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. Author manuscript; available in PMC: 2021 May 6.
Published in final edited form as: J Natl Black Nurses Assoc. 2016 Dec;27(2):11–19.

Social Support and Self-Coping of Depressed African-American Cancer Patients

Faye Gary 1, Rui Li 2, Hui Zhu 3, Amy Y Zhang 4, Cheryl Killion 5
PMCID: PMC8100995  NIHMSID: NIHMS1697101  PMID: 29932591

Abstract

This study examined the differences among 57 depressed and nondepressed African-American cancer patients and their use of social support and self-coping resources. In-depth interviews were used to elicit narrative responses and Fisher’s exact test was used to compare the two groups. The depressed patients, as determined by three depression scales, more frequently reported having no supportive family, lacking a support system, having sedentary hobbies, or using alcohol or drugs as coping strategies compared to the nondepressed patients. To better detect and treat depression, health-care providers must carefully evaluate the social support and coping resource needs in this vulnerable population.

Keywords: African American, cancer, coping, depression, family support

Introduction

Depression is a significant predictor of cancer death (Pinquart & Duberstein, 2010). Social support protects cancer patients from stress (Merluzzi, Philip, Yang, & Heitzmann, 2015) and reduces the risk of developing depression (Hamilton et al., 2013; Sheppard, Llanos, Hurtado-de-Mendoza, Taylor, & Adams-Campbell, 2013). Social support is particularly important for African-Americans, who bear a higher burden of cancer incidence and cancer-related death than other ethnic groups in the United States (American Cancer Society, 2015). This is, in part, because they have fewer human and material resources and thus have limited access to healthcare (Agency for Healthcare Research and Quality, 2012). Evidence has shown that among African-Americans, those having more social support have less distress (Chatters, Taylor, Woodward, & Nicklett, 2015) and a better quality of life (Matthews, Tejeda, Johnson, Berbaum, & Manfredi, 2012).

Background and Significance

Social support is an adaptive form of coping, according to the theory of cognitive appraisal (Lazarus & Folkman, 1984). Evidence abounds regarding the overlap among psychological well-being, social functioning, and health status, which is determined by the extent that individuals are able to cope with the stress they encounter in their lives (Gary, Yarandi, & Hassan, 2015; Delongis, Folkman, & Lazarus, 1988; Lazarus, 1966). According to this research, stress includes any type of environmental, social, or internal needs that mandate individuals to adapt and recalibrate their typical behavioral patterns. Stressors are drivers that motivate individuals to find new ways of coping with these demands and the accompanying emotional reactions that become manifest (Lazarus, 1966; Lazarus & Folkman, 1984). Eliciting support from others is one approach to coping, and an important strategy among African-Americans with cancer.

African-Americans may seek support from family, friends, community members, church, and health-care professionals (Heinze, Kruger, Reischl, Cupal, & Zimmerman, 2015; Torres, Dixon, & Richman, 2016; Sternas, 2016), but family support is especially important. Data from the National Survey of American Life show that the majority of African-American participants reported often receiving emotional support from family (Lincoln, Taylor, & Chatters, 2013). In another study, African-Americans with more family emotional support reported better emotional health (Warren-Findlow, Laditka, Laditka, & Thompson; 2011). However, cancer is associated with social stigma in African-American communities and thus may hinder family support (Heiney et al., 2011). In a study of breast cancer survivors of African descent, some participants reported that family members did not accept the fact of their having cancer and provided inadequate support (Thompson, Littles, Jacob, & Coker, 2006). The stigma of the disease and the fear of burdening families can create barriers to the disclosure of cancer diagnoses to family members (Heiney et al., 2011; Hamilton, Moore, Powe, Agarwal, & Martin, 2010). Other researchers have suggested that African-American cancer patients may not actively seek support from family members because the perceived time commitment might cost those family members their jobs (Hamilton, Moore, Powe, Agarwal, & Martin, 2010). The literature also suggests that African-American cancer patients tend to seek support from church communities more than White cancer patients (Matsuyama, Grange, Lyckholm, Utsey, & Smith, 2007).

