The Potential Mediating Effect of Symptom Burden on Demoralization Through Locus of Control and Coping Strategies in Chinese Patients With Cancer

Abstract

Background

Demoralization is a psychological syndrome that is highly prevalent in patients with cancer and detrimental to individuals’ physical and mental health. To explore effective intervention, we first determined the relationships between locus of control, coping strategies, symptom burden, and demoralization.

Objective

The aim of this study was to determine the relationship between symptom burden, locus of control, coping strategies, and demoralization in patients with cancer.

Methods

In this descriptive-correlational study, 273 valid patients were selected with convenience sampling method from a hospital in China. Data were collected using the Chinese version of the M.D. Anderson Symptom Inventory, the Chinese version of the Multidimensional Health Locus of Control Scale, the Chinese version of the Medical Coping Modes Questionnaire, and the Mandarin version of the Demoralization Scale. Data were analyzed using descriptive and inferential statistics using SPSS and AMOS.

Results

A total of 115 patients (42.12%) experienced clinical demoralization (Mandarin version of the Demoralization Scale > 30). Symptom burden (β = 0.295, P < .001), confrontation (β = −0.117, P = .028), and resignation (β = 0.456, P < .001) had direct effects on demoralization. Symptom burden also had an indirect effect on demoralization through the mediating role of resignation (β = 0.026, P = .002). Meanwhile, locus of control can affect demoralization entirely through the indirect mediating role of coping strategies (chance locus of control via resignation [β = 0.138, P < .01], powerful locus of control via confrontation [β = −0.017, P < .05]).

Conclusions

Symptom burden affects demoralization not only directly but also indirectly. Coping strategies play an important mediating role between symptom burden, locus of control, and demoralization in patients with cancer.

Implications for Practice

It is urgent to screen demoralization and identify patients with high symptom burden, maladaptive locus of control, or coping strategies. For the patients targeted, a more comprehensive and systematic approach to symptom management and more appropriate guidance related to adaptive coping strategies are needed.

To date, cancer mortality (a rate of 29% that indicates 2.9 million decreases in cancer deaths) has decreased according to the World Health Organization. Despite that, cancer remains one of the main killer diseases threatening human lives. An update on the global cancer burden showed nearly 19.3 million new cancer cases and 10.0 million cancer deaths in 2020.¹ The prevalence of cancer and the growing number of cancer survivors have led to increased attention to patients’ psychological issues.²

Demoralization is a psychological syndrome manifested by a constant experience of distress, helplessness, hopelessness, meaninglessness, incompetence, and diminished esteem, which is highly prevalent in patients with cancer^3–8 and other chronic diseases globally.^9–11 Reviewing a series of literature about demoralization since it was introduced in 1974, demoralization has been transformed from a single psychosomatic research variable to a diagnostic framework that has been included in the Diagnostic and Statistical Manual of Mental Disorders and listed as a unique psychological symptom in the latest International Classification of Diseases, Eleventh Revision, receiving more and more attention from scholars worldwide. Demoralization is of particular concern in patients with cancer because of the high prevalence^3,4,6,12 and adverse consequences (eg, extreme existential distress,⁵ low level of psychological well-being,¹³ poor quality of life,¹⁴ and high rate of suicidal ideation or hastened death^7,8). Unlike depression, it is considered that the state of demoralization would prompt individuals to seek psychotherapeutic help, which may guarantee them a heightened state of suggestibility that interacts with expectations of improvement in the psychotherapeutic context,¹² inspiring endeavors in psychiatry and psychology. In contrast to the previous studies that focused only on assessing patients’ demoralization status, more exploration has been given to how this syndrome, which is detrimental to individuals’ physical and mental health, can be alleviated or cured pharmacologically or psychologically.^6,7

Symptom management plays an irreplaceable role in the treatment of cancer, and it has always been closely monitored and highly valued by patients, oncological clinicians, and researchers.^3,15,16 Evidence strongly suggests that, in patients battling cancer, a significant physical symptom burden is closely associated with heightened existential psychological distress, including demoralization.^{11,12,15–17} In practice, the mechanisms that connect physical symptom burden with demoralization remain poorly understood, primarily due to a lack of knowledge about the associated risk factors. This limited understanding ultimately hinders the development of effective interventions aimed at addressing demoralization among patients with cancer.

