Well-being general health and coping ability: 1 -year follow-up of patients treated for colorectal and gastric cancer CHRISTINA FORSBERG, RN, BSc, PhIl',2,3 & BJORN CEDERMARK, MD, PhD3 ' The Centre of Caring Sciences North,z Department of Internal Medicine d 3Department of Surgery, Karolinska Institute and Karolinska Hospital, Stockholm, Sweden

FORSBERG C. & CEDERMARK B. (1996) European lournal of Cancer Care 5,209-216 Well-being, general health and coping ability: 1-year follow-up of patients treated for colorectal and gastric cancer

The aims of this paper were to descrnbe the patients' perceived well-being, general health, symptoms and coping ability 1 year after surgery and to compare the results with the same as recorded before and 6 weeks after surgery and with those of healthy indwiduals. The investigation was carried out in a surgical unit at the Karolinska Hospital in Stockholm, Sweden during 1992 and 1993. Sixty-nine patients (34 men, 35 women) with diagnoses of colorectal or gastric cancer participated in the study. Two randomly selected samples of healthy individuals were available for comparisons and were used as reference subjects. Main measurements were the Health Index (HI) and the General Health Rating Index (GHRI). The HI measured the change in well-being before and after surgery. There were few and small differences in the patients' sense of well-being 1 year after surgery compared with before. There was no significant difference between the total HI scores before and 1 year after surgery but the HI subscale scores for energy, bowel function and mobility had improved. The patients living alone rated their well-being as inferior in comparison with those who lived with relatives. Furthermore, the cancer patients perceived their well-being as inferior to that of healthy individuals. One year after surgery the patients had not returned to a state of normal health. Social and marital status apparently affected the patients' sense of well-being.

Keywords: well-being, general health, coping, sense of coherence.

INTRODUCTION occurs more frequently in men and is also a disease of the elderly. The prognoses for colorectal and gastric

Colorectal cancer is a common tumour in hoth sexes and cancer are both strongly correlated to the stage of the is closely associated with advanced age: the incidence disease at the time of diagnosis (Cocluccio, 1991). In increases after the age of 40 years and the majority of Sweden, the crude 5-year survival rate for colorectal cases, occur after the age of 60 years. The age-standar- cancer is approximately 40% and for gastric adenocarci- dized index has increased by about 0.6% annually during noma about 15% (Stenbeck & Rosen, 1995). Most the last 20 years [Redford & Reilly, 19911. Gastric cancer patients with colorectal and gastric cancer are treated

at surgical departments as the only curative treatment for

times in combination with adjuvant radiotherapy and/ or chemotherapy.

'Correspondence to: Christina Forsberg, C W Nord, Horgmastarvillan 1 these diseases is radlcal resection Of the turnour, some- trp, Karolinska Hospital, S-171 76 Stockholm, Sweden.

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F 0 R S BE R G ET AL. Well-being, general health and coping

Traditionally, the outcomes of treatment have often been evaluated in terms of morbidity and mortality rates. However, there is also an increasing interest in evaluating the patients’ ability to perform their daily activities, their sense of well-being, and their own personal evaluation of their general health. Health-status measurements could be of great value when it comes to clinical decision-malung in practice. Garratt et al. discuss the research focus to date with health questionnaires (Garratt et al., 1994). They conclude that most of the focus has been on establishing the reliability and validity of instruments, rather than their responsiveness or sensitivity to changes in health over time.

Patients undergoing treatment for gastrointestinal can- cer often suffer from bowel problems, nutritional pro- blems, fatigue, pain and psychological distress which may affect their health-related quality of Me in several different ways (Bozzetti, 1992; Broughton et af., 1995; Portenoy et al., 1994; Sprangers et al., 1993, 1995). Apart from identrfying physical and psychological problems, it is important to look into the patients’ own resources. htonovsky suggests that a person’s coping ability (sense of coherence) is a crucial determent of one’s perception of well-being (htonovsky, 1979, 1987). At present, there seems to be a lack of knowledge of the relation between coping ability and well-being in patients with intestinal cancer.