In addition to social support, African-American patients also use self-coping to deal with cancer (Kissil, Niño, Ingram, & Davey, 2014), especially when stigma, the fear of burdening others, and the lack of family support are evident (Hamilton, Moore, Powe, Agarwal, & Martin, 2010). A previous study shows that African-Americans prefer not to seek help from others compared to Whites (Woodward, Chatters, Taylor, Neighbors, & Jackson, 2010). African-American cancer patients value positive thinking, staying strong, and keeping busy (Kissil, Niño, Ingram, & Davey, 2014; Sternas, 2016), while they cherish religion, faith, and spirituality (Holt et al., 2009; Im, Lim, Clark, & Chee, 2008; Tate, 2011).

Despite existing evidence that African-American cancer patients utilize social support systems and self-coping to manage, the full range of social support and self-coping activities, and the extent to which these resources are utilized by these patients, are not fully understood. Further, the impacts of various social supports and self-coping have been studied, but differences between depressed and nondepressed African-American cancer patients in the use of these resources have seldom been explored. Examining such differences is important because it can illuminate specific resources that matter the most to these patients’ health and psychological well-being. A careful investigation could also provide guidance for further intervention to enhance family support and ameliorate depression among African-American cancer patients.

These patients could benefit from more active support systems, improved coping strategies, and culturally appropriate services.

Purpose of the Study

In this study, we examined social support and self-coping approaches that are employed by African-American cancer patients. Qualitative methods were utilized to allow in-depth inquiries into African-Americans’ experiences and their use of social support and self-coping to buffer cancer-related stress. Further, we compared depressed and nondepressed African-American cancer patients in the use of social support and self-coping. It was of particular interest to identify the types of social support and self-coping approaches among depressed and nondepressed African-American cancer patients and the extent to which these approaches were used.

Institutional Review Board Approval

Because this study involved human subjects, Institutional Review Board approval was sought and obtained before any data were collected.

Methodology

Design, Sample and Setting

This study was conducted in a midwestern city between 2006 and 2009. After the Institutional Review Board’s approval was obtained, the hospital tumor registry of a large medical center was utilized to identify potentially eligible patients. Subject eligibility included African-Americans with a diagnosis of early-stage breast or prostate cancer (stages I-III) within the past 3 years and the completion of all cancer treatments for at least 6 months prior to the beginning of this research. Individuals with documented psychotic disorders were excluded. Patients with an existing diagnosis of depression or who had been prescribed antidepressant medications were eligible to participate in the study.

A mixed methods approach was used to conduct the study. A sequential qualitative-quantitative design (Creswell, 2013; Tashakkori & Teddlie, 2010) was employed, which included a face-to-face interview and quantification of codes from the interview to facilitate comparisons between the depressed and nondepressed African-American patients with a cancer diagnosis. Standard depression scales were used to determine depression status.

Instrumentation

With physicians’ permission, an introductory letter from the principal investigator, the IRB-approved consent form, and the Center for Epidemiologic Studies-Depression (CES-D) scale (Radloff, 1977), were mailed to the identified cancer patients. Trained research professional staff followed up and telephoned the patients to introduce the study and to conduct the initial screening. The CES-D was used during the telephone screening to assess each patient’s depression status. Demographic and medical treatment variables were collected at this time and verified with medical records. Pain was assessed on a 0–10 point visual analog scale (VAS). In the end, 57 eligible ‘{(N = 57) were recruited consecutively.