Coping has long been defined as a set of behavioral and psychological strategies, or a series of specific efforts aimed at managing the demands imposed by stress, which may affect patients’ levels of symptom burden, self-efficacy, quality of life, and mental health.^18–24 Coping is a viable intervention approach, according to the efforts of behavioral scientists,^25–28 and acts as a multifaceted process with 2 key dimensions, including coping strategies and locus of control.¹⁸ Coping strategies have been defined as constantly changing cognitive and behavioral efforts to manage one’s specific external and internal demands, which can be active (eg, confrontation) or negative (eg, avoidance),²⁹ and have become central aspects in clinical assessment.^18,21,23,30 Coping strategies have situational specificity, and their effects are constantly changing.³¹ Patients facing stressful life events, such as a cancer diagnosis, may use a flexible repertoire of coping strategies rather than relying on a single specific strategy.^21–23,30 This flexibility allows them to adapt their coping mechanisms to the unique challenges and demands of each situation, enhancing their ability to effectively manage stress and promote well-being. By using a variety of coping strategies, patients can better navigate the challenges they face and cope with the emotional and physical demands of their illness. This flexibility in coping not only buffers the negative effects of stress but also promotes overall well-being and resilience.^18,20,21,31 Individuals may adopt completely different coping strategies when they face the same stress, which causes different psychological effects.²⁹

Locus of control, as the other key dimension of coping, has been defined as the extent to which an individual attributes their life experiences (eg, health-related issues) to either internal (eg, their own actions) or external factors such as fate or chance, which can and do change over time depending on a myriad of factors.^20,23,32 Throughout the past decades, a vast body of literature has been dedicated to exploring the concept of locus of control and its impact on individuals’ well-being. Previous research has consistently shown that locus of control can predict various outcomes, including psychological adjustment,³³ coping strategies,³⁴ treatment adherence,³⁵ and even mortality.²⁴ It has also been identified as a significant contributing factor in the outcomes of mental health^18–20 and quality of life,^23,36 in both healthy^20,37 and ill^{23,24,33–35} populations.

So far, most research on locus of control and psychological adjustment has primarily focused on depression or anxiety,^{19,20,34–36} whereas research on dealing with demoralization has emphasized the importance of coping strategies.^22,31,38 A longitudinal study has revealed that distinct coping strategies and locus of control are linked to changes in health-related quality of life.³⁹ Notably, specific coping strategies and control orientations proved more adaptive than others among breast cancer and melanoma patients.³⁹ Coping strategies serve as a crucial intervention target in the community due to their potential to enhance mental health.⁴⁰ This assertion is further validated by the structural equation model (SEM), which underscores the cascading effects of coping strategies and locus of control on mental health outcomes.⁴⁰ It has been observed that patients with an internal locus of control (IHLC) exhibit positive mental health outcomes, thanks to the mediating role of coping strategies in individuals with multiple sclerosis.¹⁹ Nevertheless, a stronger external locus of control orientation has been identified as being negatively associated with health-related quality of life among older adults, whereas coping strategies failed to exhibit significant correlations with health-related quality of life outcomes.¹⁸

Furthermore, research has shown that coping strategies serve as a mediator between illness uncertainty and demoralization in patients with breast cancer. This finding emphasizes the crucial importance of minimizing maladaptive coping strategies in the early prevention and effective treatment of demoralization.²² In addition, it has been proposed that positive religious coping may serve as a safeguard against demoralization in terminal patients with cancer.³⁸

According to Lazarus' transactional theory of stress and coping, and the health locus of control model derived from Rotter’s social learning theory, adaptive coping (locus of control or coping strategies) might constitute a crucial resource for patients with cancer when they handle illness-related events, together with medical, social support, for the mitigation of existential physical and mental concerns.^21,22,25 Although it seems logical to assume that locus of control, along with coping strategies, might be linked to demoralization among patients with cancer experiencing symptom burden, several fundamental issues still require attention. First, there is a need to establish whether locus of control is indeed associated with demoralization among Chinese patients with cancer, because this has not been previously explored. Second, it remains to be determined how different locus of control orientations (such as internal, powerful others, and chance) correlate with specific coping strategies (including confrontation, avoidance, and resignation) among Chinese patients with cancer. In addition, it is crucial to investigate whether locus of control or coping strategies, as potential intervening factors, can be considered as mediator variables in this relationship between symptom burden and demoralization.

Given these premises, we initially established a mediating model grounded in the following hypotheses: (1) coping serves as a crucial intermediary between symptom burden and demoralization in Chinese patients with cancer, and (2) locus of control holds a statistically significant influence on demoralization; specifically, the maladaptive locus of control (powerful others and chance) may be associated with severe demoralization, whereas adaptive control locus (internal) may offer protection from it. Subsequently, we tested and revised this model in a clinical setting in the study.

