Tomaselli, N. (1997). The influence of ostomy surgery on
body image in patients with cancer. Applied Nursing Research, 10, 174-180.

Jenkins, R., & Pargament, K. (1995). Religion and spirituality as resources for coping
with cancer. Journal of Psychosocial Oncology, 13(1/2), 51-74.

Jenkins, R., Schover, L. R., Fouladi, R. T., Warneke, C., & Neese, L. (2004). Sexuality
and health-related quality of life after prostate cancer in African-American and
White men treated for localized disease. Journal of Sex & Marital Therapy, 30,
79-93.

Johnson, J. (1986). Life events as stressors in childhood and adolescence. London: Sage
Publications.

Johnson, B. (1996). Older adults and sexuality: A multidimensional perspective. Journal

of Gerontological Nursing, 22(2), 6-15.

Johnson, C. M. (2001). Conncetions between sexual self-esteem and spiritual orientation

in women. Master thesis, Trinity Western University.

282
Jones, E. G., & Kay, M. (1992). Instrumentation in cross-cultural research. Nursing
Research, 41(3), 186-188.

Kaiser, H. F. (1974). An index of factorial simplicity. Psychometrika, 35, 31-36.

Katz, A. (2005). The Sounds of silence: Sexuality information for cancer patients.
Journal of Clinical Oncology, 23(1), 238-241.

Kaye, J., & Robinson, K. (1994). Spirituality among caregivers. IMAGE, 26(3), 218-221.

Kaye, J. (2000). Spirituality and the emotional and physical health of Black and White
southern caregivers of persons with Alzheimer’s disease and other dementias.
Doctoral dissertation, Medical College of Georgia, Augusta, Georgia.

Keating, J. P. (2004). Sexual function after rectal excision. ANZ Journal of Surgery, 74,
248-259.

Keister, K. J. (2004). Gerontology, nursing homes, relocating personnel, older people.

Doctoral dssertation, Case Western Reserve University (Health Sciences
Publication No. AAT 3132835).

Kendall, J. (1994). Wellness spirituality in homosexual men with HIV infection. Journal
of the Association of Nurses in AIDS Care, 5, 28-34.

Kennedy, E. M. (1996). A social cognitive model of social support and psychosocial

adjustment in women with beast cancer. Unpublished doctoral dissertation, The
Fielding Institute.

Kessler, T. A. (1998). The cognitive appraisal of health scale: Development and

psychometric evaluation. Research in Nursing & Health, 21, 73-82.

Kim, N. K., Aahn, T. W., Park, J. K., Lee, K. Y., Lee, W. H., Sohn, S. K., et al. (2001).
Assessment of sexual and voiding function after total mesorectal excision with
pelvic autonomic nerve preservation in males with rectal cancer. Diseases of the
Colon & Rectum, 45(9), 1178-1185.

Kim, Y. & Seidlitz, L. (2002). Spirituality moderates the effect of stress on emotional and
physical adjustment. Personality and Individual Differences, 32, 1377-1390.

Klainin, P. (2002). Occupational stress, dissatisfaction with family relationships, learned

resourcefulness, and women’s health. Unpublished doctoral dissertation, Case
Western Reserve University, Cleveland.

Kline, R. B. (1998). Principles and practice of structural equation modeling. New York:
Guilford Press.

283
Kofoed, L., & Bloom, J. D. (1982). Geriatric sexual dysfunction. Journal of American
Geriatric Society, 30, 437-440.

Koukouras, D., Spiliotis, J., Scopa, C. D., Kalfarenztos, F., Tzoracoleftheralsis, E., &
Andronlakis, J. (1991). Radical consequences in the sexuality of male patients
operated for colorectal carcinoma. European Journal of Surgical Oncology, 17,
285-288.

Kotkamp-Mothes, N., Slawinsky, D., Hindermann, S., & Strauss, B. (2005). Coping and
sychological well being in families of elderly cancer patients. Critical Reviews in
Oncology/Hematology, 55(3), 213-229.

Kraemer, H. C., & Thiemann, S. (1987). How Many Subjects? Newbury Park, CA: Sage.

Krause, K. (1991). Contracting cancer and coping with it: Patients’ experiences. Cancer
Nursing, 14(5), 240-245.

Kralik, D., Koch, T., & Telford, K. (2001). Constructions of sexuality for midlife women
living with chronic illness. Journal of Advanced Nursing, 35(2), 180-187.

Kreitler, K., Peleg, D., & Ehrenfeld, M. (2007). Stress, self-efficacy, and quality of life in
cancer patients. Psycho-Oncology, 16, 329-341.

Kreulen, G. J., & Braden, C. J. (2004). Model test of the relationship between self-help-
promoting nursing interventions and self-care and health status outcomes.
Research in Nursing & Health, 27, 97-109.

Kristeller, J. L., Rhodes, M., Cripe, L. D., & Sheets, V. (2005). Oncologist assisted
spiritual intervention study (OASIS): Patient acceptability and initial evidence of
effects. International Journal of Psychiatry in Medicine, 35(4), 329-347.

Labun, E. (1988). Spiritual care: An element in nursing care planning. Journal of

Advanced Nursing, 13, 314-320.

La Monica, G., Audisio, R. A., Tamburini, M., Filiberti, A., & Ventafridda, V. (1985).
Incidence of sexual dysfunction in male patients treated surgically for rectal
malignancy. Diseases of the Colon & Rectum, 28(12), 937- 940.

Lai, C. (2005). Learned resourcefulness, cognitive processes, and adaptive functioning in

depressed adults. Unpublished doctoral dissertation, Case Western Reserve
University, Cleveland, Ohio.

Lamdan, R., Taylor, K., Seigel, J., O’Connor, B., & Moran, B. (1997). Coping strategies
in African women with breast cancer. Psychosomatics, 38, 179.

284
Lamb, M. A., & Woods, N. F. (1981). Sexuality and the cancer patient. Cancer Nurses,
April, 13-44.

Lamb, M. (1990). Psychosexual issues: The woman with gynecologic cancer. Seminars
in Oncology Nursing, 6, 237-243.

Landis, B. J. (1996). Uncertainty, spiritual well-being, and psychosocial adjustment to

chronic illness. Issues in Mental Health Nursing, 17, 217-231.

