TITLE

Structural equation modeling of the relationship between posttraumatic growth and

psychosocial factors in women with breast cancer

RUNNING TITLE
Structural equation model of coping, social support and PTG

AUTHOURS
Makiko Tomita1, Miyako Takahashi1, Nobumi Tagaya2, Miyako Kakuta3, Ichiro Kai4,
Takashi Muto5

1: Division of Cancer Survivorship Research, Center for Cancer Control and Information
Services, National Cancer Center

2: Department of Surgery, Dokkyo Medical University Koshigaya Hospital

3: First Department of Surgery, Dokkyo University School of Medicine

4: University of Tokyo

5: Department of Public Health, Dokkyo Medical University, School of Medicine

CORRESPONDING AUTHOR
Makiko Tomita, Ph.D.
Project Researcher
Division of Cancer Survivorship Research,
Center for Cancer Control and Information Services,
National Cancer Center,
5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
Tel: +81-3-3547-5201 (ex.1644); Fax: +81-3-3547-6627
E-mail: matomita@ncc.go.jp

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1002/pon.4298

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ABSTRACT
Objective：
Posttraumatic growth (PTG) is a positive psychological change occurring after struggling
with a highly challenging experience. The purposes of this study were to investigate how
women’s demographic and clinical characteristics as well as psychosocial factors are
associated with PTG, and to reveal the influence of PTG on depressive symptoms.

Methods:
Participants were 157 women with breast cancer (BC) who attended a breast oncology
clinic at a university hospital in Japan. The questionnaire included demographic and
clinical characteristics, social support, coping strategies, depressive symptoms and PTG.
Structural equation modeling (SEM) was conducted.

Results:
Coping was directly related to PTG, and social support and having a religion were partially
related to PTG. There was a moderate association between social support and coping. PTG
mediated the effect of coping on depressive symptoms. PTG as well as a high level of
perceived social support and using positive coping decreased depressive symptoms,
whereas using self-restraining coping increased depressive symptoms.

Conclusion:
This study indicated the role of coping strategies and social support in enhancing PTG in
Japanese women with BC. Furthermore, perceived social support, a positive approach
coping style, and PTG may reduce depressive symptoms. Our results suggest that
healthcare professionals should consider whether patients receive enough support from
others, and whether the patients are using the appropriate coping style to adapt to stressors
associated with the diagnosis and treatment of BC.

Keywords: cancer; oncology; posttraumatic growth; structural equation modeling; coping;

social support

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BACKGROUND
Breast cancer (BC) is the most common cancer diagnosis among Japanese women.
The number of newly-diagnosed BC cases among Japanese women is estimated as 89,400
cases in 2015[1]. Although the 5-year relative survival rate of BC patients has improved in
recent years [2], the diagnosis and treatment of BC are distressing for women. Having
cancer is not a singular stressful experience, but a chronic severe stressor [3]. People with
cancer deal with various stressful events including medical treatments, fear of recurrence[4,
5], side effects, fatigue, pain, hair loss, change in appearance and body image, job-related
problems, change in relationships with partner or family, and the threat of recurrence.
Dealing with a chronic stressor such as BC causes long-term psychological distress.
Previous research indicated that the majority of patients with BC had a high level of
distress [6], and the incidence rates of depression and anxiety among patients with BC were
reported to be approximately twice those in the general female population[7].
While psychological distress is high, it was reported that people with cancer often
experience positive psychological changes in the course of their cancer trajectory, known as
posttraumatic growth (PTG) [8]. PTG is positive psychological change occurring after
struggling with a highly challenging experience [8, 9]. It includes enhanced interpersonal
relationships, appreciation for life, spirituality, personal strength and positive changes in
life priorities [9]. Many women with BC experienced PTG [5, 10, 11], and the level of PTG
among women with BC was higher than that among healthy women [12]. Previous studies
also reported that PTG was associated with lower psychological distress, less depression,
higher well-being, and higher quality of life [11, 13-15].
PTG in women with BC is related to several personal, clinical and psychosocial
factors. It has been reported that younger age, long duration after the diagnosis, clinical
status of cancer (tumor size and treatment characteristics), a positive/adaptive coping style,
and social support are associated with increased PTG[11, 16-18].
Social support is one of the psychosocial factors that has been beneficial for the
experience of PTG. Social support is related with psychological adjustment, health,
well-being, and quality of life [19]. Among cancer survivors, it has been reported that
social support reduces survivors’ distress, improves mental functioning, and predicts
well-being [20, 21]. As for the relationship with PTG, previous studies revealed that
perceived social support contributes to increased PTG[11, 18] and seeking social support
was directly related to PTG[15, 22].
Coping strategies are also important for PTG. Coping strategies play an important
role in psychological adjustment to stress. Furthermore, the type of coping strategy is
related to psychological adjustment in coping theory. In the literature on PTG, it has been
reported that avoidance coping styles (e.g., trying to minimize the problem, withdrawing
from the problem, venting emotions) were not associated with or were negatively