Methods

Study Design and Procedure

This descriptive-correlational cross-sectional study used a quantitative approach to assess the hypotheses and achieve the research objectives. The data collection for this study took place in a university-affiliated hospital in China from September 2022 to January 2023. The data collection sites encompassed 6 inpatient wards, including 4 tumor subspecialty wards that specialized in providing chemotherapy or radiotherapy to patients with various cancers, such as chest tumors, malignancies of the genitourinary system, head and neck cancers, lymphoma, and sarcoma. In addition, the breast specialty ward in general surgery and the gastroenterology specialty ward, which not only admit surgical patients but also care for patients with cancer who require postsurgical chemotherapy, were also included. All patients who resided in the 6 designated wards and met the established criteria for inclusion and exclusion were kindly invited to participate in this study. Under the expert guidance of trained research assistants, the survey participants completed the self-administered questionnaire with utmost precision and attention to detail.

We deliberately selected nursing responsibility team leaders, who hold undergraduate and graduate nursing degrees, as our trained research assistants in the designated wards. These individuals possess the expertise to effectively guide patients regarding their conditions and subsequent treatment. During the process of handling admission procedures, the nursing responsibility team leaders established a good patient-nurse relationship with patients through active communication and professional service, winning the trust of patients and laying the foundation for the smooth implementation of subsequent investigation work. The relevant data were collected from participants within 1 to 2 days after being admitted to the hospital to ensure that the data collection process did not interfere with their normal medical care. Our well-trained research assistants distributed and collected questionnaires within each shift, with a total completion time of no more than 4 hours, taking into account practical considerations. The STROBE guideline was used to report data.

Participants

The subjects for the study were carefully selected by our trained research assistants, who also serve as the leaders of the corresponding wards’ nursing responsibility teams. The selection was performed through the convenient sampling method, specifically during the assistants’ duty hours. The following were the inclusion criteria: (a) patients with confirmed primary solid cancer, of definitive pathological type, who were undergoing or planning to undergo chemotherapy; (b) patients 18 years or older confirmed by their ID number, ensuring precise verification of their age; (c) patients aware of their cancer diagnosis; (d) patients capable of verbal and written communication; (e) patients with stable conditions; and (f) patients who provided consent to participate in this study. The participants were excluded when they had other psychiatric disorders and cognitive impairment, were undergoing psychological treatment within 3 months before the study, or were critically ill and unable to self-report. Written informed consent was obtained from each participant before formal investigation.

Sample Size

When a test of statistical significance is required, the recommended ratio between sample size and the number of parameters in the SEM to be estimated is usually not lower than 5 to 10:1. In this study, 12 parameters were estimated. However, in a practical application, the sample size should be not lower than 200 cases, and the desired sample size was 250 according to a predetermined 20% loss to follow-up. In the study, 300 questionnaires were distributed among participants in the hospital, and 283 questionnaires were returned, corresponding to a response rate of 94.3%. Among the returned 283 questionnaires, 10 questionnaires (3.5%) were answered regularly or with more than 3 answers missing. Eventually, 273 patients were included with validated questionnaires, and the validated response rate was 91.0%.

Ethical Consideration

This study was approved by the institutional review board of the Second Xiangya Hospital of Central South University (approval no. LYG2022110). Eligible participants were given information verbally and a written explanation of the study details to fully understand the aims and procedure of the study and their rights before signing the informed written consent. Furthermore, we ensured the participants that their information would remain confidential and anonymous in the study.

Measures

Demographic and Clinical Information

Demographic data, including age, gender, marital status, education level, occupational status, primary caregiver, and health insurance, were collected with a self-designed demographic information collection sheet. Clinical data, including cancer type, TNM stage, chemotherapy treatment history, and radiation therapy history, were retrieved from medical records.

Symptom Burden

The M.D. Anderson Symptom Inventory has been widely used to measure the general burden of cancer symptoms in various diagnoses and different types of treatment for patients with cancer worldwide.^15,16,41 The Chinese version of the M.D. Anderson Symptom Inventory (MDASI-C) consists of 2 parts. The first assesses the severity of 13 core symptoms (including pain, fatigue, nausea, sleep disturbance, and distress) over the past 24 hours, whereas the second assesses symptom interference. This 19-item self-rating MDASI-C uses an 11-point scale (0-10), and high scores indicate a severe symptom burden or interference. The MDASI-C is a valid, convergent-reliable, and concise tool for measuring symptom severity and interference in Chinese patients with cancer.⁴² In this study, the first part of the MDASI-C was used to assess patients’ symptom burden (multisymptom severity). The internal consistency reliability for the subscale (symptom severity) in this study was satisfied (Cronbach’s α = .923).