Landis, S. H., Murray, T., Bolden, S., & Wingo, P. A. (1998). Cancer statistics. Cancer
Journal Clinics, 48, 6-29.

Laubmeier, K. K., Zakowski, S. G., & Bair, J. P. (2004). The role of spirituality in the
psychological adjustment to cancer: A test of the Transactional Model of stress
and coping. International Journal of Behavioral Medicine, 11(1), 48-55.

Lazarus, R. S. (1966). Psychological stress and the coping process. New York: McGraw-
Hill.

Lazarus, R. (1981). The stress and coping paradigm. In C. Eisdorfer, D. Cohen, A.

Kleinman, & P. Maxim (Eds.), Models for clinical psychopathology (pp. 177-214).
New York: SP Medical and Scientific Books.

Lazarus, R. S. (1998). Fifty years of the research and theory of R. S. Lazarus an analysis
of historical and perennial issues. Lawrence Erlbaum Associates, NJ, USA.

Lazarus, R. (1999). Stress and emotion: A new synthesis. New York: Springer.

Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer
Publishing Company.

Leenhouts, G. H.M. W., Kylstra, W. A., Everaer, W., Hahn, D. E. E., Weijmar Schultz,
W. C. M., van de Wiel, H. B. M., et al. (2002). Sexual outcomes following
treatment for early-stage gynecological cancer: A prospective and cross-sectional
multi-center study. Journal of Psychosomatic Obstetrics and Gynecology, 23,
123-132.

LeFort, S. M., Gray-Donald, K., Rowat, K. M., & Jeans, M. E. (1998). Randomized
controlled trial of a community-based psychoeducation program for the self-
management of chronic pain. Pain, 74(2-3), 297-306.

LeFort, S. M. (2000). A test of Braden’s Self-Help Model in adults with chronic pain.
Journal of Nursing Scholarship, 32(2), 153-160.

Lemieux, L. (2004). Sexuality in palliative care: patient perspectives. Palliative Medicine,

18, 630-637.

285
Lev, E. L. (1992). Patients’ strategies for adapting to cancer treatment. Western Journal
of Nursing Research, 14(5), 595-617.

Levine, E., & Targ, E. (2002). Spiritual correlates of functional well-being in women
with breast cancer. Integrative Cancer Therapy, 1(2), 166-174.

Levin, B., Ades, T. B., Brooks, D., Crane, C. H., Hoff, P. M., Limburg, P. J., et al. (2006).
American Cancer Society's complete guide to colorectal cancer (Ed.). (pp. 93,
180-183). Atlanta, GA : American Cancer Society.

Ley, C. H., & Corless, I. B. (1988). Spirituality and hospice care. Death Studies, 12, 101-
110.

Lieh-Mak, F., & Ng, M. L. (1981). Ejaculatory incompetence in Chinese men. American
Journal of Psychiatry, 138 (5), 685-686.

Lin, H. R. (2003). Psycho-spiritual well-being in patients with advanced cancer: An

integrative review of the literature. Journal of Advanced Nursing, 44(1), 69-80.

Lindau, S. T., Schumm, L. P., Laumann, E. O., Levinson, W., O’Muircheartaigh, C. A.,
& Waite, L. J. (2007). A study of sexuality and health among older adults in the
United States. The New England Journal of Medicine, 357(8), 762-774.

Locke, H., & Wallace, K. (1959). Short marital adjustment and prediction tests: Their
reliability and validity. Marriage and Family Living, 2, 251-255.

Lutgendorf, S. K. (2005). Stress, spirituality, and cytokines in aging and cancer.

Gynecologic Oncology, 99(3), 139-140.

Maas, C. P., Moriya, Y., Steup, W. H., Kiebert, G. M., Kranenbarg, W. M., van de Velde,
C. J. (1998). Radical and nerve-preserving surgery for rectal cancer in the
Netherlands: A prospective study on morbidity and functional outcome. British
Journal of Surgery, 85, 92-97.

Maas, K., Moriya, Y., Kenter, G., Trimbos, B., & Velde, C. (1999). A plea for
preservation of the pelvic autonomic nerves. Lancet, 354(9180), 772-773.

Mace, D. R., Banneman, R. H., & Burton, J. (1974). The Teaching of Human Sexuality in
Shcools for Health Professionals. World Health Organization, Geneva.

MacFarlane, J. K., Ryall, R. D., Heald, R. J. (1993). Mesorectal excision for rectal cancer.
Lancet,341, 457-460.

MacKnee, C. M. (1997). Sexuality and spirituality: In search of common ground. Journal

of Psychology and Christianity, 16(3), 210-221.

286
Mannaerts, G. H. H., Rutten, H. J. T., Martijn H., M., Hanssens, P. E. J., & Wiggers, T.
(2002). Effects on functional outcome after IORT-containing multimodality
treatment for locally advanced primary and locally recurrent rectal cancer.
International Journal of Radiation Oncology, Biology, Physics, 54(4), 1082-1088.

Mansen, T. J. (1993). The spiritual dimension of individuals: Conceptual development.

Nursing Diagnosis, 4(4), 140-147.

Masui, H., Ike, H., Yamaguchi, S., Oki, S., & Shimada, H. (1996). Male sexual function
after autonomic nerve-preserving operation for rectal cancer. Diseases of The
Colon Rectum, 39, 1140-1145.

Margolin, A., Beitel, M., Schuman-Olivier, Z., & Avants, S. K. (2006). A controlled
study of a spirituality-focused intervention for increasing motivation for HIV
prevention among drug users. AIDS Education and Prevention, 18(4), 311-322.

Martenson, J. A., Willett, C. G., Sargent, D., Donohue J., Goldberg, R., Wasserman, T.,
et al. (1999). A phase III study of adjuvant radiation therapy (RT), 5-Fluorouracil
(5- FU), and levamisole (LEV) vs 5-FU and LEV in selected patients with
resected, high risk colon cancer: Initial results of Int 0130. American Society of
Clinical Oncology, 18, 235a.

Marcotte, D., Avants, S. K., & Margolin, A. (2003). Spiritual self-schema therapy, drug
abuse and HIV. Journal of Psychoactive Drug, 35(3), 389-391.

