Psychology, Health & Medicine, 2016

VOL. 21, NO. 5, 551–561

http://dx.doi.org/10.1080/13548506.2015.1109674

Quality of life and mental health among women with ovarian

cancer: examining the role of emotional and instrumental
social support seeking
Erin M. Hill
Department of Psychology, West Chester University, West Chester, PA, USA

ABSTRACT ARTICLE HISTORY

The purpose of the present study was to examine the role of emotional Received 8 March 2015
and instrumental social support seeking in the quality of life (QOL) Accepted 13 October 2015
and mental health of women with ovarian cancer. Participants were KEYWORDS
recruited through the Pennsylvania Cancer Registry, and one hundred Coping; social support
women took part in a mail questionnaire that collected information on seeking; quality of life;
their demographics, medical status, social support seeking, QOL and mental health; ovarian
mental health including anxiety, depression and stress. Hierarchical cancer
linear regression analyses were conducted to assess the influence
of emotional and instrumental social support seeking on QOL and
mental health. After controlling for remission status, greater emotional
social support seeking was predictive of higher overall QOL, social/
family QOL, functional QOL and lower depression scores. Instrumental
social support seeking was not significant in the models. The results
illustrate that social support seeking as a coping mechanism is an
important consideration in the QOL and mental health of women with
ovarian cancer. Future studies should examine the psychological and
behavioral mediators of the relationship to further understand the
QOL and mental health of women with ovarian cancer.

Due to poor early detection methods and vague symptoms, women with ovarian cancer
are often not diagnosed until the later stages of the disease (Jayson, Kohn, Kitchener, &
Ledermann, 2014). As such, prognosis can be poor, risk of recurrence is high and ovarian
cancer patients often undergo multiple rounds of invasive treatment including surgery,
chemotherapy and radiation (Trivers, Patterson, Roland, & Rodriguez, 2013). Women who
currently live with or have experienced ovarian cancer can have high physical symptom
burden and report significant levels of psychological distress (Hipkins, Whitworth, Tarrier,
& Jayson, 2004; Matulonis et al., 2008; Norton et al., 2005; Shinn et al., 2009). The quality
of life (QOL) and mental health of ovarian cancer patients and survivors is therefore a
significant clinical consideration.
Social support has been identified as an important factor that can influence emotional
well-being (Hipkins et al., 2004; Norton et al., 2005; Roland, Rodriguez, Patterson, & Trivers,

CONTACT Erin M. Hill ehill@wcupa.edu

© 2015 Taylor & Francis
552 E. M. Hill

2013; Shinn et al., 2009) as well as disease-related biomarkers and clinical outcomes among
women with ovarian cancer (Costanzo et al., 2005; Lutgendorf et al., 2002, 2005, 2012).
Research has shown that social support is associated with decreased anxiety and depression
symptoms (Hipkins et al., 2004; Price et al., 2010), and greater positive affect and self-
reported health in women with ovarian cancer (Champion et al., 2007). Ovarian cancer
patients with higher levels of social support are also more likely to use healthcare and sup-
port services (Jackson et al., 2007), a factor that may play a role in the link between social
support and physical and mental health in this population.
There is also evidence that social support may impact disease-related physiological pro-
cesses and clinical outcomes. Ovarian cancer patients with social attachment (emotional
support and connections with others) were found to have lower levels of vascular endothelial
growth factor (Lutgendorf et al., 2002), and interleukin-6 (Costanzo et al., 2005), cytokines
associated with tumor growth. Social support has also been positively linked to greater
activity of natural kill cells, immune cells that can slow the progression of cancerous growth
(Lutgendorf et al., 2005). Furthermore, social attachment was recently linked to an increased
probability of survival among ovarian cancer patients, even after controlling for depression
(Lutgendorf et al., 2012).
Social support seeking is an important mechanism for coping with chronic illness
and distress; the experience of social support can decrease psychological stress and
promote the use of other coping strategies and behaviors that facilitate QOL (Park,
Edmondson, Fenster, & Blank, 2008). Carver, Scheier, and Weintraub (1989) described
both instrumental (seeking support for advice, assistance or information) and emo-
tional social support seeking (seeking moral support, sympathy and understanding) as
important behaviors relevant to problem-focused coping. Emotional social support can
help with the processing of personal concerns and psychological distress, while instru-
mental social support seeking can result in tangible and information-based support.
Such benefits could, in turn, help improve or maintain QOL and alleviate psychological
distress among women with ovarian cancer.
Both emotional and instrument social support seeking are forms of coping that are active,
which is a particularly beneficial type of coping mechanism for cancer patients (Faller &
Bülzebruck, 2002; Kershaw, Northouse, Kritpracha, Scafenacker, & Mood, 2004). Active
coping has been found to predict QOL in previous research among advanced breast can-
cer patients (Kershaw et al., 2004), and it was found to mediate the link between religion/
spirituality and QOL among women with ovarian cancer (Canada et al., 2006). In a related
vein, other research among women with ovarian cancer found that problem-focused coping
was associated with greater QOL than emotion-focused coping (Tuncay, 2014). Therefore,
actively engaging in coping strategies that will help to alleviate problems or related concerns
may be particularly important for well-being in this population.
The aim of the present study was to examine and compare the influence of emotional
and instrumental social support seeking in terms of their influence on QOL and men-
tal health among women with ovarian cancer. The following research questions were
tested in the present study: (1) Does coping through emotional and instrumental social
support seeking positively predict QOL and negatively predict mental health problems
(anxiety, depression, stress) in women with ovarian cancer? (2) Which form of social
support seeking (emotional vs. instrumental) is more strongly predictive of QOL and
mental health problems?
 Psychology, Health & Medicine  553