The aims of the study

‘The aims of this study were:

To describe the patients‘ perceived well-being,

gastro-

general health, symptoms and coping ability 1 year after surgery and compare the results with those before surgery. To correlate the scores of the sense of coherence, the sense of well-being and the general health, in order to investigate a possible relationship between these con- cepts as measured by their spechc instruments. To describe and analyse the cancer patients‘ well-being and general health 1 year after surgery and to compare the results with those of healthy indmiduals.

The following research questions were being posed:

1. In what way does the cancer patients’ sense of well- being dlffer before and 1 year after surgery?

2. Do age, gender, tumour sites and marital status influence the patients’ sense of well-being and general health?

3. Is the sense of coherence related to the perceived well- being and general health?

4. Is the patients‘ sense of coherence stable over time? 5. In what way does the cancer patients’ sense of well-

being and general health M e r 1 year after surgery, compared with those of healthy individuals?

METHODS

Samples

The investigation was carried out in a surgical unit at the Karolinska Hospital in Stockholm, Sweden during 1992 and 1993. The criteria for inclusion were (1) verified or suspected colorectal or gastric cancer for whch major surgery was planned, (2) residence in the Stockholm area, with ability to speak and read Swedish, and (3) physical and mental ability to answer questionnaires.

Initially, 96 consecutive patients with hagnoses of colorectal or gastric cancer participated in the study and they were evaluated before the operation. Of these, 69 patients (34 men, 35 women) were available for the study 1 year after the operation. The reasons for non-participation after 1 year were postoperative deaths (n=14), refusal (n=8) and medical reasons (n=5).

Data from two randomly selected samples of healthy individuals from the Stockholmer County were available for comparisons and were used as reference values (Cronqvist et al., unpublished data, 1995; Forsberg & Bjorvell, 1993). As the sample size was small only two age- groups were formed, one younger than 67 and the other aged 67 years or older. The median value was chosen as a cut-off point.

Health definitions

Health is a basic concept in nursing. There are many definitions in the literature. Antonovsky has described a salutogenic model of health whch is contrasted with the pathogenic and focuses on the origin of health (Antonovs- ky, 1979,1987). He defines health as a continuum between ease and disease, rather than a health-disease dichotomy. He says that, as long as there is a breath of life in us, we are all to some degree healthy. Furthermore, Antonovsky suggests that one of the most crucial determinants in an individual’s perception of health is the degree of the sense of coherence. The sense of Coherence is defined as a prerequisite for the coping capacity of an indwidual and consists of three components: comprehensibility, manage- ability and meaningfulness. King views health as a dynamic state with continuous adaptation to stress in the internal and external environments through the optimum use of one’s resources to acheve the maximum

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potential for daily living (King, 1990). Benner and Wrubel propose that health is being, as well as becoming, and that it is based on an integrated view of mind and body. They use the terms ‘well-being’ and ‘illness’. Well-being reflects the lived experience of health, and illness the lived experience of disease (Benner & Wrubel, 198’9).

Ware says that an important feature of health is its dimen- sionality. Health has distinct components: physical health, mental health, everyday functioning in social and role ac- tivities, and general perceptions of well-being (Ware, 1987).

Data-collection questionnaires

Health Index [HI) The HI has been used on several groups of patients as well as on healthy reference groups (Forsberg & Bjorvell, 1993; Klang et al., 1996; Langius e t al., 1993; Nordstrom et al., 1992). The questionnaire consists of 10 iterrts concerning the sense of well-being and includes nine items with four response categories: very poor, rather poor, rather good and very good. The nine items concern energy, temper, fatigue, loneliness, sleep, vertigo bowel function, pain and mobi- lity. An extra item concerning general health is used as a single item. The patients were asked to rate their subjective statements on each item. The irtdex refers to ‘the last week’.

Items 1-9 are summarized to form an index with scores ranging from 9 to 36. The higher the score, the better the perceived general health. The questionnaire is considered to have robust psychometric properties (Forsberg & Bjorvell, 1993; Klang et al., 1996; Langius et al., 1993; Nordstrom e t al., 1992).