Matthews, D. A. (1997). Faith and medicine: Reconciling the twin traditions of healing.
Mind/Body Medicine, 2, 3-119.

Mattison, D. (2006). The forgotten spirit: Integration of spirituality in health care.

Nephrololgy News & Issues, 20(2), 30-32.

McCartney, C., & Larson, D. (1987). Quality of life in patients with gynecological cancer.
Cancer, 71, 1024-1030.

McCormick, D. P., Holder, B., Wetsel, M. A., & Cawthon, T. W. (2001). Spirituality and
HIV disease: An integrated perspective. Journal of the Association of Nurses in
AIDS Care, 12(3), 58-65.

McCorkle, R., & Benoliel, J. (1981). Symptom distress, current concerns and mood
disturbance after diagnosis of life-threatening illness. Social Science Medicine, 17,
431-438.

Mcllmurray, M.B., Francis, B., Harman, J. C., Morris, S. M., Soothill, K., & Thomas, C.
(2003). Psychosocial needs in cancer patients related to religious belief. Palliative
Medicine, 17, 49-54.

287
McSherry, W. (1996). Raising the spirits. Nursing Times, 92, 48-49.

McSherry, W. (1997). A descriptive survey of nurses’ perceptions of spirituality care.

Unpublished master’s thesis, University of Hull, Yorkshire, UK.

McSherry, M. (2000). Making sense of spirituality in nursing practice: An interactive

approach. London, England: Churchill Living Stone.

McSherry, W., Draper, P., & Kendrick, D. (2002). The construct validity of a rating scale
designed to assess spirituality and spiritual care. International Journal of Nursing
Studies, 39, 723-734.

Meichenbaum, D. (1977). Cognitive-behavior modification: An integrative approach.

New York: Plenum Press.

Ménard, A. D., & Offman, A. (2009). The interrelationships between sexual self-esteem
sexual assertiveness and sexual satisfaction. Canadian Journal of Human
Sexuality, 18(1/2), p35-45, 11p.

Mertler, C. A., & Vannatta, R. A. (2005). Advanced and multivariate statistical methods
(3rd eds.). California: Pyrczak Publishing.

Meston, C. M. (2003). Validation of the female sexual function index (FSFI) in women
with female orgasmic disorder and in women with hypoactive sexual desire
disorder. Journal of Sex & Marital Therapy, 29, 39-46.

Mickley, J. R., Soeken, K., & Belcher, A. (1992). Spiritual well-being, religiousness and
hope among women with breast cancer. IMAGE, 24(4), 267-272.

Mickley, J. R., Carson, V., & Soeken, K. L. (1995). Religion and adult mental health:
State of the science in nursing. Issues in Mental Health Nursing, 16, 345-360.

Mickley, J. R., & Soeken, K. (1993). Religiousness and hope in Hispanic- and Anglo-
American women with breast cancer. Oncology Nursing Forum, 20(8), 1171-1177.

Miller, J. F. (1985). Assessment of loneliness and spiritual well-being in chronically ill

and healthy adults. Journal of Professional Nursing 1(2), 79-85.

Miller, M. A. (1995). Culture, spirituality, and women’s health. Journal of Obstetric,

Gynecologic, and Neonatal Nursing, March/April, 257-263.

Miller, N. E. (1980). A perspective on the effects of stress and coping on disease and
health. In S. Levine & H. Ursin (Eds.), Coping and health (NATO Conferences
Series III: Human Factors). New York; Plenum.

Miller, J. F. (1983). Coping with Chronic Illness: Overcoming Powerlessness.

Philadelphia: F. A. Davis.

288
Miller, J. F. (2000). Coping with chronic illness: Overcoming powerlessness (3rd ed.).
Philadelphia: F. A. Davis Company.

Miller, M. A. (1995). Culture, spirituality, and women’s health. Journal of Obstetric,

Gynecologic, and Neonatal Nursing, March/April, 257-263.

Mishel, M. H., Hostetter, T., King, B., & Graham, V. (1984). Predictors of psychosocial
adjustment in patients newly diagnosed with gynecological cancer. Cancer
Nursing, 7, 291-300.

Molassiotis, A. (1997). A conceptual model of adaptation to illness and quality of life for
cancer patients treated with bone marrow transplants. Journal of Advanced
Nursing, 26, 572-579.

Molassiotis, A., Chan, C. W. H., Yam, B. M. C., & Chan, S. J. (2000). Quality of life in
Chineses women with gynecological cancers. Support Care Cancer, 8, 414-422.

Monga, U. (1995). Sexuality in cancer patients. Archives of Physical Medicine and

Rehabilitation, 9, 417-442.

Monga, U. (2002). Sexual functioning in cancer patients. Sexuality & Disability, 20(4),
277-295.

Moret, L. B., Glaser, B. A., Page, R. C., & Bargeron, E. F. (1998). Intimacy and sexual
satisfaction in unmarried couple relationships: A pilot study. The Family Journal:
Counseling and Therapy for Couples and Families, 6(1), 33-39.

Morino, M., Parini, U., Allaix, M. E., Monasterolo, G., Contul, R. B., & Garrone, C.
(2009). Male sexual and urinary function after laparoscopic total mesorectal
excision. Surgical Endoscopy, 23, 1233-1240.

Mo, H. J. (2002). The relationship between psychosocial adjustment and social support
for the colorectal cancer patients. Unpublished master’s theses, National Yan-
Ming University, Taiwan.

Mullens, A. B., McCaul, K. D., Erickson, S. C., & Sandgren, A. K. (2004). Coping after
cancer: Risk perceptions, worry, and health behaviors among colorectal cancer
survivors. Psycho-oncology, 13, 367-376.

Murray, J. (1991). Sexuality and spirituality: The intersection of medieval theology and
medicine. Fides et Historia, 23, 20-36.

Munro, B. H. (2001). Statistical methods for health care research (4th eds.). Philadelphia:
Lippincott.

Nadler, A. (1990). Help-seeking behavior as a coping resource. In M. Rosenbaum (Ed.),

289
 Learned resourcefulness: On coping skills, self-control, and adaptive behavior.
Springer series on behavior therapy and behavioral medicine: Vol. 24. (pp. 127-
162). New York: Springer Publishing Co. xxxv, pp. 248

Narayanasamy, B. (1991). Spiritual care: A resource guide. Guildford: Quay

Publishing.