Method
Participants and procedure
Participants of the study were recruited through the Pennsylvania Cancer Registry (PCR);
the research team contacted the PCR to gain access to the addresses of women diagnosed
with ovarian cancer in 2011. A total of 782 addresses were identified, and packages were
mailed in April and May 2014 and returned between May and August 2014. The mailing
packages included a PCR brochure, a note stating that participants could opt out of the
study, copies of the consent form, the questionnaire and a postage-paid envelope. The
questionnaire (details of measures provided below) collected information on emotional and
instrumental social support seeking (independent variables), QOL (dependent variable),
mental health problems (dependent variable), as well as medical and demographic infor-
mation. Questionnaires were mailed only once; no follow-up notices were sent to potential
participants and no incentives were used in the recruitment process. The study protocol
was approved by the university institutional review board.

Measures
Quality of life
Participants were asked to complete the functional assessment of cancer therapy – ovarian
cancer version (FACT-O version 4; Basen-Engquist et al., 2001). The FACT-O is designed
to assess QOL using various subscales: physical (7 items), social/family (7 items), emo-
tional (6 items), functional (7 items) and ovarian cancer-specific concerns (12 items). The
total FACT-O score (possible score range: 0–152) is a summation of the physical, social/
family, emotional, functional and ovarian cancer-specific subscales. For the total scale and
subscales, higher scores indicate higher QOL. In this study, the FACT-O subscales had ade-
quate reliability: physical (α = .90), social/family (α = .78), emotional (α = .77), functional
(α = .90) and ovarian cancer-specific concerns (α = .62).

Depression, anxiety and stress

Depression and anxiety symptoms, as well as stress levels, were measured using the 21-item
version of the depression anxiety and stress scale (DASS-21; Lovibond & Lovibond, 1995).
The scale includes 7 items for each domain – depression, anxiety and stress. For each item,
participants responded on a Likert scale ranging from 0 (did not apply to me at all) to 3
(applied to me very much, or most of the time). Scores are summed for each domain and
then multiplied by two in order for the scores to be comparable with the full 42-item DASS
(Lovibond & Lovibond, 1995). Higher scores indicate greater levels of depression, anxiety
and stress. The scores can also be used to classify participants across clinical severity lev-
els (mild, moderate, severe, extremely severe; Lovibond & Lovibond, 1995). The anxiety
(α = .71), depression (α = .88) and stress (α = .86) scales had acceptable internal reliability.

Emotional and instrumental social support seeking

The COPE measures thirteen forms of coping strategies (Carver et al., 1989); the two of
focus in the present study are the use of instrumental social support (instrumental social
support seeking) and the use of emotional social support (emotional social support seeking).
Each construct was measured with a 4-item subscale. For each item, participants respond
554 E. M. Hill

on a Likert scale ranging from 1 (I usually don’t do this at all) to 4 (I usually do this a lot).
Higher scores on each of the subscales indicate greater use of the social support seeking
coping mechanism. Both instrumental (α = .79) and emotional social support seeking
(α = .84) had good internal consistency in this study.

Sociodemographic and medical information

Participants were asked to report their age, ethnicity, highest level of education completed,
marital status and family income. They were also asked about their medical status, including
their date of diagnosis, disease stage at diagnosis, current and previous treatment, current
medical status and number of times of cancer recurrence.