Reliability The HI has earlier been tested on hospital patients in Sweden by Nordstrom et al. and Langius et a l . (Forsberg & Bjoorvell, 1993; Klang et a]., 1996; Langius et a]., 1993; Nordstrom et al., 1992). Cronbach’s u in these studies was 0.79 and 0.77, respectively. The HI had a Cronbach‘s 0: of 0.74 when used on a healthy sample of the Swedish population (Forsberg & Bjorvell, 1993; Klang e t al., 1996; Langius et al., 1993; Nordstrom et al., 1992).

Validi ty Langius et al. (1993) found significant and negative correlations between the HI score and the .number of re- ported symptoms. The fewer the symptoms reported, the better was the perceived health. Forsberg and Bjorvell (Forsberg & Bjorvell, 1993) found that the HI was corre- lated positively and significantly with the well-established General Health Rating Scale developed by Ware (1 976).

General Health Rating Index (GHRI) The first version of the GHRI was designed by Ware and Kamos in 1976 (then called the Health Perception Questionnaire (HPQ-36)) in order to measure multiple dimensions of self-rated health in the general population (Ware, 1976). The GHRI instrument used in this study consists of 26 items from the HPQ Form 11, of which 22 items are selected to create a general health index score and the subscales current health (9 items), prior health (3 items), health outlook (4 items), health worry (4 items), resistance to illness (4 items) and sickness orientation (2 items). The items are formed as statements regarding health. As an example, one item from each subscale in the GHRI is given:

Current health: I am not as healthy now as I used to be. Prior health: I have never been seriously ill. Health outlook: I will probably be sick a lot in the future. Resistance to illness: I get sick more easily than others. Health worry: I worry about health more than others. Sickness orientation: getting sick is part of my life.

In this study a form of four response categories (scored 1- 41, excludmg the ‘don‘t know’ alternative, were used. Thus, the minimum/maximum score for the GHRI (22 items) ranged from 22 to 88. The higher the score, the better the perceived general health.

Reliability The results of the Health Insurance Study in the USA indicate the good reliability and stability of the GHRI (Davies & Ware, 1981). The stability coefficient of the subscale current health proved to be the least stable over time, as might be expected if the measurements reflect perceptions of health status at time of the questionnaire. The GHRI has also been tested in Sweden, again also showing good psychometric properties (Forsberg & Bjor- vell, 1993; Gardulf e t al., 1993; Sullivan et al., 1993).

Validi ty The validity of the subscales and the GHRI has been investigated and shown to be significantly related to other measurements of health: number of days on sick-leave; number of days admitted to hospital; number of visits to doctors; self-reported, acute, physical and psychosom- atic symptoms; and self-reported psychological dis- tress and well-being (Davies & Ware, 1981; Forsberg & Bjorvell, 1993).

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F 0 R S B ER G ET AL. Well-being, general health and coping

Symptom checklist A symptom checklist earlier developed and used by Bjorvell et al. and Forsberg et al. was moddied for this study (Bjorvell & Hylander, 1989; Forsberg et al., 1996). The checklist consists of 25 items concerning symptoms frequently mentioned by cancer patients. These items have four response categories-always, often, seldom and never.

Validity The validity of the symptom checklist has been investi- gated and shown to be significantly related to measure- ments of well-being. Thus, the fewer the symptoms, the better the well-being of an inlvidual (Forsberg et al., 1996).

Sense of Coherence Scale (SOC scale) In this study, the %item version of the Sense of Coherence Scale (SOC) developed by Antonovsky to measure the concept of sense of coherence was used (Antonovsky, 1979, 1987; Langius et al., 1992). He considered the items to measure comprehensibility (5 items), manageability (4 items) and meaningfulness (4 items). The SOC construct does not refer to specific types of coping strategies; it is intended to be a prerequisite for the perception of a stressful situation. The SOC items have a semantically differential format with two anchor- ing responses. The respondents are requested to choose a number from 1 to 7. The added scoring range is 13 to 91; the higher the score the stronger the sense of coherence. The 13-item version of the SOC scale has been tested on different groups of patients as well as on healthy reference groups (Cronqvist et al., 1995; Forsberg et al., 1996; Klang et al., 1996; Langius et al., 1992). The SOC scale has been shown to be reliable and valid (Antonovsky, 1979, 1987; Cronqvist et al., unpublished data, 1995; Forsberg et al., 1996; Klang et al., 1996; Langius et al., 1992).