Narayanasamy, A. (1999). ASSET: A model for actioning spirituality and spiritual care
education and training in nursing. Nurse Education Today, 19, 274-285.

National Cancer Institute. (2009). Surveillance Epidemiology and End Results. Retrieved
November, 10, 2009, from http://seer.cancer.gov/statfacts/html/colorect.html

Ng, M. S., Yau, J. K. Y., Chan, C. L. W., Chan, C. H. Y., & Ho, D. Y. F. (2005). The
measurement of body-mind-spirit well-being: Toward multidimensionality and
transcultural applicability. Social Work in Health Care, 41(1), 33-52.

Ngan, H. Y., Tang, G. W., & Lau, O. W. (1994). Psychosocial study on Hon Kong
Chinese with gynecological cancer. Journal of Psychosomatic Obstetrics and
Gynecology, 15, 111-117.

Nagia, S. A., & Hoda, Z, K. (1989). Effect of psyhcoeducational intervention on anxiety

among Egyptian bladder cancer patients. Cancer Nursing, 12(4), 236-242.

Nagai-Jacobson, M. G., & Burkhardt, M. A. (1989). Spirituality: Cornerstone of holistic

Nursing practice. Holistic Nursing Practice, 3, 18-26.

Neuman, B., Newman, D. M. L., & Holder, P. (2000). Leadership-scholarship integration:

Using the Neuman Systems Model for 21st-century professional nursing practice.
Nursing Science Quarterly, 13(1), 60-63.

Neuman, B., & Fawcett, J. (2002). The Neuman Systems Model (4th ed., pp. 4). New
Jersey: Prentice Hall.

Neuman, B., & Young, R. J. (1972). A model for teaching total person approach to
patient problems. Nursing Research, 21(3), 264-269.

Neuman, B. (1982). The Neuman Systems Model application to nursing education and
practice. Norwalk, Connecticut: Appleton-Century-Crofts.

Neuman, B. (1995). The Neuman Systems Model (3rd ed.). Norwalk, CT: Appleton &
Lange.

Neuman, B. (1989). The Neuman Systems Model (Ed.). Norwalk, CT: Appleton & Lange.

Newman, M. (1986). Health as expanding consciousness. St. Louis, MO: Mosby.

290
Newman, M. A. (1989). The spirit of nursing. Holistic Nursing Practice, 3(3), 1-6.

Newman, T. B., Browner, W. S., Cummings, S. R., & Hulley, S. B. (2001). Designing an
observational study: Cross-sectional and case-control studies. In S. B. Hulley, S.
R. Cummings, W. S. Browner, D. Grady, N. Hearst, & T. B. Newman (2nd ed.),
Designing clinical research (pp.107-111). Philadelphia: Lippincott Williams &
Wilkins.

Ness, R. M., Holmes, A., Klein, R., Greene, J., & Dittus, R. (1998). Outcome states of
colorectal cancer: Identification and description using patient focus groups. The
American Journal of Gastroenterology, 93(9), 1491-1497.

Nesbakken, A., Nygaard, K., Bull Njaa, T., Carlsen, E., Eri, L. M. (2000). Bladder and
Sexual dysfunction after mesorectal excision for rectal cancer. British Journal of
Surgery, 87, 206-210.

Norbeck, J. (1985). What constitutes a publishable report of instrument development?

Nursing Research, 34, 380-382.

Northouse, L. L. (1988). Social support and patients’ and husbands’ adjustment to breast
cancer. Nursing Research, 37, 91-95.

Northouse, LL., Mood, D., Templin, T., Mellon, S., & George, T. (2000). Couples’
patterns of adjustment to colon cancer. Social Science & Medicine, 50, 271-284.

Nosek, M. A. (1996). Wellness among women with physical disabilities. Journal of

Applied Rehabilitation Counseling, 25(1), 50-58.

Nunnally, J. C., & Bernstein, I. H. (1994). Psychometric theory. New York: McGraw-
Hill.

Nye, R. A. (1999). Sexuality (Ed.) Oxford University Press, Oxford.

O’Connor, A. P., Wicker, C. A., & Germino, B. B. (1990). Understanding the cancer
patient’s search for meaning. Cancer Nursing, 13, 167-175.

O’Connell, J. B., Maggard, M. A., & Ko, C. Y. (2004). Colon cancer survival rates with
the new American Joint Committee on Cancer sixth edition staging. Journal of
National Cancer Institute, 96, 1420-1425.

Ofman, U. S., & Auchincloss, S. S. (1992). Sexual dysfunction in cancer patients.

Current Opinion in Oncology, 4, 605 - 613.

Oldnall, A. (1996). A critical analysis of nursing: Meeting the spiritual needs of patients.
Journal of Advanced Nursing, 23, 138-144.

291
Olson, D. H., McCubbin, H. I., Barnes, H. L., Larsen, A. S., Muxen, M.J., & Wilson,
M. A. (1983). Families: What makes them work. Beverly Hills, CA: Sage
Publications.

Olson, D. H., Fournier, D. G., & Druckman, J. M. (1983). PREPARE/ENRICH

Counselor’s Manual. PREPARE/ENRICH, Inc., P.O. Box 190, Mineapolis, MN
55458.

Olson, D. H. (1996). Counselor’s manual for PREPARE/ENRICH: Version 2000.

Mineapolis, MN: Life Innovations, P.O. Box 190.

Oncologychannel (1998-2009). Rectal cancer: Overview, screening, diagnosis &

Staging. Healthcommunities.com, Inc. Retrieved from December 3, 2009,
from http://www.oncologychannel.com/rectalcancer/index.shtml

Padhazur, E. J. (1997). Multiple regression in behavioral research: Explanation and

prediction (3rd ed.). Fort Worth, Texas: Harcourt Brace Jovanovich College
Publishers.

Pedhazur, E. J., & Schmelkin, L. P. (1991). Measurement, Design, and Analysis: An

Integrated Approach. New Jersey: Lawrence Erlbaum Associates Publishers.