Statistical analyses
Hierarchical linear regression models were conducted to assess the influence of emotional
and instrumental social support seeking on the outcome variables (QOL, mental health).
Age and remission status (in remission coded as 1, not in remission coded as 0) were entered
into the model as covariates in block one, followed by emotional and instrumental social
support seeking in block two. Although nine regression analyses were conducted, given
the relatively small sample used in the analyses (n = 98), and therefore limited power, no
adjustment of the traditional alpha of .05 was made.
Missing data were treated according to test scoring guidelines (FACT-O) or expecta-
tion maximization was used to estimate missing values for cases with less than 30% of the
scale items missing (Schlomer, Bauman, & Card, 2010). Data were screened for regression
assumptions and normality. One hundred women completed the study; however, due to
missing data, two cases were removed. Outliers were identified for some of the outcome
variables. Analyses were conducted including the outliers as well as excluding the outliers,
and the models did not change significantly; therefore, the results with all cases (n = 98)
are presented.

Results
Descriptive statistics and bivariate correlations
Participant sociodemographics and medical information are presented in Table 1.
Descriptive statistics for the regression model variables are presented in Table 2 and
their bivariate correlations are presented in Table 3. The FACT-O scores observed in
the present study were comparable to the FACT-O scores reported by Basen-Engquist
et al. (2001) in their psychometric assessment of the instrument. The mean scores for
the DASS-21 fell within the normal range in terms of clinical severity (Lovibond &
Lovibond, 1995), a result is consistent with previous research (Arden-Close, Gidron,
& Moss-Morris, 2008).

Regression models
Table 4 presents a summary of the final model statistics and the significant predictors in the
final regressions. For the QOL outcomes, all regression models were significant. Remission
 Psychology, Health & Medicine  555

Table 1. Participant sociodemographic and medical information.

Variable Category n (%) (Valid %)
Ethnicity White American 95 (96.9) (97.9)
Asian 2 (2.0) (2.1)
Missing 1 (1.0)
Total 98 (100.0) (100.0)
Education (Completed) College graduate 29 (29.6) (29.9)
High school graduate 27 (27.6) (27.8)
Post-graduate degree 17 (17.3) (17.5)
Trade school/some college 24 (24.5) (24.7)
Missing 1 (2.6)
Total 98 (100.0) (100.0)
Family income $20,000 or less 13 (13.3) (13.8)
$20,001–$30,000 7 (7.1) (7.4)
$30,001–$50,000 16 (16.3) (17.0)
$50,001–$70,000 14 (14.3) (14.9)
$70,001–$100,000 19 (19.4) (20.2)
$100,001 or more 25 (25.5) (26.6)
Missing 4 (4.1)
Total 98 (100.0) (100.0)
Marital status Married 68 (69.4) (69.4)
Widowed 8 (8.2) (8.2)
Living with a partner 1 (1.0) (1.0)
Single 8 (8.2) (8.2)
Divorced/Separated 13 (13.3) (13.3)
Total 98 (100.0) (100.0)
Disease stage at diagnosis Stage I 20 (20.4) (21.7)
Stage II 16 (16.3) (17.4)
Stage III 44 (44.9) (47.8)
Stage IV 12 (12.2) (13.0)
Missing 6 (6.1)
Total 98 (100.0) (100.0)
Current medical status Presence of disease, active treatment 23 (23.5) 23.5)
Presence of disease, no treatment 8 (8.2) (8.2)
Presence of disease, palliative treatment 1 (1.0) (1.0)
In remission 66 (67.3) (67.3)
Total 98 (100.0) (100.0)
Cancer recurrence 0 times 66 (67.3) (67.3)
1 time 18 (18.9) (18.9)
2 times 9 (9.2) (9.2)
3 times 5 (5.1) (5.1)
Total 98 (100.0) (100.0)

Table 2. Descriptive statistics of regression model variables.

Mean (SD) Range Possible range
Emotional SS Seeking 10.87 (3.22) 4.00–16.00 4.00–16.00
Instrumental SS Seeking 10.08 (3.20) 4.00–16.00 4.00–16.00
FACT-O total 114.65 (22.12) 57.00–151.00 0–152.00
FACT-O physical 21.14 (6.22) 0–28.00 0–28.00
FACT-O social/family 22.11 (5.48) 6.00–28.00 0–28.00
FACT-O emotional 17.66 (4.53) 4.00–24.00 0–24.00
FACT-O functional 20.11 (6.27) 4.00–28.00 0–28.00
FACT-O ovarian 33.64 (5.35) 19.25–43.00 0–44.00
Depression 7.35 (7.54) 0–32.00 0–42.00
Anxiety 4.81 (5.67) 0–28.00 0–42.00
Stress 7.91 (7.62) 0–38.96 0–42.00

status was significant in all of the QOL models with the exception of the regression with
FACT-O social/family QOL as an outcome variable. Specifically, women currently in remis-
sion were more likely to have higher overall QOL and higher QOL across the physical,
 556
E. M. Hill

Table 3. Bivariate zero-order correlations among study variables.