Locus of Control

The Multidimensional Health Locus of Control Scale developed by Wallston et al³² was used to assess patients’ locus of control and is widely used to assess general locus of control beliefs in students, medical workers, and patients with cancer, hypertension, and diabetes. The Chinese version of the Multidimensional Health Locus of Control Scale (MHLC-C) consists of 3- to 6-item independent subscales. The IHLC measures the extent to which individuals believe that they are in control of their own health; the powerful locus of control (PHLC) measures the extent to which individuals believe that their own health is largely controlled by other “powerful” figures, such as doctors and nurses; the chance locus of control (CHLC) measures the extent to which individuals believe that their own health is mainly controlled by uncontrollable external forces, such as fate, chance, or luck. Items on this self-report scale are rated on a 6-point scale ranging from 1 (strongly disagree) to 6 (strongly agree). High specific subscale scores reflect increased possibility that individuals believe their own health control. The MHLC-C (form A) is reliable and valid, which can be used in the Chinese population.⁴³ The internal consistency reliability for the IHLC, PHLC, and CHLC in this study was acceptable (Cronbach’s α of .791, .673, and .750).

Coping Strategies

The Medical Coping Modes Questionnaire (MCMQ) developed by Feifel et al was used to assess patients’ coping strategies in relation to cancer, which is suitable for patients with all kinds of diseases, especially serious or life-threatening chronic diseases. The MCMQ covered 3 domains: confrontation, avoidance, and resignation. Confrontation is usually recognized as an active and adaptive coping strategy, whereas avoidance and resignation are usually recognized as negative or maladaptive coping strategies.^29,39 The revised 20-item Chinese version of the MCMQ is a suitable measurement for medical coping strategies with satisfactory psychometric properties.⁴⁴ The internal consistency reliability for the subscales in this study was acceptable (Cronbach’s α of .725, .604, and .720).

Demoralization

The Demoralization Scale (DS) developed by Kissane was a multidimensional instrument used to assess patients’ demoralization, which is widely used and has been validated in different samples of patients with cancer from various countries or areas.¹² The Mandarin version of the Demoralization Scale (DS-MV) consists of 5 factors (loss of meaning, dysphoria, disheartenment, helplessness, and sense of failure) and is consistent with the original scale. This 24-item self-report scale is rated on a 5-point scale ranging from 0 (never) to 4 (all the time) and has a maximum score of 96. A score > 30 indicates demoralization. The DS-MV demonstrated satisfactory performance in a previous validation study (overall Cronbach’s α of .928, subscale Cronbach’s α ranged from .63 to .85) in the Chinese population.⁴⁵ The internal consistency reliability for the overall scale and subscales in this study was satisfied (Cronbach’s α of .912, .838, .704, .824, .727, and .734, respectively).

Statistical Analysis

All data analyses were performed using SPSS 26.0 (IBM Corp) and AMOS 26.0 (IBM Corp), and all the P values were 2-sided with an α of .05. Study variables for patients were described using descriptive statistics (frequency, range, mean, and standard deviation). Pearson correlation analyses were conducted to explore the correlations among symptom burden, locus of control, coping strategies, and demoralization. Structural equation model was calculated to evaluate the fitness of the overall model: the ratio of χ² to degrees of freedom (df), comparative fit index, goodness of fit index (GFI), adjusted GFI (AGFI), Tucker-Lewis index (TLI), incremental fit index, and root-mean-square error of approximation (RMSEA). Comparative fit index, GFI, AGFI, TLI, incremental fit index ≥ 0.90, χ²/df < 5, and RMSEA < 0.08 indicate good model fitting. Moreover, the maximum likelihood method was used to estimate the parameters of the model. A bias-corrected nonparametric percentile bootstrap method was used to test the mediating effects of locus of control and coping strategies in the modified model, and sampling was repeated 2000 times.

Results

Before analysis, we replaced the values of the missing variables with the sample mean scores (5 items of DS-MV and 8 items of MHLC-C were involved; obtained from 9 participants). Skewness and kurtosis tests showed that the study variables did not substantially depart from a normal distribution, indicating that the study variables of the samples were appropriate for SEM.

Profile of Patients

The demographic and clinical characteristics of the 273 Chinese patients with cancer are listed in Table 1. This study encompassed a diverse group, with an average age of 52.99 ± 12.35 years (IQR, 47.0-61.0). Most patients were married (89.0%). More than half of the patients’ primary caregivers were their spouses. Most patients were in stage III (49.1%) or IV (35.5%), and most patients (88.3%) had received chemotherapy. Less than half of the patients (32.6%) were receiving simultaneous radiation therapy. The evaluation results related to patients’ symptom burden, locus of control, coping strategies, and demoralization are shown in Table 2. Approximately 42.1% of the patients experienced clinical demoralization (DS-MV > 30). When the average scores were examined,⁸ 13.6%, 70.3%, and 16.1% of the patients had mild (score < mean − SD), moderate (mean − SD ≤ score ≤ mean + SD), and severe (score > mean + SD) levels of demoralization.