After initial screening and sample selection was completed, a 1-hour, semistructured interview with each study participant took place in their homes or at other private, safe locations. Written consent was obtained at the beginning of each interview. Two African-Americans with decades of clinical experience working with mentally ill individuals—one licensed in psychiatric nursing, the other licensed in social work—conducted the interviews and administered the depression scales following completion of a 4-hour training session. An interview guide was used to collect information and included the following open-ended questions: “Would you please tell me briefly what happened when you were diagnosed with cancer and what has happened afterwards?” and “Can we talk about your experiences with times and events at which you felt depressed (or stressed)?” Participants’ responses to this portion of the interview were analyzed and the responses regarding social support and self-coping were reported in the study. Interviews were audio taped and transcribed by an experienced African-American transcriptionist. Study investigators (authors) listened to 40% of the taped interviews to safeguard against interview deviations. During the interviews, the interviewers recorded observational ratings (not depressed, mildly depressed, moderately depressed, or severely depressed). Also, memos were written describing noticeable nonverbal signs and any events or incidents that could have influenced the interviews. Thereafter, study participants were administered the Hamilton Rating Scale for Depression (HRSD) (Bagby, Ryder, Schuller, & Marshall, 2004) and the Beck Depression Inventory-II (BDI-II) (Gary & Yarandi, 2004), for evaluating their depressive symptom status. The internal reliability alpha coefficient of the total Hamilton depression scale for more than 30 studies ranged from 0.46 to 0.97, and 10 studies reported estimates of 0.70. The majority of Hamilton depression scale items show adequate reliability (Bagby et al., 2004). The BDI-II, published in 1996, is a revised version of the original BDI designed to represent the criteria for depression. The BDI-II presents the individual with 21 items, each item having four responses to reflect the increasing severity of a particular symptom. This tool has been administered to diverse populations and in diverse settings, yielding high internal consistency coefficients alpha from 0.90 to 0.95 (Gary & Yarandi, 2004). Study participants received a $30 honorarium for participating in the study.

Data Analysis

Directed content analysis was used to analyze the data (Braun & Clarke, 2006; Hsieh & Shannon, 2005; Vaismoradi, Turunen, & Bondas, 2013). Scores derived from the administration of the three depression scales (CES-D, HRSD, and BDI-II) were used to confirm depression status and to divide participants into two groups: depressed and nondepressed. Two experienced coders (one White, one African-American) developed a codebook based on responses related to social support and self-coping in five initial transcripts from both the depressed and nondepressed participants. Then, the two researchers independently coded all other transcripts in accordance with “social support” and “self-coping” strategies using Atlas.ti 5.2 software (Muhr & Friese, 2004). The researchers met biweekly to discuss merging codes and to check coding consistency according to these a priori themes. A single coding file from the two coders was developed to allow for exhaustive groupings of textual content from the transcripts. In addition, the principal investigator and an independent coder read the text associated with each code, checked coding against original transcripts, and finalized the codes. This peer debriefing took place to ensure the veracity of the codes and to expose any biases or explanations that could possibly impact categorization of the codes. Similar coded segments of text were clustered according to the related theme. Since no new codes emerged after 30 of the transcripts of depressed and nondepressed participants were coded, thematic saturation was established. The codes were converted to a SPSS (IBM SPSS Statistics 20.0) database as a nominal variable, with “1” indicating the presence and “0” indicating the absence of a code in each transcript. The Fisher’s exact test was performed to compare the depressed and nondepressed African-American groups on the frequency (occurrence) of each code in order to identify group differences among the 57 participants.

Throughout the study, assessments were made of the research protocol during regularly held research meetings and auditing of the research process was done by holding periodic data safety monitoring sessions.

Results

The response rate for the study was 64%. Because existing measures of depression are not fully validated for African-Americans, multiple measures were used to ensure accuracy of the depression assessment. Subjects that exceeded a cutoff score on the CES-D scale (CES-D ≥ 16) and one of other scales (HRSD ≥ 8, BDI-II ≥ 14, and an interviewer’s rating of each participant on a 0–3 scale as no depression, mild, moderate, or severe depression) were identified as “depressed.” This process identified 34 depressed (n = 34) and 23 nondepressed (n = 23) African-American patients with cancer.