Reliability Antonovsky reports alpha values between 0.74 and 0.91 in 16 s tu les with SOC-13 (Antonovsky, 1993).

Validity Antonovsky presents correlational data between the SOC and measures in four domains: a global orientation to one- self and one’s environment; stressors; health, illness and well-being; attitudes and behaviour (Antonovsky, 1993).

Procedure

Patients were asked to participate in the study approxi- mately 1 week before surgery and at the same time they were informed about further tests after a period of 6 weeks

and 1 year after discharge from the surgical unit. Written and oral information was given about the study. One’s own free will to participate or not was stressed, con- fidentiality was guaranteed and instructions were given on how to fill in the questionnaires. Informed consent was obtained orally and then noted by the investigator in the patients’ melca l record. The patients filled in the questionnaires at their homes. The project was approved by the Ethical Committee of the Karolinska Hospital.

Statistical methods

Statistics were calculated according to standard methods. Since most of the variables were approximately normally distributed, parametric methods (Student‘s t-test, one-way and two-way ANOVA) were used in most analyses (Knapp, 1990).

Further relations between variables were expressed by Pearson‘s product-moment-correlation coefficients. Inter- nal consistency for each scale was measured by Cronba- ch’s c1 (Cronbach, 1951).

RESULTS

Demographic data for the samples before and after surgery and the drop-outs are shown in Table 1. Sixty-nine patients could be followed-up after 1 year. The instruments used in the study showed acceptable reliability: the total GHRI 0.90, the HI 0.82, and the SOC 0.81, 1 year after surgery.

The HI scores, the GHRI scores and the SOC scores were tested and analysed with regard to differences between age groups, gender, ddferent cancer types, patients with metastatic lsease or without, patients with ostomies and without, and patients living with relatives or alone (data not shown). For all those analyses, the only ddference found was that the patients who lived alone rated their well-being as inferior in comparison with those who lived with relatives. Further, in three patients of the total group, one had a residual &sease (n=1) or had undergone adjuvant chemotherapy (n=2) 1 year after surgery. Only one of the three patients reported poorer well-being compared to the mean value of total group (18.0 and 28.0, respectively).

Therefore, the values of the total group of the patients were used for comparisons.

Comparisons before and after surgery

The HI and SOC There were no significant differences between the total HI and SOC scores before and 1 year after surgery (Student’s

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Table 1. Demographic characteris- Drop-outs Six weeks Drop-outs tics for the patients before, 6 weeks Before between after between One year after and 1 year after surgery and for surgery 0-6 weeks surgery 6 weeks-1 year after surgery the drop-outs (numbers are given) n 96 17 79 10 69

Cancer sites Rectum Colon Stomach

Age in years, X Maleifemale Metastatic disease Colo- or ileostomy Radiotherapy before surgery

24 7 59 6 13 4 67 62 46/50 1017 26 9 11 1 7 1

17 1 53 7

9 2 67 68

17 4 10 6 1

36/43 218

-

16 46 7

67 34/35 13 10 5

t-test, one-way ANOVA). The HI scores were 27.6 before compared with 28.0 after surgery. The corres:ponding SOC scores were 69.8 and 69.0, respectively.

There were significant differences between the HI subscales scores before and after surgery (Table 2). Six weeks after surgery the patients scored lowest on the items concerning energy and mobility, but these item scores were improved 1 year after surgery. Bowel function was rated as better both 6 weeks and 1 year after surgery.

Symptoms

The five symptoms most frequently mentioned as present always and often by the total sample, before, 6 weeks and 1 year after surgery were flatulence (46%, 38% and 48%, respectively), fatigue (40%, 51 % and 36%), sleep disorders (27%, 33% and 24%), worry (l6%, 24% and 20%) and pain (32%, 11% and 16%).