Table 1.

Demographic and Clinical Characteristics of the Sample (N = 273)

Characteristics	n (%)
Age, y
<29	7 (2.6)
30-50	96 (35.2)
51-64	125 (45.8)
≥65	45 (16.5)
Gender
Men	146 (53.5)
Women	127 (46.5)
Marital status
Married/civil partnership/cohabiting	243 (89.0)
Single/divorced/widowed	30 (11.0)
Educational level
Elementary school or lower	32 (11.7)
Junior high school	91 (33.3)
Senior high school	72 (26.4)
Junior college	43 (15.8)
University or higher	35 (12.8)
Occupational status
Not working	146 (53.5)
Working	61 (22.3)
Retired	66 (24.2)
Primary caregiver
Spouse	160 (58.6)
Children	72 (26.4)
Parents	19 (7.0)
Other informal caregivers	16 (5.9)
None	6 (2.2)
Health insurance
Basic medical insurance for urban employees or residents	124 (45.5)
New rural cooperative medical insurance	124 (45.42)
Commercial health insurance	25 (9.16)
Cancer type
Gastrointestinal neoplasms	85 (31.1)
Thoracic tumor	61 (22.3)
Tumor of reproductive system	63 (23.1)
Head and neck tumor	44 (16.1)
Tumor of urinary system	17 (6.2)
Bone and soft tissue sarcoma	3 (1.1)
TNM stage
I	9 (3.3)
II	33 (12.1)
III	134 (49.1)
IV	97 (35.5)
No. chemotherapy treatments received
0	32 (11.7)
1-3	113 (41.4)
4-6	82 (30.0)
7-9	27 (9.9)
≥10	19 (7.0)
Simultaneous radiation therapy
Yes	89 (32.6)
No	184 (67.4)

Table 2.

Pearson’s Correlates and Descriptive Statistics for Main Study Variables (N = 273)

Variables	Mean	SD	1	2	3	4	5	6	7
1. Symptom burden	40.69	25.64	1
2. IHLC	22.66	5.12	−0.139a	1
3. PHLC	24.39	4.01	−0.013	0.383b	1
4. CHLC	16.6	4.21	0.104	0.164b	0.304b	1
5. Confrontation	19.45	3.71	−0.059	0.024	0.145a	−0.021	1
6. Avoidance	15.34	2.63	0.003	−0.016	0.05	0.037	0.128a	1
7. Resignation	8.73	2.43	0.303b	−0.165b	0.017	0.296b	−0.067	0.017	1
Demoralization	28.93	11.95	0.401b	−0.150a	−0.003	0.247b	−0.165b	−0.011	0.523b

Abbreviations: CHLC, chance locus of control; IHLC, internal locus of control; PHLC, powerful locus of control.

^aP < .05.

^bP < .01.

Correlation Analyses

Table 2 presents the significant relationships among symptom burden, coping strategies, locus of control, and demoralization, despite the small to moderate correlation coefficients (r = −0.139 to 0.401, P < .05, P < .01). Symptom burden exhibits a positive correlation with coping strategies (specifically resignation) while exhibiting a negative correlation with IHLC. Resignation exhibits a negative correlation with resignation IHLC while exhibiting a negative correlation with CHLC. Demoralization exhibits a positive correlation with symptom burden, CHLC, and resignation, while exhibiting a negative correlation with IHLC and confrontation.

SEM Analyses

To further explore the effects of symptom burden, locus of control, and coping strategies on demoralization, SEM was used to analyze route correlations, especially for the mediator between symptom burden and demoralization. We first constructed the structure of study variables according to the results of correlation analyses (Table 2) and our hypotheses, and symptom burden was used as the independent variable, locus of control and coping strategies as the mediating variables, and demoralization as the dependent variable. The initial model showed an unsatisfied fit to the data: χ²/df = 2.55, P < .001, RMSEA = 0.075, comparative fit index = 0.906, GFI = 0.923, AGFI = 0.883, and TLI = 0.878. Given that the relationship between IHLC and demoralization was not statistically significant (P > .05), we made a modification and eliminated this route to obtain a better structural model (Figure; χ²/df = 1.439, comparative fit index = 0.980, GFI = 0.996, AGFI = 0.938, TLI = 0.971, incremental fit index = 0.980, RMSEA = 0.040 [0.010-0.062]). Corresponding numerical results are summarized in Table 3.

Table 3.