Paloutzian, R. F., & Park, C. L. (2005). The handbook of the psychology of religion and
spirituality. New York: Guilford Press.

Parkin, D. M. (2001). Gobal cancer statistics in the year 2000. Lancet Oncology, 2(9),
533-543.

Pedro, L. W. (1998). The relationship of self-esteem, learned resourcefulness and social

support to health-related quality of life in long-term cancer survivors.
Doctoral dissertation, University of San Diego, San Diego, California.

Pedro, L. W. (2001). Quality of life for long-term survivors of cancer: influencing

variables. Cancer Nursing, 24(1), 1-11.

Persson, E., Gustavsson, R., Hellstrom, A., Lappas, G., & Hulten, L. (2005). Ostomy
patients’ perceptions of quality of care. Journal of Advanced Nursing, 49(1), 51-8.

Penna, C., & Nordlinger, B. (1996). Locoregional chemotherapy for adjuvant treatment
of colorectal adenocarcinoma. European Journal of Cancer, 32(7), 1117-1122.

Peri, T. C. (1995). Promoting spirituality in persons with acquired immunodeficiency

syndrome: A nursing intervention. Holistic Nurse Practitioner, 10(1), 68-76.

Pilch, J. (1988). Wellness spirituality. Health Values, 12, 29-31.

292
Philips, R. E., Lakin, R., & Pargament, K. I. (2002). Development and implementation of
a spiritual issues psychoeducational group for those with serious mental illness.
Community Mental Health Journal, 38(6), 487-495.

Piles, C. L. (1990). Providing spiritual care. Nurse Educator, 15, 36-41.

Platell, C. F. E., Thompson, P. J., & Makin, G. B. (2004). Sexual health in women
following pelvic surgery for rectal cancer. British Journal of Surgery, 91, 465-468.

Pocard, M., Zinzindohoue, F., Haab, F., Caplin, S., Parc, R., & Tiret, E. (2002). A
prospective study of sexual and urinary function before and after total mesorectal
excision with autonomic nerve preservation for rectal cancer. Surgery, 131, 368-
372.

Polit, D. F., & Hungler, B. P. (1999). Research control in quantitative research. In D. F.

Polit, & B. P. Hungler (6th ed.), Nursing research: Principles and methods
(pp.219-237). Philadelphia: Lippincott.

Polit, D. F. & Hungler, B. P. (1999). Nursing Research: Principles and Methods (6th ed.).
Philadelphia: J. B. Lippincott.

Polit, D. F. & Sherman, R. E. (1990). Statistical power in nursing research. Nursing

Research, 39, 365-369.

Potter, M. L. (1997). Spirituality, learned resourcefulness, and health perception in the

older adult with rheumatoid arthritis. Thesis, Case Western Reserve University,
Cleveland, Ohio.

Potter, M. L., & Zauszniewski, J. A. (2000). Spirituality, resourcefulness, and arthritis

impact on health perception of elders with rheumatoid arthritis. Journal of
Holistic Nursing, 18(4), 311-331.

Prescott, P. A., & Soeken, K. L. (1989). The potential uses of pilot work. Nursing
Research, 38, 60-62.

Quah, H. M., Jayne, D. G., Eu, K. W., & Seow-Choen, F. (2002). Bladder and sexual
dysfunction following laparoscopically assisted and conventioinal open
mesorectal resection for cancer. British Journal of Surgery, 89, 1551-1556.

Reed, P. G. (1992). An emerging paradigm for the investigation of spirituality in nursing.

Research in Nursing & Health, 15, 349-357.

Rice, A. M. (2000). Sexuality in cancer and palliative care: Exploring the issues.
International Journal of Palliative Nursing, 6(9), 448-453.

Rapp, S. R., Shumaker, S., Schmidt, S., Naughton, M., & Anderson, R. (1998). Social

293
 resourcefulness: Its relationship to social support and well-being among
caregivers of dementia victims. Aging and Mental Health, 2(1), 40-48.

Reed, P.G. (1986). Religiousness among terminally ill and healthy adults. Research in
Nursing and Health, 9, 35-41.

Reed, P.G. (1987). Spirituality and well-being in terminally ill hospitalized adults.
Research in Nursing and Health, 10, 335-344.

Reed, P. G. (1992). An emerging paradigm for the investigation of spirituality in nursing.

Research in Nursing and Health, 15, 349-357.

Relf, M. V. (1997). Illuminating meaning and transforming issues of spirituality in HIV

disease and AIDS: An application of Parse’s theory of human becoming. Holistic
Nursing Practice, 12(1), 1-8.

Ries, L. A. G., Eisner, M. P., Kosary, C. L., et al. (2002). SEER Cancer Statistic Review,
1973-1999. Bethesda, MD: National Cancer Institute. Retrieved 2002 (Ed.), from
http://seer.cancer.gov/csr/1973-1999/

Ries, L. A. G., Eisner, M. P., Kosary, C. L., et al. (2003). SEER Cancer Statistic Review,
1975-2000. Bethesda, MD: National Cancer Institute (NCI), Retrieved 2003, from
http://seer.cancer.gov/csr/1975-2000/

Robbins, A. (1989). Genitourinary changes. In K. K. Esbergr, & S. T., Hughes, Jr. (Eds.),
Nursing care of the aged (pp.109-151). East Norwalk, CT: Appleton & Lange.

Rong, J. (2000). Perceived stress, learned resourcefulness, and adaptive functioning

among older adults. Unpublished doctoral disseration, Case Western Reserve
University, Cleveland, Ohio.

Rosen, R. C., Riley, A., Wagner, G., Osterloh, I. H., Kirkpatrick, J., & Mishra, A. (1997).
The international index of erectile function (IIEF): A multidimensional scale for
assessment of erectile dysfunction. Urology, 49(6), 822-830.

Rosen, R., Brown, C., Heiman, J., Leiblum, S., Meston, C., Shabsigh, R., et al. (2000).
The Female Sexual Function Index (FSFI): A multidimensional self-report
instrument for the assessment of female sexual function. Journal of Sex & Marital
Therapy, 26, 191-208.

Rosen, R. C., Riley, A., Wagner, G., Osterloh, I. H., Kirkpatrick, J., & Mishra, A. (1997).
The international index of erectile function (IIEF): A multidimensional scale for
assessment of erectile dysfunction. Urology, 49(6), 822-830.

Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton
University Press.

294
Ronsenberg, M. (1979). Conceiving the Self. New York: Basic Books.

Rosenbaum, M. (1980). A schedule for assessing self-control behaviors: Preliminary

findings. Behavior Therapy, 11(1), 109-121.

Rosenbaum, M. (1983). Learned resourcefulness as a behavioral repertoire for the self-

regulation of internal events: Issues and speculation. In M. Rosenbaum, C. M.
Franks, & Y. Jaffee (Eds.), Perspectives on behavior therapy in the eighties (pp.
54-73). New York: Springer Publishing.

Rosenbaum, M. (1990). The role of learned resourcefulness in the self-control of health

behavior. In M. Rosenbaum (Ed.), Learned resourcefulness: On coping skills,
self-control, and adaptive behavior (pp. 3-30). New York: Springer.

Rosenbaum, M., & Ben-Ari, K. (1985). Learned helplessness and learned resourcefulness:
effects of noncontingent success and failure amongst individuals differing in self-
control skills. Journal of Personality and Psychology, 48, 198-215.

Rosenbaum, M., & Jaffe, Y. (1983). Learned helplessness: The role of individual
differences in learned resourcefulness. British Journal of Social Psychology, 22,
215-225.

Rosenbaum, M., Franks, C. M., & Jaffee, Y. (1983). Perspectives on behavior therapy in
the eighties (Eds.). (pp. 54-73). New York: Springer Publishing.

Rosenbaum, M., & Rolnick, A. (1983). Self-control behaviors and coping with
seasickness. Cognitive Therapy and Research, 7, 93-98.

Rosenbaum, M., & Palmon, N. (1984). Helplessness and resourcefulness in coping with
epilepsy. Journal of Consulting and Clinical Psychology, 52(2), 244-253.

Rothenberger, D. A. (2006). Understanding your prognosis. In B. Levin, T. Ades, D.

Brooks, C. H. Crane, P. M. Hoff, P. J. Limburg, & D. A. Rothenberger (Ed.),
American Cancer Society’s: Complete guide to colorectal cancer (pp.180-181).
Atlanta: American Cancer Society.

Ruffing-Rahal, M. A. (1984). The spiritual dimension of well-being: Implications for the

elderly. Home Healthcare Nursing, 2(2), 12-13, 16.

Santangelo, M. L., Romano, G., S., & Sassaroli, C. (1987). Sexual function after
resection for rectal cancer. American Journal of Surgery, 154, 502-504.

Salter, M. (1992). What are the differences in body image between patients with a
conventional stoma followed by a continent pouch? Journal of Advanced Nursing,
17, 841-848.

295
Schag, C. A., Ganz, P. A., Wing, D. S., Sim, M. S., & Lee, J. J. (1994). Quality of life in
adult survivors of lung, colon and prostate cancer. Quality of Life Research, 3,
127-141.

Schmidt, C. E., Bestmann, B., Küchler, T., & Kremer, B. (2005a). Factors influencing
sexual function in patients with rectal cancer. International Journal of Impotence
Research, 17, 231-238.

Schmidt, C. E., Bestmann, B., Küchler, T., Longo, W. E., & Kremer, B. (2005b). Ten-
year historic cohort of quality of life and sexuality in patients with rectal cancer.
Disease of Colon Rectum, 48, 483-492.

Schnarch, D. M. (1991). Constructing the sexual crucible: An integration of sexual and

marital therapy. New York: Norton.

Schover, L. R. (1999). Counseling cancer patients about changes in sexual function.

Oncology, 13, 1585-1591.

Schover, L. R., Schain, W. S., & Montague, D. K. (1989). Sexual problems of patients
with cancer. In V. T. DeVita, S. Hellmain, & S. A. Rosenberg (3rd ed.), Cancer:
principles and practice of oncology (pp.2206-2225). Philadelphia: Lippincott.

Schover, L. R. (1987). Psychosexual issues in cancer survivors. In Proceedings of the

fifth international conference on human values and cancer. (pp. 42-44).
Atlanta, GA: American Cancer Society.

Schwarzer, R., & Leppin, A. (1992). Social support and mental health: A conceptual and
empirical overview. In L. Montada, S. H. Filipp, & H. J. Lerner (Ed.), Life crisis
and experience of loss in adulthood (pp. 435-58). Hellsdale, NF: Lawrence
Erlbaum.

Schulz, U., & Mohamed, N. E. (2004). Turning the tide: Benefit finding after cancer
surgery. Social Science & Medicine, 59, 653-662.

Selye, H. (1950). The physiology and pathology of exposure to stress (pp.12-13).

Montreal, Canada: ACTA.

Shahabi, L., Powell, L. H., Musick, M. A., Pargment, K. I., Thoresen, C. E., Williams, D.,
et al. (2002). Correlates of self-perceptions of spirituality in American adults.
Annals of Behavioral Medicine, 24, 59-68.

Shell, J. A. (2002). The longitudinal effects of cancer treatment on individuals with lung
cancer. Unpublished doctoral dissertation, Michigan State University.

296
Shell, J. A., & Smith, C. K. (1994). Sexuality and the older person with cancer. Oncology
Nurses Forum, 21 (3), 553-558.

Shelly, J. A., & Fish, S. (1988). Spiritual Care The Nurse’s Role (3rd ed.). Illinois: Inter
Varsity Press.

Smith, D. (1995). Power and spirituality in polio survivors: A study based on Rogers’
Science. Nursing Science Quarterly, 8, 133-139.

Smith, D. (1994). Toward developing a theory of spirituality. Visions, 2, 35- 43.

Smith, J. Z. (1995). The Harper Collins Dictionary of Religion. San Francisco: Harper
San Francisco.

Sodestrom, K., & Martinson, I. M. (1987). Patients’ spiritual coping strategies: A study
of nurse and patient perspectives. Oncology Nursing Forum, 14, 41-46.

Soeken, K. L., & Carson, V. J. (1987). Responding to the spiritual needs of the
chronically ill. Nursing Clinics of North America, 22(3), 603-611.

