Correlates of Mental Health in Survivors of Colorectal Cancer : The Influence of Individual , Family , and Community Level Factors

An often neglected factor in the examination of the mental quality of life of survivors of colorectal cancer is the role of family and community level resources and support. The aim of this study was to develop a deeper understanding of the influence of family and community level resources over and above previously examined mental health variables. A survey-based pilot study was conducted with 101 colorectal cancer survivors. Four multiple linear regression models were developed to examine the associations between demographic, healthrelated, individual psychosocial, family and community level factors, and specific dimensions of mental quality of life (measured using the mental health subscales of the SF-12). In addition to examining all of the correlates of mental quality of life, the unique role of family and community level factors over and above previously examined factors was examined. Analyses found that family and community level factors, as a whole, explained a significant portion of the variance in role emotional health, mental health, and social functioning over and above demographic, health-related, and individual psychosocial factors. Family cohesion was a significant, unique predictor of role limitations due to mental health, and family and community social support was a significant, unique predictor of role limitations due to mental health and overall mental health. These results suggest the potential importance of considering family and community level resources when conducting research and designing interventions to improve mental quality of life in colorectal cancer survivors. DOI : 10.14302/issn.2474-9273.jbtm-16-1105 Corresponding Author: Elizabeth J. Siembida, Ph.D, Department of Human Development and Family Studies, University of Connecticut, 348 Mansfield Road, U-2058, Storrs, CT 06269, Email: elizabeth.siembida@gmail.com


Introduction
Colorectal cancer survivors have received little attention in the post-treatment mental quality of life research [1] . Colorectal cancer is the third most common cancer in the United States [2] . With an increased utilization of screening tests and treatments, the 5-year survival rate for early, localized stage colorectal cancer is 90% [2] . Due to the high occurrence and survival rate of this type of cancer, and lack of research regarding this population, the aim of this study was to better understand the factors that influence the mental quality of life in survivors of colorectal cancer in order to identify potential mechanisms through which survivors' mental well-being may be increased.
The few quality of life studies that have been conducted with post-treatment colorectal cancer survivors found that despite a trend for improvement in quality of life over time [3] [4] [5] a significant segment of the population experiences considerable challenges in a variety of domains, such as psychosocial and relational health [5] [6] . However, little is known about how commonly examined psychosocial correlates of mental quality of life in other cancer populations, such as perceived stress [7] perceived control [8] , fear of recurrence [9] [10] and constructed meaning [11] , are associated with mental quality of life in colorectal cancer survivors.
Additionally, research has often overlooked family and community level resources, such as family hardiness, family cohesion, and social support, and their role in adjustment to illness. Families characterized by high levels of family resources are often able to endure and adjust better under difficult circumstances, develop a strong emotional bond among family members, and support family members during difficult times [12] [13] [14] .
Research with various cancer populations have found increased family resources to be associated with positive outcomes such as improved illness adjustment, higher quality of life, lower emotional distress, and improved post-illness adjustment and coping [15] [16] [17] [18] .
Similarly, cancer survivors who perceive higher levels of social support reported a higher quality of life [19] [20] [21] .

Participants and Procedures
Mail-based questionnaires were sent to 400 randomly selected colorectal cancer survivors from the Five individuals were eliminated because they were not in remission, 2 individuals were eliminated because they were younger than 50 years of age, and 1 person was eliminated for being only one year from diagnosis.
Therefore, the final analytic sample for this study included 101 participant questionnaires.

Mental quality of life:
Mental quality of life was measured using the validated SF-12 [31] . As the dependent variable of the study, we utilized all four subscales of the SF-12 in our analyses.

Role emotional:
The role emotional subscale measured how daily roles were impacted by the person's emotional well-

Demographic and health-related variables:
Demographic and health-related variables, including gender, marital status, age, race, level of education, employment status, living arrangement, years since diagnosis, type of treatment, and recurrence and remission status were measured via self-report. The additional health-related variables of comorbidity and symptoms were collected using specific measures.