As shown in Table 1, the nondepressed group was significantly older than the depressed group (p ≤ .01), but the two groups did not significantly differ in gender, marital status, education, employment, income, and the type of treatment (surgery, radiation, and chemotherapy). However, the depressed group reported more comorbidities (p ≤ .01), more pain in past week (p ≤ .001), and were using more medications than the nondepressed group (p ≤ .01) (See Table 1).

Table 1.

Sample Demographics

Variable Nondepressed Depressed P-value*
African-Americans African-Americans
n/Mean %/SD n/Mean %/SD
Age 67 10 60 9 0.007
Gender 0.8
 Male 12 52% 16 47%
 Female 11 48% 18 53%
Marital status 0.3
 Married 12 52% 10 29%
 Single 4 17 10 29
 Other (e.g., divorced, separated) 7 30 14 41
Education 0.2
 ≤ High school 7 30% 12 36%
 Some college 12 52 17 52
 ≥ College 4 17 4 12
Employment 0.9
 Full time 6 26% 8 25%
 Half time 2 9 4 13
 Unemployed 15 65 20 63
Income (optional) 0.2
 < $15,000 (household) 7 30% 10 29%
 < $25,000 4 17 4 12
 < $50,000 5 22 6 18
 ≥$50,000 6 26 3 9
 Unknown 1 4 11 32
Had surgery 16 70% 19 56% 0.3
Had radiation 11 48% 24 71% 0.2
Had chemotherapy 6 26% 11 32% 0.6
Number of chronic diseases 2.1 2 5.3 3.8 0.01
Pain in past 7 days 2.1 2 5.6 2.9 0.001
Number of medications 1.8 1.9 5.9 6.5 0.007
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*

Fisher’s exact test, chi-square test, and t-test were performed as appropriate.

Both groups identified a wide range of supportive sources including family, friends, colleagues, neighbors, people at church, patient peers, and professionals that provide care. The received support can be described as either emotional (e.g., talking) or instrumental (e.g., helping with driving, shopping). The responses from both groups were similar regarding whether they received support or the extent of support they received from friends, colleagues, neighbors, people at church, patient peers, and professionals. However, they differed significantly in receiving family support and overall support. The depressed group more frequently reported a lack of family support (35.3% vs. 0, p ≤ .001), and in particular, the family support was not available (20.6% vs. 0, p ≤ .03). Further, they more often reported that they did not have a support system (26.5% vs. 0, p ≤ .01) as compared to the nondepressed group (See Table 2).

Table 2.

African-American Cancer Patient’s Social Network and Support

Themes (yes) Depressed African-Americans %(n) Nondepressed African-Americans % (n) P-value
Family
 Supportive 50.0% (17) 69.6% (16) 0.178
 Emotional support 35.3% (12) 56.5% (13) 0.174
 Instrumental support 26.5% (9) 21.7% (5) 0.762
 Not supportive 35.3% (12) 0 0.001
 Did not want family’s involvement 8.8% (3) 0 0.265
 Did not have family involvement 20.6% (7) 0 0.034
 Feeling alienated from family 17.6% (6) 0 0.071
 Family adds emotional burden 26.5% (9) 13.0% (3) 0.325
Friends
 Supportive 23.5% (8) 21.7% (5) 1.00
 Emotional support 20.6% (7) 21.7% (5) 1.00
 Instrumental support 2.9% (1) 4.3% (1) 1.00
 Not supportive 11.8% (4) 0 0.14
Colleague
 Supportive 2.9% (1) 0 1.00
 Not supportive 8.8% (3) 0 0.265
Church people were supportive 23.5% (8) 17.4% (4) 0.744
Neighbors cannot understand situation 2.9% (1) 4.3% (1) 1.00
Patient peers
Attended support group 8.8% (3) 17.4% (4) 0.423
Did not want to attend support group 14.7% (5) 8.7% (2) 0.689
Professionals, have seen 14.7% (5) 4.3% (1) 0.385
 Psychiatrist 8.8% (3) 4.3% (1) 0.641
 Counselor 5.9% (2) 0 0.51
 Social worker 5.9% (2) 0 0.51
Does not have a 26.5% (9) 0 0.008
support system
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Tables 3 presents the kinds of mental and behavioral efforts that the participants have used to help themselves cope with cancer. Both groups reported similarly on seeking health information, psychological coping (i.e., positive thinking, keeping routines, and venting), and exercising. However, the two groups differed significantly in reporting personal hobbies and lifestyle behaviors. Significantly more depressed than nondepressed patients mentioned engaging in hobbies (73.5% vs. 21.7%; p = .0001) including shopping, eating out, playing with kids or pets, singing, fishing, traveling, reading, visiting museums, artwork, computer games, meditation, sports, watching TV or movies, and listening to audio books or music. Of the 17 hobbies mentioned, the depressed group more frequently reported liking to read (p = .016), watching television (p = .018), or using alcohol and drugs (p = .034) to cope with distress than the nondepressed group (See Table 3).