Decomposition of Standardized Effects From the Path Model

Variables	Total Effects	Direct Effect	Indirect Effect
Symptom burden
IHLC	−0.142a	−0.142a	0.000
Resignation	0.274a	0.249c	0.026
Demoralization	0.420a	0.295c	0.125
Locus of control
IHLC
Resignation	−0.182b	−0.182b	0.000
PHLC
Confrontation	0.145a	0.145a	0.000
Demoralization	−0.017a	0.000	−0.017
CHLC
Resignation	0.303c	0.303c	0.000
Demoralization	0.138b	0.000	0.138
Coping strategies
Confrontation
Demoralization	−0.117a	−0.117a	0.000
Resignation
Demoralization	0.456c	0.456c	0.000

Abbreviations: CHLC, chance locus of control; IHLC, internal locus of control; PHLC, powerful locus of control.

^aP < .05.

^bP < .01.

^cP < .001.

Figure.

A mediation model for the relationships between symptom burden, health locus of control, and coping strategies on demoralization in Chinese cancer patients. Note that standardized path coefficients were presented. All direct path coefficients were statistically significant (P < .05, P < .001).

As illustrated: (1) symptom burden (β = 0.295, P < .001), confrontation (β = −0.117, P = .028), and resignation (β = 0.456, P < .001) had direct effects on demoralization. (2) Symptom burden (β = 0.249, P = .026) had direct effects on resignation. (3) Symptom burden (β = −0.142, P < .001) had a direct effect on IHLC. (4) CHLC (β = 0.303, P < .001) and IHLC (β = −0.182, P < .001) had direct effects on resignation; PHLC (β = 0.145, P < .001) had a direct effect on confrontation. The indirect pathway between symptom burden and demoralization through the mediating effect of resignation was statistically significant (B = 0.125; 95% confidence interval, 0.005-0.015; P = .001). Overall, the total effect of symptom burden toward demoralization was 0.420 (P < .05). The results from the bootstrap test for the significance of indirect pathways are summarized in Table 4. Regrettably, the 95% bootstrap percentile confidence intervals included “0” for the chain mediation pathway “demoralization ← resignation ← IHLC ← symptom burden,” failing to confirm the mediating role of locus of control in the relationship between symptom burden and demoralization. Furthermore, locus of control had only indirect effects on demoralization through the routes of coping strategies. The results indicated that coping strategies are important mediators in the relationships among symptom burden, locus of control, and demoralization in Chinese patients with cancer.

Table 4.

Bias-Corrected Bootstrap Test for All Analyzed Direct and Indirect Pathways of the Model

Direct Pathway	Bootstrap Estimate (95% CI)	P
Demoralization ← symptom burden	0.295 (0.181-0.411)	.001
Resignation ← symptom burden	0.249 (0.134-0.357)	.001
IHLC ← symptom burden	−0.142 (−0.260 to −0.027)	.014
Demoralization ← confrontation	−0.117 (−0.230 to −0.016)	.021
Demoralization ← resignation	0.456 (0.362-0.539)	.001
Resignation ← IHLC	−0.182 (−0.274 to −0.070)	.003
Confrontation ← PHLC	0.145 (0.031-0.253)	.014
Resignation ← CHLC	0.303 (0.183-0.412)	.001
Indirect pathway
Demoralization ← resignation ← symptom burden	0.125 (0.005-0.015)	.001
Resignation ← IHLC ← symptom burden	0.026 (0.060-0.014)	.002
(Path deleted)	0.012 (0.000-0.003)a	.008
Demoralization ← resignation ← CHLC	0.138 (0.041-0.105)	.001
Demoralization ← confrontation ← PHLC	−0.017 (−0.001 to −0.024)	.016

Abbreviations: CHLC, chance locus of control; CI, confidence interval; IHLC, internal locus of control; PHLC, powerful locus of control.

^aThe pathway “demoralization ← resignation ← IHLC ← symptom burden” was deleted because the bootstrap 95% CI included 0.

Discussion

On the basis of our sample, more than four-fifths of patients with cancer experienced moderate to severe demoralization, as the DS-MV score of ≥17 was set as the lower quartile and >40 was set as the upper quartile in this study. When the DS-MV score surpasses 30, indicating severe demoralization, a rate detection reveals that the risk of developing severe demoralization among Chinese patients with cancer was 42.1%. This is a relatively high level when compared with those reported in previous studies involving diverse cancer samples across different regions,^{3,4,9,10,12,14} highlighting the critical importance of promptly identifying and implementing effective follow-up interventions for demoralization in the Chinese clinical setting.

Accordingly, in this study, we aimed to investigate whether coping strategies and locus of control can serve as mediating variables in the relationship between symptom burden and demoralization. Our objective was to identify potential intervening factors that could assist patients among Chinese patients with cancer facing this specific existential suffering. As proposed by the mediation model, we discovered that symptom burden has the potential to impact demoralization both directly and indirectly. This aligns with previous research showing a positive correlation between symptom burden and demoralization, partially mediated by a loss of dignity in patients with cancer.¹⁵ This highlights the paramount importance of symptom management among patients with cancer, particularly those experiencing this kind of psychological distress.