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correlated with PTG [10, 13], whereas a positive approach coping style (e.g., logical
analysis of the situation, positive reappraisal, support seeking, active coping) was
positively correlated with PTG [3, 11, 17].
Several studies showed PTG in different cultures [3, 5, 10, 14, 23, 24]. For example,
a study in Japanese patients with hepatocellular carcinoma and hepatitis C reported that
patients experienced personal growth with regard to appreciation of social support and life;
however, changes in personal strength and spirituality were not observed [25]. Taku et al.
[23] developed the Japanese version of the Post Traumatic Growth Inventory (PTGI-J). The
Japanese version, however, had different subcategories compared with the original Post
Traumatic Growth Inventory (PTGI) [9].
Although there are a growing number of studies focusing on PTG, to our knowledge,
little research has examined PTG and related factors in Japanese women with BC. The
purposes of this study were: (1) to investigate how women’s demographic and clinical
backgrounds as well as psychosocial factors such as social support and coping strategies
affect PTG, and (2) to reveal the influence of PTG on depressive symptoms.

METHODS
Participants and Procedures
This was a retrospective and cross-sectional study. This study was approved by the
ethics committee of Dokkyo Medical University. We conducted an anonymous,
cross-sectional survey of outpatients attending a breast oncology clinic at a university
hospital in Japan from February to March 2011. The inclusion criteria were as follows: age
20 years or older, more than one month since diagnosis, and being physically and mentally
able to complete the written questionnaire. No restrictions were made regarding upper age
limit, marital status, stage of BC, and treatment modalities. Following a regular,
post-surgery consultation at the outpatient clinic, patients were asked by a breast surgeon to
participate in the anonymous survey, and were handed a questionnaire package that
included the questionnaire with a pre-addressed, stamped return envelope. Patients were
informed verbally and by a flyer that their participation in the survey was anonymous, by
their own free will, and that they would not experience any disadvantage in not
participating.

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 Of the 283 patients who were handed a questionnaire package, we received 201
responses (71.0%).
A previous study reported that support from the spouse is most beneficial for women
with BC, and that even good support from other family members or friends could not
compensate for insufficient support from her spouse [26]. Taking this into account, we
decided to evaluate three different support resources (spouse, family, and friends) and
excluded 44 respondents who did not have a spouse from the analysis.

The final analysis included 157 participants. Table 1 summarizes the

socio-demographic and clinical characteristics of the participants.

Measures
Demographic and clinical characteristics
Participants were asked about the following demographic and clinical characteristics:
age (years), time since diagnosis (months), religion (yes/no), presence of children (yes/no),
education (junior high school, high school, junior college, college or higher, and other),
treatment modality (type of surgery, chemotherapy, radiation therapy, hormonal therapy,
and reconstructive surgery), and stage of BC.

Coping
Coping was assessed using the Stress Coping Scale for Japanese cancer survivors[27],
which had been developed based on the Ways of Coping Questionnaire for Cancer [28].
The Stress Coping Scale consists of 26 items in four subscales: self-restraining coping (e.g.,
‘Endure the illness by treating it as a challenge of life’, ‘Suppress my feelings although I
feel distress.’), distancing coping (e.g., ‘Do nothing special, thinking that whatever will be
will be.’, ‘Accept my fate. There is nothing else I can do’), positive coping (e.g., ‘Having
hope for the future’, ‘Enjoy my favorite sports and/or activities’), and coping by depending
on others (e.g., ‘Ask family or friends for advice’, ‘Talked to a doctor or nurse about my
concern.’). Each item was rated on a 4-point Likert scale (1 = never to 4 = very often).
These four subscales had been constructed based on the results of factor analysis [27].
Cronbach’s alpha for each of the four factors were larger than 0.70, except for
self-restraining coping (0.65) [27]. In the current study, Cronbach’s alpha coefficients were
0.64, 0.79, 0.74, and 0.78 for self-restraining coping, distancing coping, positive coping,
and coping by depending on others, respectively.