Differences between groups with regard to the HI, GHRI and SOC scores

There were no statistically significant differences between age groups, gender, different cancer types, patients with or without metastatic disease, or between patients with or without ostomies. The HI and the GHRI scores dlffered

significantly ( p < 0.001 ) between the patients living with relatives and those who lived alone. Thus, patients living alone had a mean HI score of 25.6 (SD 4.5) and those living with relatives had a mean score of 29.1 (SD 3.3). The corresponding values for the total GHRI and for the GHRI subscale current health were 5.6 (SD 9.7) and 62.7 (SD 8.5), ( P < O . O O l ) and 23.5 (SD 6.6) and 27.5 (SD 5.1) (P<O.OOl), respectively. There were no significant differences be- tween the two groups with regard to the other GHRI subscales. Student’s t-test, one-way and two-way ANOVA

were used in the above-mentioned analyses.

Correlations between measurements There were positive and significant correlations, expressed by Pearson’s product-moment-correlation coefficients, between the scores of the two health measurements and the SOC score (Table 3). Furthermore, there was a significant correlation between the HI scores before and after surgery. Thus, those who did well before surgery continued to do so also afterwards.

Comparisons between the cancer patients and the healthy individuals

The mean scores for the HI, the GHRI and the SOC scales in the totai sample of cancer patients and in two randomly

Before After 6 After 1 Table 2. The scores of the HI sub- scale before and after surgery [mean (n=69) weeks [n=66) year (n=69) and SD are given)

-

Items f SD f SD x SD P-value Energy 2.8 0.6 2.5 0.5 2.8 0.5 <0.05 Temper 3.0 0 6 3.0 0.6 3.1 0.6 NS Fatigue 2.6 0.8 2.4 0.7 2.6 0.7 NS Lonehess 3.6 0.6 3.4 0.7 3.3 0.7 NS Sleep disorders 3.1 0.8 2.8 0.9 3.1 0.8 NS

0.7 NS Bowel function 2.7 0.8 2.9 0.8 3.1 0.7 <0.05

0.9 NS Pain 2.8 0.9 3.0 0.8 3.0 Mobility 3.6 0.6 3.4 0.7 3.6 0.6 <0.05

NS not significant, P<0.05, one-way ANOVA.

Vertigo 3.3 0.7 3.1 0.7 3.3

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Table 3. Correlations between the HI, the GHRI and the SOC scale after surgery (number, r-value and P-value are given] Measures n r-value P-value HI:GH€U 69 0.6 t 0.001 msoc 69 0.6 to.001 GHRI:SOC 69 0.3 < 0.05 HI: before and after 69 0.6 to.001 SOC: before and after 69 0.6 to.001

selected reference groups are given in Table 4. There were s ighcan t ddferences (P<O.001) between the HI scores and the GHRI scores. Thus, the cancer patients perceived their well-being as worse than that of healthy individuals [Student's t-test).

There were no significant differences between the SOC

Table 4. Total scores on the Health Index scale (HI), the General Health Rating Index (GHRI) and the Sense of Coherence scale (SOC) in the total sample of cancer patients 1 year after surgery and the Swedish, randomly selected, healthy samples (n, t, SD, median and range are given) Sample Cancer patients Healthy individuals The HI n 69 180 X 28.0 29.7' * SD 4.0 3.3

n 69 180 8 60.7 67.6"' SD 9.3 11.0

n 69 176 X 69.0 65.9 NS SD 1 1 . 1 11.5

The GHRI

The SOC

Student's t-test, * **PtO.Ool, NS not sigdicant.

scores for the study sample and the population sample [Student's t-test). Table 5. Distribution of the GHRI scores in the sample of cancer

patients after surgery and in a randomized Swedish healthy sample (number, mean and SD are given)

The GHRI after surgery Cancer patients Healthy individuals The distributions of the scores of the GHRI and the GHRI subscales in the samde of cancer Datients and in the healthy Total GHRI mean 60.7 67.6 * * *

(n=69) (n- 180)

(22 items) SD 9.3 11.0 population sample are given in Table 5. There were Current health mean 26.2 28.3 sigmficant differences on the total GHRI score, as well 19 items1 SD 6.0 5.7 as on the subscales current health, prior health, resistance k o r health mean 7.5 8.8 * *

to illness and health worry. The cancer patients scored (3 items) SD 2.3 3.0

(4 items] SD 2.4 2.6 worse for well-being on the total index and the subscales compared with healthy inlviduals (Student's t-test). Resistance to illness mean 11.9 12.5