Table 3.

Self-Coping Behaviors

Themes Depressed African-Americans %(n) Nondepressed African-Americans % (n) P-value
Seeking health Information 11.8% (4) 21.7% (5) .46
Psychological coping
 Positive thinking 35.3% (12) 43.5% (10) .59
 Keeping occupied with routines 14.7% (5) 34.8% (8) .11
 Venting 23.5% (8) 17.4% (4) .74
Hobbies (17 kinds) 73.5% (25) 21.7(5) .0001
 Read to release stress 23.5% (8) 0 .016
 Watch TV 32.4% (11) 4.3% (1) .018
Lifestyle
 Exercise 23.5% (8) 13.0% (3) .50
 Use alcohol or drugs to buffer depression 20.6% (7) 0 .034
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Selected narratives from depressed African-American cancer patients are presented in the following paragraphs to elucidate some of the study findings regarding the lack of family support and a support system, and patterns of self-coping, showing a contrast to that of the nondepressed patients.

Lack of family support.

As shown in Table 2, 12 depressed African-American cancer patients reported not receiving family support. Of them, seven received no support because they perceived that family members did not want to talk about the patient’s cancer or refused to help after learning about the cancer diagnosis; six felt ignored or as if family members were not sympathetic about their illness; and three did not want family involvement because they did not want to burden or become dependent on them. The following are quotes from some of the patients:

“Well, all went with me over to hospital the first day, but after that, they didn’t bother.” “And it’s just like they know I’m sick. They know I need help, but they refuse.”

“[My family] figured that I was going to die and they got very upset. It seemed they were like, you know like shunning me in a way … like they didn’t want to come near me or they kept a distance from me.”

“[My mom said] I don’t want to hear about it. You’re a grown woman and you were supposed to been checking yourself. I ain’t got nothing to do with it.”

Lack of a support system.

Nine depressed African-Americans reported that they did not have any support from their social network of family, friends, colleagues, church, neighbors, support groups, and health-care professionals. For example, one person said:

“I have no family … not having nobody around to talk to … I don’t have any.”

To the contrary, 16 nondepressed African-Americans reported both emotional and instrumental supports from their families. For example, one person said:

“When I need to cry, I would tell him and he’d cry with me. Even now, if he sees me maybe having a little down look, he’ll say, ‘you need a hug.’”

Another person said:

“I had my brothers and sisters, they were talking to me and saying about it’s going to be all right, you know, and that uplifted me.”

Read to relax.

Eight depressed African-Americans used reading as a way to cope. Four of them read the Bible frequently to soothe themselves; the other four used reading to find inspiration for living, to be preoccupied and get away from sadness, and to relax. As one participant said:

“Started reading more about religion and delving into various theologians’ philosophies and so forth and so on. It did bring me some comfort, and to this day it still does.”

Watching TV.

Eleven depressed African-Americans reported watching TV for coping. Four of them wanted to watch TV and stay at home; two wanted to watch TV and did not want to be bothered by or talk to people, and others watched TV to relax or escape from feeling sad. For example, the following are quotes from two patients:

“I don’t really go out anymore you know to the movies and things like that. I sit at home and watch TV and things.”