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Social Support
Social support was assessed using the Jichi Medical School Social Support Scale
(JMS-SSS), which measures perceived social support in Japanese people [29]. This 24-item
questionnaire contains items about perceived social support from three different resources,
i.e., spouse, family, and friends. Each item was rated on a 4-point Likert scale (1 = strongly
disagree to 4 = strongly agree).
The scale has demonstrated cross validity and reliability (Cronbach’s alpha: 0.89,
0.95, and 0.94 for spouse, family, and friends, respectively) [29]. In this study, Cronbach’s
alpha coefficients were 0.91, 0.90, and 0.90 for spouse, family, and friends, respectively.

Posttraumatic growth
Posttraumatic growth was assessed using the Posttraumatic Growth
Inventory-Japanese version (PTGI-J) [23]. It consists of 18 items in the following four
subscales: relating to others, new possibilities, personal strength, and spiritual change and
appreciation of life. The PTGI-J was developed based on the PTGI [9]. Although two
subscales in the original PTGI (spiritual change and appreciation of life) were combined in
the PTGI-J, the Japanese version has established reliability and validity[23]. Cronbach’s
alpha coefficients in this study were 0.86, 0.83, 0.79, and 0.70 for relating to others, new
possibilities, personal strength, and spiritual change and appreciation of life, respectively.
Participants were asked to indicate for each of the statements the degree to which this
change occurred since her cancer diagnosis. Items were rated on a 6-point Likert scale (0 =
not at all to 5 = a very great degree).

Depressive symptoms
Depressive symptoms were assessed using the Japanese version of the Center for
Epidemiological Studies Depression scale (CES-D), a well-validated self-report measure of
depressive symptoms in the Japanese [30, 31]. The scale has demonstrated test-retest
reliability and split-half reliability (0.84 and 0.79, respectively) [31]. The CES-D consists
of 20 items measuring the frequency of depressive symptoms that occurred during the
previous week. All 20 items were completed on a 4-point Likert scale (1 = never to 4 = 5
days or more). Cronbach's alpha for the total score in the current study was 0.85.

Data analyses
Preliminary analyses were conducted to examine the association of participants’
demographic and clinical characteristics with PTGI-J subscales. The results of t-test and
analysis of variance (ANOVA) did not show significant associations between each PTGI-J
subscale and marital status, presence of children, education, and cancer stage. Only
participants having a religion (N=25, mean=30.40, SD=7.48) had a significantly higher

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level of spiritual change and appreciation of life (t = 2.31, p = 0.022, df = 138) compared
with participants having no religion (N=115, mean=27.20, SD=5.99).
Correlation analyses were used to examine the associations of age, time since
diagnosis, social support (total score), coping (4 subscales, i.e., self-restraining coping,
distancing coping, positive coping, coping by depending on others), and depressive
symptoms with the PTGI-J total score. Significant correlations were found between the
PTGI-J score and social support (r = -0.290, p = 0.001), self-restraining coping (r = 0.260,
p = 0.003), positive coping (r = 0.529, p = 0.000), coping by depending on others (r = 0.407,
p = 0.000), and depressive symptoms (r = -0.265, p = 0.002).
Based on previous research and the results of the preliminary analyses, structural
equation modeling (SEM) was used to test the relationship between social support, coping,
having a religion, depressive symptoms and PTG. Social support, coping, and PTG were
entered into the model as latent variables. Depressive symptoms and having a religion were
entered as observed variables. Social support from the spouse, family, and friends were
used to represent the latent variables of social support. The four subscales of coping were
used to represent the latent variable of coping.
We hypothesized that having social support, coping, and having a religion predicted
PTG, and that PTG was negatively associated with depressive symptoms.
Statistical analyses were conducted using IBM SPSS Statistics 22 and AMOS 22.

RESULTS
Figure 1 shows the results of the structural equation model. This model was an
adequate fit of the data with NFI (normed fit index) = 0.907, CFI (comparative fit index) =
0.975, and RMSEA (root mean square error of approximation) = 0.044.
PTG was a latent variable represented by four PTGI subscales. New possibilities was
the highest factor loader for PTG (ß = 0.93).
Coping was directly related to PTG (ß = 0.64). The more coping was used (especially
positive coping and coping by depending on others; the path coefficient from coping was
0.85 and 0.52, respectively), the more PTG was enhanced.
Having a religion was only directly related to spiritual change and appreciation of
life (ß = 0.18).
Social support was directly related to relating to others (ß = 0.22), but was not related
to PTG. Similarly, coping by depending on others was directly related to relating to others
(ß = 0.24). The more social support was perceived and coping by depending on others was
used, the more relating to others was enhanced. There was a moderate association between
social support and coping (ß = 0.32).