Health outlook mean 10.9 11.5 NS

DISCUSSION

In this study few and small differences were found 1 year after surgery compared to before. Although there was no signlficant differences between the total HI scores before and 1 year after surgery, there were sigmficant differences on some HI subscale scores. Thus, 6 weeks after surgery the patients scored lowest on the items concerning energy and mobility. These item scores were improved 1 year after surgery. Bowel function was rated as better both 6 weeks and 1 year after surgery. These results are in line with those of other studes comparing the quality of life at two or more points in time (Bergman et al., 1992; Kaasa et al., 1988; Morris et al., 1986). Few and small ddferences have been found and bring into question the general view that cancer patients generally have reduced well-being [Bergman et al., 1992; Kaasa et al., 1988; Moms et al., 1986). An alternative interpretation of the results is that the total HI score used to measure well-being may not be sensitive enough to detect changes over time, but that the HI subscales are more sensitive to detect reduced or improved well-being.

(4 items] SD 1.7 2.1 Health worry mean 10.1 9.3 * *

(4 items) SD 1.8 1.9

(2 items) SD 1.2 1.4 Sickness orientation mean 4.7 4.6 NS

NS-not significant, 'P>0.05, *'Pt0.01, "'PtO.OO1, Student's t-test.

There were no significant differences between age, gender patients with ddferent cancer types, patients with or without metastatic disease, and patients with or without ostomies with regard to the HI, the GHRI and the SOC scores 1 year after surgery. Also Portenoy et al. found that the prevalences and characteristics of symp- toms were remarkably similar across tumour types, age and gender in a cancer population (Portenoy et al., 1994).

About half the patients perceived common symptoms such as flatulence and fatigue. Also other investigators have found that cancer patients report fatigue as a common, disturbing symptom (Jamar, 1989; McArthur, 1992; Portenoy et al., 1994; Rhodes et al., 1988). Interven- tions aimed at reducing emotional distress or enhancing coping responses may be one way to decrease feehgs of fatigue.

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The patients living alone rated their well-being as worse than the patients living with relatives. This finding could indicate that social and marital status also affect the patients’ sense of well-being. Jamar (1989) found that levels of fatigue were significantly related to living arrangements. Kaplan et al. (1977) pointed out a possible connection between an individual’s social network and the development of physical and psychosomatic illness. This is in line with the results of our study. A social network may function as a buffer against the discomfort of having a cancer lsease.

In a previous study we found that coping, ability was related to the cancer patients’ well-being, measured by the HI before and 6 weeks after surgery (Forsberg et al., 1996). The results in the present study concerning the same patients 1 year after surgery, show a sigmficarit correlation between the SOC and the health-measurements scores: the weaker the sense of coherence, the worse the perceived general health and well-being. Furthermore, no sigdicant dlfference was found between the SOC score before and 1 year after surgery. These finding support Antonovsky’s suggestion that the perception of health may be related to the sense of coherence (Antonovsky, 1979, 1987). He has also suggested that the sense of coherence is; a relatively stable trait showing only minor fluctuations over time. Some other results with the SOC instrument also indxate that the sense of coherence is a stable trait (Coe et al., 1993; Langius et al., 1992). Thus, the degree of sense of coherence may be stable over time and it may be at lea.< i t one reason for the dlfferences in the patients’ perceptions of their well-being. Further research is needed to investigate the stability of the senses of coherence over an inlvidual’s life-span.

One year after surgery, the patients in this study perceived their general health and well-being as inferior to that of the healthy individuals. The patients were also more worried about their health. This finding is in agreement with a study of quality of life in adult survivors of colon cancer, in which it was shown that the patients had problems with their functional health status many years after surgery (Schag et al., 1994). Comparisons between the cancer survivors and the healthy controls provided evidence that both short-term and long-term survivors had ongoing problems related to the cancer disease. Both physical and psychosocial problems such as reduction in energy, weight loss and psychological distress were reported (Schag et al., 1994).