“You won’t talk to anybody.” “You just, and you’re looking at TV.”

Use of alcohol or drugs.

Seven depressed African-American patients in the study used alcohol or drugs to keep depression away. Two of the patients used drugs to get rid of depressed feelings and five of them used alcohol to deal with depression. One subject explained:

“That takes the depression away.” Another person said, “It doesn’t solve what’s wrong with me, but it makes me feel better.”

Discussion

The findings show that African-American cancer patients in this study used a wide range of support from family to community, including informal (e.g., neighbors, church) and formal (health professionals) networks. The range of utilized supportive resources was not significantly different between the depressed and nondepressed African-American cancer patients. However, the depressed patients reported significantly less access to general support (p = .008), and particularly from their families (p = .001), than the nondepressed. In this study, African-American cancer patients coped with cancer positively (e.g., seeking health information and exercise), irrespective of mental status.

The contrast between patients’ expressed need for support and the lower availability of such support reveals that meeting depressed patients’ needs may be a challenge. As shown in Table 1, the depressed patients had more diseases and pain and were taking more medications, suggesting a greater need for help. Their age (mean = 60) might be also a factor, because mid-aged cancer patients (aged 40–60) may face more challenges during communication with family and friends about their disease than cancer patients aged 61–80 (Rose, Radziewicz, Bowmans, & O’Toole, 2008). Despite this, 26.5% of depressed African-American cancer patients did not have a support system and over a third (35.3%) had nonsupportive family. Without adequate support, unmet needs can put these patients in a more vulnerable situation for developing depression. This key finding mirrors past and current literature. In patients with cancer and other conditions, such as hypertension, family support is essential not only for the patient’s emotional well-being, but also for better health outcomes (Dressler & Bindon, 2000; Lincoln, Taylor, & Chatters, 2013).

Given the importance of family support to African-Americans, the reported lack of general support may be an indicator of fewer family resources. A previous study has shown the importance of spousal support for the outcomes of cancer treatment (Aizer et al., 2013); however, only 29% of the depressed patients in this study were married, a much lower rate compared to 52% in the nondepressed patient group. Family relations can also complicate the availability of support. Although half of the depressed patients received family support in this study, those who reported not receiving family support (n = 12, 35.3%) stated that their families offered no support (n = 7, 21%), that they felt alienated from their families (n = 6, 18%), or they did not want to involve their families out of fear of burdening them (n = 3, 9%). It is possible that these families were unable to provide the needed support because they lacked time, money, or emotional capital due to previously strained relations. This lack of instrumental and/or emotional support has been documented in a number of studies (Agency for Healthcare Research and Quality, 2012; Ashing-Giwa et al., 2012). Existing depression can also precipitate and fuel negative family interaction (Oh, Ell, & Subica, 2014). Regardless of the reasons, these findings demonstrate that less family support is associated with worsening depression in African-American cancer patients. Hence, it is imperative that family support for African-American cancer patients be assessed appropriately so the formal (e.g., agencies, health-care providers) or informal (e.g., friends, church) supports can be provided to those in need. In addition, more information should be provided to family members to help them understand how to best offer physical and psychological support and services for their family members suffering from cancer.

Implications for Health-Care Providers

It is encouraging to have observed from this study that both depressed and nondepressed African-American cancer patients used self-coping activities such as seeking health information, psychological coping (e.g., positive thinking, venting, and keeping routines), and exercise. The depressed African-American cancer patients reported personal hobbies more frequently than the nondepressed patients (p = .0001), suggesting the important role of hobbies in the lives of these individuals who might live alone and be lonely without family and friends. It is possible that hobbies were used to keep attention away from distress, because evidence has shown that distraction is a main coping strategy of cancer survivors (Lauver, Connolly-Nelson, & Vang, 2007). Further, the depressed patients in this study preferred more sedentary activities (i.e., reading and watching TV) for stress relief. This preference may be a result of lacking social connections and support or feeling depressed, but it can have unintended consequences, such as social isolation. The detection of a sedentary lifestyle and proper intervention, such as encouraging social activities, can be very helpful to aid these depressed patients in coping. It is known that people suffering from depression often use drugs and alcohol to elevate mood (Thornton et al., 2012). The study findings show that a sizable portion of depressed patients (21%) continued using substances after receiving their cancer diagnoses and treatments. This finding alerts us to the adverse impact of depression on cancer outcomes and emphasizes the urgency of combating depression in these patients.