Comorbidity:
Comorbidity was measured via a 13 item checklist [22] including conditions such as: heart failure, heart attack, high blood pressure, chronic lung disease, liver disease, or diabetes. Participants were asked to indicate whether they had the comorbid condition by responding yes or no. Scores ranged from 0 to 13 with higher scores indicating more comorbid conditions.

Symptoms:
The 22-item Rotterdam Symptom Checklist Physical Distress subscale [23] was used to measure

Fear of recurrence:
The five-item Fear of Recurrence Scale (FRS) [24] was used and scored on a five-point Likert scale with response options ranging from "strongly disagree" to "strongly agree". Questions included "I am certain that I have been cured of cancer," and "I will probably relapse within the next five years". Possible scores ranged from 5 to 25 with higher scores indicating greater fear of recurrence.

Perceived stress:
Perceived stress was measured with the 10-item Perceived Stress Scale [25] . The scale included questions such as: "How often have you been upset because of something that happened unexpectedly" and "How often have you felt that you were unable to control the important things in your life." Participants responded to each question using a five-point Likert scale ranging from "never" to "very often." Possible scores ranged from 0 to 40 with higher scores indicating higher levels of perceived stress.

Constructed meaning:
The Constructed Meaning Scale [26] included eight items that measured the impact the illness had on the individual's sense of identity, interpersonal relationships, and expectations for the future.
Participants responded to items such as: "I feel my illness is something I will never recover from," "I feel my illness has changed my life permanently so it will never be as good again," and "I feel that my relationships with other people have not been negatively affected by my illness." Possible scores ranged from 8 to 32 with higher scores indicating a higher illness impact.

Perceived control:
The 4-item Perceived Control Scale [27] was used to measure participants' perception of the control they had over their illness. Questions included items such as "Your emotional responses to your cancer" and "The physical side of your cancer," and were answered on a five-point Likert scale ranging from "no control at all" to "complete control." Possible scores range from 4 to 20 with higher scores indicating more control.

Family hardiness:
The Family Hardiness Index [28] was used to measure the internal strength of the family in regard to commitment, challenge and control of family experiences. The index asks participants to assess the statements to the degree of "False," "Mostly False," "Mostly True," and "True." Questions included items such as "We work together to solve problems," "Trouble results from

Family relations and cohesion:
The Family Relations and Cohesion Scale [29] was used to measure the emotional bond between family members. The measure asks participants questions such as, "I listen to what other family members have to say, even when I disagree," "Family members ask each other for help," "Family members feel very close to each other," and "We can easily think of things to do together as a family" utilizing a four-point Likert scale ranging from "not true" to "always true or most always." Possible scores range from 6 to 24 with higher scores indicating closer, more cohesive relations among family members.

Social support:
Using the 17-item Social Support Index [30] , social support was evaluated by the extent to which an individual is integrated into the community and views the community as a support source. Participants responded to items such as, "If I had an emergency, even people I do not know in this community would be willing to help," and "People can depend on each other in the community," on a five-point Likert scale ranging from "strongly disagree" to "strongly agree." Scores range from 17 to 68 with higher scores indicating greater degrees of social support.

Data Analysis:
One-way ANOVAs (for categorical IVs) and   Table 2.

Models of Mental Quality of Life
Multiple linear regression models were developed for each of the four mental health quality of life subscales. Below we describe the results for each model separately.

Role emotional:
The overall model explained 45.2% of the variance in the role emotional subscale and can be found in Table 3

Mental health:
The overall regression model explained 46.1% of the variance in mental health (

Social functioning:
The overall model explained 30.2% of the variance in social functioning and can be found in Table   4.

Vitality:
The overall model accounted for 45.5% of the total variance in vitality ( Table 4) [6] , and identify the So the question remains who is responsible for recognizing and referring patients who may be at risk for decrements in mental quality of life.