Other studies in which the quality of life of severely ill patients was compared with that of healthy ;subjects have shown surprisingly few and small lfferences (De Haes et a]., 1992; Stensman, 1985; Whynes & Neilson, 1993).

i

For routine use in a variety of clinical settings, a measurement of health status must provide information that is valid, reliable, responsive to change and quick and easy to collect. Our findings suggest that the HI scale is valid and reliable enough for monitoring the sense of well-being of groups of patients. The HI is suggested to be a possible measure of outcome in evaluating nursing interventions. For individual use, it gives hints of per- ceived problems that may be further discussed with the patient.

The findings in this study are limited by the sample size and must accordmgly be interpreted with caution. A systematic evaluation of differences with regard to the sense of well-being between patients with different cancer types, patients with or without metastatic dsease and those with or without ostomies would require much larger samples. Thus, further research is needed to examine possible lfferences in the sense of well-being between these groups.

C O N C L U S I O N

One year after surgery the patients had not returned to a state of normal health. The patients were also more worried about their health compared with healthy in- dwiduals. Social and marital status apparently affect the patients’ sense of well-being. There is a relationship between the sense of coherence and the sense of well- being of an indwidual, but it was not possible to determine the causal direction of that relationship. Such a question needs to be examined longitudinally, controlling for the actual disease status of the patients. The question of whether the sense of coherence is stable over time also needs further research.

Acknowledgements

This study was supported by the Swedish Nurses Asso- ciation (SSF), the Cancer Society in Stockholm (Grants Nos. 93:103, and 94:104), the Swelsh Red Cross College of Nursing and Health, and from the Karolinska Hospital and the Karolinska Institute, Stockholm, Sweden.

References

Antonovsky A. (1979) Health, Stress and Coping. Jossey-Bass, San Francisco.

Antonovsky A. (1987) Unraveling the Mystery of Health. How people manage stress and stay well. Jossey-Bass, San Francisco.

Antonovsky A. [ 1993) The structure and properties of the sense of coherence scale. Social Science and Medicine, 36, 725-733.

Benner P. h Wrubel J. (1989) The Primacy of Caring. Stress and coping in health and dlness. Addison-Wesley, California.

0 1996 Blackwell Science Ltd, European Jotunal of Cancer Care, 5, 209-216 215

F 0 R S B ER G ET AL. Well-being, general health and coping

Bergman B., Sullivan M. & Sorensen S. (1992) Quality of life during chemotherapy for small-cell lung cancer. Acta Oncologica, 31, 19-28.

Bjorvell H. & Hylander B. ( 1989) Functional status and personality in patients on chronic dialysis. Iournal of lnternal Medicine,

Bozzetti F. ( 1992) Total versus subtotal gastrectomy in cancer of the distal stomach: facts and fantasy. European Iournal of Sur- gical Oncology, 18,572-579.

Broughton M., Doulton G., Topham C. & Marks C. (1995) Informal out-patient discussions with patients following sur- gery for large bowel cancer: are they beneficial? European Iournal of Cancer Care, 4, 57-62.

Cocluccio T. ( 1991) Esophageal and Gastric Cancer, sixth edn. American Cancer Society. Professional Education Publication, USA.

Coe R.M., Romeis J.C., Tang B. & Wolinsky F.D. [ 1993) Correlates of a measuring of coping in older veterans: a preliminary report. Iournal of Community Health, 15, 287-296.

Cronbach L.J. (1951) Coefficient alpha and the internal structure of tests. Psychometrika, 16, 297-334.

Davies A.R. & Ware J.E.J. (1981) Measuring Health Perceptions in the Health lnsurance Experiment. The Rand Corporation, Santa Monica, CA.

De Haes J.C.J.M., de Ruiter R., Tempelaar R. & Pennink J.W. (1392) The distinction betwen affect and cognition in the quality of life of cancer patients-sensitivity and stability. Quality of Life Research, 1, 315-322.

Forsberg C. & Bjoorvell H. { 1993) Swemsh population norms for the GHRI, HI and STAI-state. Quality of Life Research, 2, 349-356.

Forsberg C., Bjorvell H. & Cedermark B. ( 1996) Well-being and its relation to coping ability in patients with colo-rectal and gastric cancer before and after surgery. Scandinavian Iournal of Caring Science, 10, 35-44.