Sowell, R. L., Moneyham, L., Hennessy, M., Guillory, J., Demi, A., & Seals, B. (2000).
Spiritual activities as a resistance resource for women with Human
Immunodeficiency Virus. Nursing Research, 49(2), 73-82.

Spagnola, S., Zabora, J., BrintzenhofeSzoc, K., Hooker, C., Cohen, G., & Baker, F.
(2003). The satisfaction with life domains scale for breast cancer (SLDS-BC). The
Breast Journal, 9(6), 463-471.

Sprangers, M. A. G., Taal, B. G., Aaronson, N. K., & te Velde, A. (1995). Quality of life
in colorectal cancer: Stoma vs. nonstoma patients. Diseases of the Colon &
Rectum, 38, 361- 369.

Stamogiannou, I., Grunfeld, E. A., Denison, K., & Muir, G. (2005). Beliefs about illness
and quality of life among men with erectile dysfunction. International Journal of
Impotence Research, 17, 142-147.

Steinke, E. E. (1994). Knowledge and attitudes of older adults about sexuality in ageing:
A comparison of two studies. Journal of Advanced Nursing, 19, 477-485.

Steinke, E. E., & Patterson-Midgley, P. E. (1998). Perspectives of nurses and patients on

the need for sexual counseling of MI patients. Rehabilitation Nursing, 23(2), 65-
70.

Stevens, J. (1992). Applied multivariate statistics for the social sciences (2nd ed.).
Hillsdale, NJ: Lawrence Erlbaum Associates.

297
Stoll, R. I. (1989). The essence of spirituality. In V. B. Carson (Eds.), Spiritual
dimensions of nursing practice (pp. 4-23). Philadelphia: W.B. Saunders.

Sutherland, A. M., Orbach, C. E., Dyk, R. B., & Bard, M. (1952). The psychological
impact of cancer surgery: I. adaptation to the dry colostomy: preliminary report
and summary of findings. Cancer, 5, 857-872.

Sarason, G., Johnson, J., & Siegel, J. (1978). Assessing the impact of life changes:
Development of the life experiences survey. Journal of consulting and clinical
psychology, 46, 932-946.

Tabachnick, B. G., & Fidell, L. S. (2001). Using multivariate statistics (4th ed.). Boston :
Allyn and Bacon.

Tang, C. S. K., Siu, B. N., Lai, F. D. M., & Chung, T. K. H. (1996). Heterosexual
Chinese women’s sexual adjustment after gynecologic cancer. Journal of Sexual
Research, 33, 189-195.

Taiwan Reports (2006). Incidence of colon and rectal caners in Taiwan. Department of
Heath, Executive Yuan, R. O. C. (Taiwan). Retrieved October 30, 2009 from
http://www.doh.gov.tw/CHT2006/DM/DM2_2.aspx?now_fod_list_no=10919&cl
ass_no=440&level_no=3

Takahashi, M., & Kai, I. (2005). Sexuality after breast cancer treatment: Changes and
coping strategies among Japanese survivors. Social Science & Medicine, 61,
1278-1290.

Temple,L.D.F., Wong, W.D., &Minsky, B. (2003). The impact of radiation on functional

outcomes in patients with rectal cancer and sphincter preservation. Seminars in
Radiation Oncology, 13(4), 469-477.

Tepper, J. E., O’Connell, M. J., Petroni, G. R., Hollis, D., Cooke, E., Benson, A. B. et al.
(1997). Adjuvant postoperative fluorouracil modulated chemotherapy combined
with pelvic radiation therapy for rectal cancer: Initial results of intergroup 0114.
Journal of Clinic Oncology, 15(5), 2030-2039.

Thaler-DeMers, D. (2002). Sexuality, fertility issues, and cancer. Illness Crisis & Loss,
10(1), 27-41.

Thomas, C., Turner, R., & Madden, F. (1988). Coping and the outcome of stoma surgery.
Journal of Psychosomatic Research, 32, 457-467.

Throne, B. (2001). The prophetic nature of pastoral counselling. British Journal of

Guidance & Counselling, 29(4), 435-445.

298
Tuck, I., McCain, N. L., & Elswick Jr, R. K. (2001). Spirituality and psychosocial factors
in persons living with HIV. Journal of Advanced Nursing, 33(6), 776-783.

Tuck, I. (2004) Development of a spirituality intervention to promote healing. Journal

of Theory Construction and Testing, 8 (2), 67-71.

Ullery, E. K. (2004). Consideration of a spiritual role in sex and sex therapy. Sex Therapy,
12(1), 78-81.

Üstündag, H., Demir, N., Zengin, N., & Gül, A. (2007). Body image and self-esteem in
patients with stoma. Turkiye Klinikleri Journal of Medical Sciences, 27(4), 522-7.

Van der Riet, P. (1998). The sexual embodiment of the cancer patient. Nursing Inquiry, 5,
248-257.

Varricchio, C. G. (2004). Measurement issues concerning linguistic translations. In M.

Frank-Stromborg & S. J. Olsen (Eds.), Instruments for clinical health-care
research (3rd ed., pp. 56-64). Boston: Jones and Bartlett Publishers.

Victor, M., Ilana, D., & Daniela, M. (2009). Disabled people, women, self image,
sexuality, Happiness. Sexuality and Disability, 27 (2), 83-95.

Vinokur, A., & Selzer, M. (1975). Desirable versus undesirable life events: Their
relationships to stress and mental distress. Journal of Personality and Social
psychology, 32, 329-337.

Vos, P. J., Garssen, B., Visser, A. P., Duivenvoorden, H. J., & de Haes, H. C. J. M.
(2004). Early stage breast cancer: Explaining level of psychosocial adjustment
using structural equation modeling. Journal of Behavioral Medicine, 27(6), 557-
580.

Walker, M. T. (1992). Spirituality: Implications for nursing care. American Association

of Rehabilitation Nurses, 48(6), 17-18.

Walsh, F. (1999). Spiritual resources in family therapy. New York: Guilford Press.

Watson, J. (1988). Nursing: Human science and human care: A theory of nursing. New
York: National League for Nursing.

Watson, J. (1999). Nursing Human Science and Human Care: A theory of nursing.
Sudbury, MA: Jones and Bartlett.