In line with previous research, our study further supports the positive correlation between resignation and demoralization,^31,46 while highlighting a negative correlation between confrontation and demoralization.³¹ That is, individuals who use maladaptive coping strategies, characterized by increased confrontation and decreased resignation, are at a higher risk of experiencing demoralization among Chinese patients with cancer. Moreover, this study also demonstrates that 29.8% of the impact of symptom burden on demoralization was mediated by resignation. This highlights another noteworthy finding that coping, particularly coping strategies, played crucial mediating roles in the relationship between symptom burden and demoralization. To explain this finding, referring to Lazarus' transactional theory of stress and coping may prove beneficial. In line with the theory, the confrontation coping strategy captured by our measurement instrument (MCMQ) signifies a problem-focused coping approach that enables patients to focus on assessing the situation and finding solutions (such as seeking social support, solving problems by making decisions, or coping by direct action) to cope with stressful situations. This coping strategy promotes the rectification of the troubled person-environment relationship and not only alleviates stress levels but is also associated with enhanced cognitive abilities.²³ However, essential to note that the resignation coping strategy, as measured by MCMQ, signifies the ineffective emotional-oriented coping approach that may protect patients from significant distress at certain moments,²⁴ potentially aiding in the avoidance of stressful situations. Nevertheless, this strategy ultimately hinders further attempts to effectively address the persistent stressor. In agreement with this, in the context of cancer, the use of the maladaptive coping strategy (resignation) may cause patients to avoid treatment and medical advice, which may result in more long-term negative consequences including heightened mental distress, such as demoralization.

In our study, we failed to provide evidence for the importance of avoidance coping strategies, which is consistent with another study carried out in patients with multiple sclerosis.¹⁹

When patients have minimal control over their illness and there is no optimal cure, it has been posited that avoidance serves as a short-term adaptive strategy, distracting attention from unpleasant emotions and mitigating the stress caused by the illness.²⁹ It is believed to ward off negative thoughts about the future progression of illness and prevent depressive reactions.¹⁹ Besides, according to extensive research, it has been established that avoidance coping strategies are inversely related to mental well-being and are considered inadequate mechanisms for dealing with stress.^31,47,48 Therefore, the failure to provide evidence for the significance of avoidance coping strategies in our study highlights the need for further investigation into the relationship between avoidance and demoralization.

Although the impact of locus of control on demoralization has not been extensively explored, it is well established that locus of control plays a significant role in various mental disorders (including depression).^{19,24,35,39,40} In line with the transactional theory of stress and coping, we assumed that locus of control should be linked with demoralization through coping strategies. As proposed by the mediation model, we found that PHLC indirectly and negatively impacted demoralization by promoting confrontation, whereas CHLC indirectly and positively impacted demoralization by promoting resignation, supporting the conceptual assumption. Our findings align with previous research,⁴⁰ demonstrating that locus of control exerts indirect influence yet has no direct impact on mental health outcomes. Clinically, according to Rotter’s social learning theory, the perception of control can be taught,^24,35 which offers another effective means of mitigating demoralization. Our finding was consistent with previous results showing that CHLC has a lower correlation with efforts to improve mental health than PHLC.^33,34 We attributed this finding to the possibility that patients with a high level of PHLC can seek someone (such as doctors and nurses) to guide them. By leaning on their physicians and adhering to every rule and recommendation, they can effectively navigate through stressful situations and act more effectively confronted with cancer.³⁵ Consequently, their demoralization is alleviated, whereas individuals with a high level of CHLC often hold the belief that they are less likely to locate accessible resources to prevent problems. This belief can result in a lack of motivation and a sense of helplessness, leading to the adoption of more coping strategies (eg, resignation) associated with poorer well-being,^19,35,39 thereby increasing the risk of demoralization. In addition, individuals with a strong CHLC tend to have a more external focus, investing less time in self-reflection and personal growth. This can lead to a narrower perspective and a limited ability to effectively problem-solve,²⁰ further exacerbating the risk of demoralization.