Gardulf A., Bjorvell H., Gustafson R. & Hammarstrom L. ( 1993) The life situation of patients with primary antibody deficiency untreated or treated with subcutaneuous gammaglobulin infusions. C h c a l and Experimental Immunology, 92, 2Ml-204.

Garratt A.M., Ruta D.A., Abdalla M.1. & Russel LT. (1994) SF 36 health survey questionnaire: II. Responsiveness to changes in health status in four common clinical conditions. Quality in Health Care, 3, 186-192.

Jamar S. (1989) Fatigue in Women Receiving Chemotherapy for Ovarian Cancer. Springer Publishing Company, New York.

Kaasa S., Mastekaasa A. & Naess S. (1988) Quality of life of lung cancer patients in a randomized clinical trial evaluated by a psychological well-being questionnaire. Acta Oncologica, 27,

Kaplan B., Cassel J. & Gore S. (1977) Social support and health.

King I.M. ( 1990) Health as the goal for nursing. Nursing Science

226, 319-324.

335-342.

Medical Care, 15, 47-58.

Quarterly, 3, 123-128.

Klang B., Bjorvell H. & Clyne N. (1996) Quality of life in pre- dialytic uremic patients. Quality of Life Research, 5, 109-1 16.

Knapp T.R. [ 1990) Treating ordinal scales as interval scales: an at- tempt to resolve the controversy. Nursing Research, 39,121-123.

Langius A., Bjorvell H. & htonovsky A. (1992) The sense of co- herence concept and its relation to personality traits in Swedish samples. Scandinavian Iournal of Caring Science, 6, 165-1 71.

Langius A., Bjorvell H. & Lind M. (1993) Oral and pharyngeal cancer patients’ perceived symptoms and health. Cancer Nursing, 16, 214-221.

McArthur M. (1992) A study of fatigue in cancer patients receiving chemotherapy: University of Surrey Thesis.

Morris J.N., Suissa S., Sherwood S., Wright S.M. & Greer D. (1986) Last days: a study of the quality of life of terminally ill cancer patients. Iournal of Chronic Disease, 39, 47-62.

Nordstrom G.M., Nyman G. & Theorell T. (1992) Psychosocial adjustment and general state of health in patients with ileal conduit urinary diversion. Scandinavian Iournal of Urology and Nephrology, 26, 139-147.

Portenoy R.K., Thaler H.T., Kornblith A.B. et al. (1994) Symptom prevalence, characteristics and distress in a cancer population. Quality of Life Research, 3, 183-189.

Redford C.S. & Reilly N. (1991) Colo-rectal Cancer, sixth edn. American Cancer Society. Professional Education Publication, USA

Rhodes V.A., Watson P.M. & Hanson B.M. (1988) Patients’ descriptions of the influence of tiredness and weakness on self-care abilities. Cancer Nursing, 11, 186-194.

Schag C.A.C., 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.

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 o f the Colon and Rectum, 38, 361-369.

Sprangers M.A.G., te Velde A,, Aaronsson N.K. & Taal B.G. (1993) Quality of life following surgery for colorectal cancer: a literature review. Psycho-Oncology, 2, 247-259.

Stenbeck M. & Rostn M. (1995) Cancer survival in Sweden 1961- 1991. Acta Oncologica Supplement, 4, 11-37.

Stensman R. ( 1985) Severly mobility-msabled people assess the quality of their lives. Scandinavian Iournal of Rehabilitation Medicine, 17, 87-99.

Sullivan M., Karlsson J., Sjostrom L. et al. (1993) Swedish obese subjects [ SOS)-an intervention study of obesity. Baseline eva- luation of health and psychosocial functioning in the first 1743 subjects examined. Internal Iournal of Obesity, 17, 503-512.

Ware Jr J.E. ( 1976) Scales for measuring general health perceptions. Health Services Research, 11, 394-514.

Ware Jr J.E. (1987) Standards for validating health measures: definition and content. Iournal of Chronic Disease, 40,473-480.

Whynes D.K. & Neilson A.R. ( 1993) Convergent validity of two measures of the quality of life. Health Economics, 2, 229-235.

216 0 1996 Blackwell Science Ltd, European /ournu1 of Cancer Care, 5, 209-216