Waterhouse, J., & Metcalfe, M. (1991). Attitudes towards nurses discussing sexual
concerns with patients. Journal of Advanced Nursing, 16, 1048-54.

299
Waxman, B. (1996). Commentary on sexual and reproductive health. Sex Disability,
14(3), 237-244.

Weber, B. A. (2001). The effect of dyadic intervention on self-efficacy, social support,

and depression for men with prostate cancer. Unpublished doctoral disseration,
Case Western Reserve University, Cleveland, Ohio.

Weeks, J. (1986). Sexuality. Routledge, London.

Weinbergr, S. L. (1991). Analysis of a clinical situation using the Neuman Systems

Model. Rehabilitation Nursing, 16, 278, 280-81.

Weir, H. K., Thun, M. J., Hankey, B. F., Ries, L. A. G., Howe, H. L., Wingo, P. A., et al.
(2003). Annual report to the nation on the status of cancer, 1975-2000, featuring
the uses of surveillance data for cancer prevention and control. Journal of
National Cancer Institution, 95(17), 1276-99.

Wellisch, D. K., Jamison, K. R., & Pasnau, R. O. (1978). Psychosocial aspects of

mastectomy: The man’s perspective. American Journal of Psychiatry, 135, 543-
546.

Werner, L., & Campbell, D. T. (1970). Translating, working through interpreters and the
problem of decentering. In R. Naroll & R. Cohen (Eds.), American Handbook of
Methods in Cultural Anthropology (pp. 398-420). Garden City, NY: Natural
History Press.

White, R. W. (1985). Strategies of adaptation: An attempt at systematic description. In A.

Monat & R. Lazarus (2nd ed.), Stress and coping, an anthology (pp.121-143). New
York: Colombia University Press.

Wiegel, M., Meston, C., & Rosen, R. (2005). The Female Sexual Function Index (FSFI):
Cross-validation and development of clinical cutoff scores. Journal of Sex &
Marital Therapy, 31, 1-20.

Willgerodt, M. A., Kataoka-Yahiro, M., Kim, E., & Ceria, C. (2005). Issues of instrument
translation in research on Asian immigrant populations. Journal of Professional
Nursing, 21(4), 231-239.

Williams, N.S., & Johnston, D. (1984). Survival and recurrence after sphincter saving
resection and abdominalperineal resection for carcinoma of the middle third of the
rectum. British Journal of Surgery, 71, 278-282.

Woods, N. F. (1987). Toward a holistic perspective of human sexuality: Alterations in

sexual health and nursing diagnoses. Holistic Nursing Practice, 1(4), 1-11.

300
Woods, N. F., & Catanzaro, M. (1988). Nursing Research: Theory and practice.
Washington, DC: The C. V. Mosby.

World Health Organization (WHO). (1975). Education and Treatment in human sexuality:
The training of health professionals, Report of a WHO meeting (Technical report
series No. 572). Geneva: Author.

World Health Organization. (1995). Concepts for sexual health. Retrieved October 4,
1997, from http://www.WHO.int/reproductive-health/publications/interagency-
manual-on-RH-in-regugee-situations/ch1.phf.

Yarandi, H. N. (1994). Using the SAS system to estimate sample size and power for
comparing two binominal proportions. Nursing Research, 43, 124-125.

Yu, D. S., Lee, D. T. F., & Woo, J. (2004). Issues and challenges of instrument
translation. Western Journal of Nursing Research, 26(3), 307-320.

Yura, H., & Walsh, M. B. (1983). Human Needs 3 and the Nursing Process. Norwalk,
Connecticut: Appleton-Century-Crofts.

Yurek, D. L. (1997). Surgical treatment of breast cancer: Sexual self-schema, stress

reactions, and sexuality outcomes. Unpublished doctoral dissertation, The Ohio
State University, Columbus, Ohio.

Zauszniewski, J. A. (1995). Health-seeking resources in depressed outpatients. Archives

of Psychiatric Nursing, 9(4), 179-187.

Zauszniewski, J. A. (1996). Self-help and help-seeking behavior patterns in healthy

elders. Journal of Holistic Nursing, 14(3), 223-236.

Zauszniewski, J. A. (1997). Evaluation of a measure of learned resourcefulness in older

adults. Journal of Nursing Measurement, 5(1), 71-86.

Zauszniewski, J. A. (1998). Development of the Help-Seeking Resources Scale as a

measure of social resourcefulness for older adults. Unpublished manuscript.

Zauszniewski, J. A. (2001). Learned resourcefulness. In J. J. Fitzpatrick (Ed.),

Encyclopedia of Psychiatric Nursing Research. New York: Springer Publishing.

Zauszniewski, J. A., & Chung, C. (2001). Resourcefulness and health practices of

diabetic women. Research in Nursing and Health, 24(2), 113-121.

Zauszniewski, J. A., Chung, C., & Krafcik, K. (2001). Social cognitive factors predicting
the health of elders. Western Journal of Nursing Research, 23(5), 490-503.

Zauszniewski, J. A. (2006). Resourcefulness: A new mid-range theory. In J. J. Fitzpatrick

301
 & M. Wallace (Eds.), Encyclopedia of Nursing Research (pp. 256-258). New
York: Springer Publishing.

Zauszniewski, J. A., Lai, C. Y., & Tithiphontumrong, S. (2006). Development and testing
of the resourcefulness scale for older adults. Journal of Nursing Measurement,
14(1), 57-68.

Zauszniewski, J. A., Picot, S. F., Roberts, B. L., Debanne, S., & Wykle, M. L. (2005).
Predictors of resourcefulness in African American women. Journal of Aging and
Health, 17(5), 609-633.

Zauszniewski, J. A., Bekhet, A. K., Lai, C., McDonald, P. E., & Musil, C. M. (2007).
Effects of teaching resourcefulness and acceptance on affect, behavior, and
cognition of chronically ill elders. Issues in Mental Health Nursing, 28, 575-592.

Zinnbauer, B. J., Pargament, K. I., Cole, B., Rye, M. S., Butter, E. M., Belavich, T. G.,
et al. (1997). Religion and spirituality: Unfuzzying the fuzzy. Journal for the
Scientific Study of Religion, 36, 549-564.

302