Limitations of the Study

Our study has certain limitations that warrant caution. It used a small sample, and study outcomes could vary with a larger sample size. The data were retrospectively collected from self-report and therefore subject to recall biases. The findings were extracted from natural reference in the narratives and may look different when a systematic and proactive probing approach is applied to solicit a response from every participant. For example, low frequency of support from friends, colleagues, church, and professionals may be due to inadequate probes used in the interview. These findings are at best implicating family support in the experience of depression, but cannot ascertain a causal relationship due to the nature of the study design. Nevertheless, the findings provide good clues for further investigation. Using a larger study sample, along with a multivariate statistical analysis with adequate control for socioeconomic, demographic, and medical covariates such as age, gender, and comorbidity, can produce a more accurate estimate of the associations among family support, self-coping, and depression in African-American cancer patients. In this study, women were more likely to report family being supportive than men (p = .03); however, the gender mix is quite balanced (p = 0.8). The gender impact on perceived social support of African-American cancer patients needs to be further examined. Social network analyses of African-Americans diagnosed with cancer may also be extremely useful in identifying culturally specific modes of mutual exchange and support. Finally, since it is well documented that depression is under-recognized and manifested differently in African-Americans than in White Americans, on which most depression scales are based (Gallo, Cooper-Patrick, Lesikar, 1998, Alang, 2016), continued efforts must be made to find or develop tools that more accurately assess depression in African-Americans, particularly among those who have a chronic disease.

Conclusions

The process of coping, which involves finding meaning in a stressor and assessing related resources for addressing the stressor, as depicted in the theory of cognitive appraisal, was manifested in several ways in this investigation. Overall, this study has shown that social support is important and lack of family support is most closely associated with depression among African-American cancer patients. Without adequate family support, these patients may be at a higher risk for experiencing depression. Furthermore, African-American cancer patients utilize a variety of activities to cope with cancer, but sedentary activities and substance use may be more common among those who are depressed. These factors—lack of family support, a sedentary lifestyle, and continuous substance use—may be considered red flags when monitoring mental states of African-American cancer patients. Health-care providers should pay attention to these factors and evaluate them in a timely manner in order to effectively detect and treat depression in African-American cancer patients and subsequently improve their quality of life.

A more in-depth examination of stress and coping among African-Americans with cancer is essential for health-care professionals who continue to work toward improving outcomes among this vulnerable population. It is essential to examine and understand perceptions of stress and the various ways of coping within and across cultures, age, gender, geographical locations, life experiences, religion, and spiritual practices, as well as learned responses to stress that have developed over time (Flanagan, 2014; Folkman & Lazarus, 1988).

Acknowledgements:

The study was supported by the National Institutes of Health/National Cancer Institute (R03 CA115191–01A2; PI: Zhang). The University Hospitals of Cleveland Medical Center, the Cleveland Department of Veterans Affairs Medical Center, and MetroHealth System affiliated with Case Western Reserve University provided support for patient access. The authors declare that they have no conflict of interest.

Contributor Information

Faye Gary, School of Nursing, Case Western Reserve University, Cleveland, OH..

Rui Li, School of Nursing, Case Western Reserve University, Cleveland, OH..

Hui Zhu, School of Medicine, Case Western Reserve University, Cleveland, OH..

Amy Y. Zhang, School of Nursing, Case Western Reserve University, Cleveland, OH..

Cheryl Killion, School of Nursing, Case Western Reserve University, Cleveland, OH..

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