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 PTG mediated the effect of coping on depressive symptoms (ß = -0.24). Depressive
symptoms were also directly affected by social support (ß = -0.25), self-restraining coping
(ß = 0.56), and positive coping (ß = -0.22). That is, PTG, a high level of perceived social
support and using positive coping reduced depressive symptoms, whereas using
self-restraining coping increased depressive symptoms.

DISCUSSION
This study investigated how the demographic and clinical background of Japanese
BC survivors as well as psychosocial factors such as social support and coping strategies
affect their PTG. This study also tried to reveal the influence of women’s PTG on their
depressive symptoms.
The SEM revealed that the use of coping strategies such as positive coping and
coping by depending on others was an important factor for the perception of PTG among
Japanese women with BC. Similarly, social support and having a religion affected specific
aspects of PTG, i.e., social support affected relating to others, and having a religion affected
spiritual change and appreciation of life. Moreover, PTG was associated with fewer
depressive symptoms, and mediated the relationship between coping and depressive
symptoms.
As for the relationship between coping style and PTG, this study revealed that
positive coping and coping by depending on others were linked to stronger perception of
PTG. In the present study, positive coping means coping with the stressor positively, and
coping by depending on others means adjusting to a stressful event by receiving active
support from others. Thus, both types of coping indicate a positive, approach coping style.
Consistent with previous studies [3, 11, 17], our results showed that a positive, approach
coping style enhances women’s perception of PTG.
Although previous studies demonstrated that perceived social support is associated
with PTG, our results indicated that social support had a direct positive effect on only
relating to others. Similarly, coping by depending on others had a direct positive effect on
PTG. In the theory of PTG, relating to others implies significant changes in relationships,
including a sense of increased compassion, a greater sense of intimacy, and closeness [23,
32]. Also, perceived social support and coping styles, including seeking and using support
from others, are necessary to have better relationships with others. Therefore, the
participants of the present study may have experienced more growth in relating to others.
Compared with support from friends or other family members, support from her
spouse was seen as the most important in women with BC [26], and was associated with
higher quality of life [33]. Consistent with these previous studies, our model suggested that

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social support, particularly from one’s spouse, plays an important role in PTG and was
associated with lower levels of depression among women with BC.
The social support scale used in the present study could differentiate social support
resources; however, the scale could not distinguish the types of social support, i.e.,
emotional support, informational support, received support, perceived availability of
support, etc. Although previous studies suggested making a distinction of the type of social
support [3, 5], our results revealed that perceived social support had a positive relationship
with coping; similarly, social support affected relating to others, which was one part of PTG.
However, it remains unclear how social support influences the well-being and quality of
life of single women with BC. Our results on social support are limited to women who have
a spouse, and they need to be replicated in other groups of women.
Religious status directly affected spiritual change and appreciation of life. This result
is consistent with that of Danhauer et al.[11] who found that religious preference was only
associated with spiritual change. Similar to previous studies in Western countries, it was
revealed that religious status was associated with increasing one part of PTG.
However, it is difficult to understand people’s real religious beliefs just by asking
whether they have a religion, especially in Japanese people. A previous study indicated that
many Japanese have a positive attitude toward religiousness, but the rate of people having a
religion is comparatively low[34]. It may be important to evaluate the degree of their
religious beliefs or faith when investigating the relationship with PTG.
In addition, previous studies reported that cross-cultural differences exist in PTG [14,
23, 24, 32]. For example, it is commonly found that the PTGI score of non-American
peoples, which was measured by various translated versions of the PTGI, was lower than
that of American people [35]. Studies of PTG among Japanese people reported that lower
PTGI scores may reflect personality traits that are peculiar to Japanese people (e.g.,
humility, self-effacement, and traditional cultural aspects) [35] or a traditional Japanese
cultural value that articulating one’s positive change is unfavorable [36]. Moreover,
although we used the Japanese version of the PTGI, it remains unclear whether direct
translations of PTGI reflect some culture-specific connotations of PTG [14, 36]. A further
study of PTG considering culture-specific meanings of growth should be conducted.