Interestingly, we observed that symptom burden had a negative correlation with IHLC in patients with cancer. In addition, IHLC was negatively associated with resignation, and resignation was positively associated with demoralization in this population. These findings suggest that individuals with cancer who experience a high symptom burden may be less likely to adopt an internal health locus of control, which can lead to a greater risk of demoralization through the adoption of resignation as a coping strategy. Unfortunately, we were unable to establish that IHLC serves as a mediating factor between symptom burden and demoralization through resignation due to the bootstrap 95% confidence interval of the mediating chain including 0, indicating statistical insignificance. On the basis of Leventhal’s widely accepted model of self-regulation of health and illness, locus of control is intricately linked to the concept of controllability. Individuals who believe they have significant control over their health and illness are more likely to engage in adaptive coping strategies. Therefore, it is plausible that individuals with a strong IHLC may be better equipped to cope with the demands of their illness, leading to higher levels of quality of life, which is supported by a study conducted among women with early-stage breast cancer.²³ This aligns with the findings of Wilski et al¹⁹ who discovered positive relationships between IHLC, problem-focused coping, and mental health in patients with multiple sclerosis. In addition, another study has found that IHLC is negatively associated with the risk of depression in cancer patients.⁴⁹ In contrast, it has been suggested that for patients with uncontrollable or unpredictable diseases, such as cancer, a strong IHLC and problem-focused coping may not always lead to positive psychological or behavioral health outcomes.⁵⁰ When individuals with high internal control attempt to employ direct problem-solving strategies to cope with uncontrollable situations, they may experience setbacks, leading to negative psychological outcomes.⁵⁰ However, the current study failed to establish a significant mediating effect of IHLC on the relationship between symptom burden and demoralization through resignation. This may be due to limitations in the study design or the inherent complexity of the mechanisms involved. Consequently, further research is warranted to clarify the role of IHLC in the development of demoralization and to identify potential mediators or moderators that may influence this relationship. This knowledge could inform the development of interventions aimed at improving coping strategies and reducing demoralization among individuals facing significant symptom burden.

Limitations

This study has offered deeper insights into the potential intervening factors of demoralization among Chinese patients with cancer. Nevertheless, the current findings are subject to several important limitations that cannot be overlooked and should be addressed in further studies. First, considering the nature of the cross-sectional study design, it is not feasible to establish any causal relationships between the study variables. Second, the inability to use true random sampling in this study may have resulted in sample bias, potentially limiting the ability to draw conclusions about causal relationships between the study variables. Third, the significant number of scales and items also posed a challenge in ensuring patients’ accurate completion, particularly given their unique situation as patients with cancer. Fourth, factors such as cancer-related surgical history, cancer type, cancer stage, ethnicity, social support status, and so forth, which may have influenced the studied variables and potentially mediated their relationships, were not included in the SEM primarily because of practical challenges and the potential for future research interventions in this project. In addition, the data were collected through self-report questionnaires at a specific point in time, potentially limiting generalizability or introducing inaccuracies.

Future studies can aim to further expand the sample size to comprehensively investigate the relationship between variables in patients with diverse cancer-related surgical history, cancer type, cancer stage, ethnicity, social support status, and other relevant factors. In addition, future studies using a longitudinal design are necessary to validate or refine our findings to achieve greater objectivity, stability, and precision. Finally, instead of relying solely on self-report measures, future studies could incorporate qualitative methods such as in-depth interviews to enhance our comprehension of demoralization among patients with cancer. This approach would enable a deeper exploration of their perspectives, feelings, and coping mechanisms, ultimately providing valuable insights for improving their mental health and overall well-being.

Clinical Implications

This study highlights the prevalence of demoralization in Chinese patients with cancer, prompting the urgency to screen demoralization and identify patients with high symptom burden, maladaptive locus of control, or coping strategies who have a high susceptibility to develop this specific existential suffering. For the patients targeted, a more comprehensive and systematic approach to symptom management and more appropriate guidance related to adaptive coping are highly worth implementing. Our study suggested 2 different approaches to mitigate demoralization, focusing on symptom burden or coping (eg, resignation), respectively, may be linked. Formal and informal counseling interventions that prioritize coping strategies as the driving forces behind demoralization are essential. Interventions such as logotherapy, mindfulness practices, and cognitive behavior therapy have significant potential for managing physical symptoms and enhancing coping strategies that support cancer care.

Conclusion

To the best of our knowledge, no previous study investigated the associations among symptom burden, 2 key dimensions of coping (locus of control and coping strategies), and demoralization. As expected, this study showed that symptom burden has a direct positive impact on demoralization. In addition, symptom burden and locus of control have an indirect impact on demoralization mediated by coping strategies. These resources (low symptom burden; coping strategies featured with increased level of confrontation, decreased level of resignation, increased tendency toward IHCL or PHCL, and decreased tendency toward CHLC) may reduce demoralization in Chinese patients with cancer. In summary, our findings add to the existing body of knowledge by demonstrating that coping strategies and locus of control are valuable focal points for reducing demoralization, and by offering further insights into the intricate relationships between these constructs.