Consistent with previous studies, higher PTG was directly associated with lower
depressive symptoms. In our model, PTG was associated with coping, and the subscales of
PTG were affected by social support and religious status. Furthermore, a positive, approach
coping style and social support reduced depressive symptoms, while a negative, avoidance
coping style increased depressive symptoms. In addition, the direct effects of social
support and coping subscales on depressive symptoms were larger than the effect of PTG
on depressive symptoms. It is suggested that appropriate social support and coping style

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may be more important for the well-being and quality of life of women with BC, rather
than enhancing PTG. These findings have clinical implications. Several studies cautioned
that healthcare professionals should not focus only on enhancing PTG of patients [5, 13,
37]. Not all patients experience PTG, and it may unnecessarily pressure patients if
healthcare professionals expect PTG of them [13, 16]. It is important for health care
professionals to support patients with a multidimensional understanding of reactions to BC
[13], listening attentively and actively to the patients [37], assisting them to elicit
supportive behaviors from others[5], and facilitating an appropriate coping style[17]. Our
results imply the importance of social support, coping style, and other factors in the
well-being and quality of life of women with BC.
In the preliminary analyses, most of the demographic and clinical characteristics of
the participants were not significantly associated with PTG, and therefore we decided to
remove these variables from SEM. The results of previous studies investigating the
relationship between socio-demographic characteristics, medical variables, and PTG have
been mixed. Some researchers have found that younger patients more frequently reported
PTG [4, 22, 24], whereas others did not find an age difference [3, 12]. On the other hand,
several studies indicated that subjective evaluation of cancer severity may be more
important in predicting PTG than objective measures such as stage of disease [12, 38]. For
this reason, these variables may not have significant relationships with PTG. These results
suggest that healthcare professionals should consider not only objective medical
information, but also the subjective health status or distress reported by patients.

There are several limitations in our study. First, we did not ask patients whether the
cancer diagnosis was traumatic for them. Although the participants were instructed to
indicate for each of the statements the degree to which this change occurred in her life as a
result of her cancer diagnosis, we could not confirm the impact of the cancer diagnosis and
the level of traumatic/stressful event. In patients with low PTG, more research is needed to
examine whether PTG does not occur even if she struggles with a highly stressful or
traumatic experience, or whether PTG does not occur because her experience was not
stressful or traumatic.
The second limitation is that participants were simply asked whether PTG occurred
using the PTGI-J scales. Previous research indicated that positive changes may sometimes
represent biased, self-enhancing, and self-protecting illusions rather than actual
improvements [39, 40]. Future research will need to consider the problem of these biases
when using self-reported measures of PTG.

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 Finally, as a cross-sectional study, it was not possible to assess changes in PTG of the
patients over time. Although our model demonstrated the direction of the relationship
between variables, further studies are needed to assess the change in PTG over time, and
the more causal relationship between PTG and other factors.

CONCLUSION
This study indicated the role of coping strategies and social support in enhancing
PTG in Japanese women with BC. Furthermore, perceived social support, positive
approach coping and PTG may reduce depressive symptoms. Although it may be important
to be aware of patients’ PTG, the findings from our results suggest that healthcare
professionals should consider whether patients receive enough support from others, and
whether the patients are using the appropriate coping style to adapt to stressors associated
with the diagnosis and treatment of BC.
ACKNOWLEDGEMENTS
This work was supported by a Grand-in-Aid for Cancer Research from Japan
Ministry of Health, Labour and Welfare (H22-ganrinsho-ippan-008 to M.T.) and the
National Cancer Center Research and Development Fund (24-B-5 to M.T.).

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Table 1. Characteristics of the women with BC in this study (N=157)
Mean SD
Age (years) 59.08 10.06
Months since diagnosis 64.13 45.4
N %
Have children
yes 143 91.1%
no 14 8.9%
Education
Junior high school 18 11.5%
High school 96 61.1%
Junior college 27 17.2%
College or more 11 7.0%
missing 5 3.2%
Religion
yes 25 15.9%
no 125 79.6%
missing 7 4.5%
Surgery
mastectomy 53 33.8%
lumpectomy 96 61.1%
Missing 8 5.1%
Reconstructive surgery
yes 7 4.5%
no 138 87.9%
missing 12 7.6%
Radiation therapy
yes 103 65.6%
no 49 31.2%
missing 5 3.2%
Chemotherapy
yes 79 50.3%
no 73 46.5%
missing 5 3.2%
Hormonal therapy
yes 119 75.8%
no 32 20.4%
missing 6 3.8%
Cancer Stage
0 1 0.6%
1 69 43.9%
2 62 39.5%
3 19 12.1%
4 6 3.8%

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Figure 1. Structural equation model of the relationship between posttraumatic growth,
coping and social support. Path coefficients are standardized.

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