Variable 1 2 3 4 5 6 7 8 9 10
1. EmotSS
2. InstruSS .680**
3. QOLtotal .373** .322**
4. QOLphys .155 .141 .831**
5. QOLsocial .526** .378** .711** .408**
6. QOLemot .152 .136 .648** .473** .252*
7. QOLfunct .363** .330** .894** .707** .587** .478**
8. QOLovar .269** .279** .844* .628** .536** .463** .698**
9. Depression −.329** −.251** −.597** −.431** −.485** −.370** −.594** −.462**
10. Anxiety −.147 −.146 −.569** −.566** −.320** −.369** −.534** −.428** .529**
11. Stress −.088 .018 −.447** −.376** −.293** −.408** −.389** −.311** .522** .605**

Notes: EmotSS = Emotional Social Support Seeking, InstruSS = Instrumental Social Support Seeking, QOLtotal = FACT-O total score, QOLphys = FACT-O physical subscale score, QOLsocial = FACT-O
social/family subscale score, QOLemot = FACT-O emotional subscale score, QOLfunct = FACT-O functional subscale score, QOLovar = FACT-O ovarian subscale score, Depression = DASS-21 depres-
sion score, Anxiety = DASS-21 anxiety score, Stress = DASS-21 stress score.
*p < .05
**p < .01.
 Psychology, Health & Medicine  557

Table 4. Summary of QOL and mental health hierarchical linear regression models.
Outcome variable Final model summary Significant predictors in final model
FACT-O total F (4, 93) = 12.10, p < .001, R2 = .342, Adj. R2 = .314 Remission status (β = .445, p < .001)
2
Rchange = .135, p < .001 Emotional SS seeking (β = .331, p = .005)
FACT-O physical F (4, 93) = 9.11, p < .001, R2 = .282, Adj. R2 = .251 Remission status (β = .510, p < .001)
2
Rchange = .022, p = .252
FACT-O social/family F (4, 93) = 10.11, p < .001, R2 = .303, Adj. R2 = .273 Emotional SS seeking (β = .521, p < .001)
2
Rchange = .280, p < .001
FACT-O emotional F (4, 93) = 12.25, p < .001, R2 = .345, Adj. R2 = .317 Remission status (β = .569, p < .001)
2
Rchange = .020, p = .244
FACT-O functional F (4, 93) = 6.97, p < .001, R2 = .231, Adj. R2 = .198 Remission status (β = .292, p = .002)
2
Rchange = .133, p = .001 Emotional SS seeking (β = .282, p = .026)
FACT-O ovarian F (4, 93) = 6.16, p < .001, R2 = .209, Adj. R2 = .175 Remission status (β = .349, p < .001)
2
Rchange = .076, p = .014
Depression (DASS-21) F (4, 93) = 3.82, p = .006, R2 = .141, Adj. R2 = .104 Emotional SS seeking (β = −.309, p = .021)
2
Rchange = .106, p = .005
Anxiety (DASS-21) F (4, 93) = 1.50, p = .208, R2 = .061, Adj. R2 = .020 Final model not significant
2
Rchange = .022, p = .341
Stress (DASS-21) F (4, 93) = 2.31 p = .064, R2 = .090, Adj. R2 = .051 Final model not significant
2
Rchange = .029, p = .237
Notes: Each hierarchical linear regression included two blocks. Block one included covariates only – age and remission
status. Block two (the final model) included covariates with the addition of emotional social support seeking and instru-
mental social support seeking. Statistics reported in the table refer to the final model.

emotional, functional and ovarian cancer-specific domains than women who were not in
remission. After controlling for age and remission status, emotional social support seeking
was predictive of overall QOL, social/family QOL and functional QOL.
For the mental health regression models, only the depression model was significant. In
the depression model, emotional social support seeking was negatively predictive of depres-
sion scores. The anxiety and stress models were not significant. Instrumental social support
seeking was not a significant predictor in the QOL or mental health regression models.

Discussion
The aim of the present study was to examine the role of emotional and instrumental social
support seeking in the QOL and mental health of ovarian cancer survivors. Results indicated
that after controlling for remission status, emotional social support seeking was predictive
of higher overall QOL, social/family QOL, functional QOL and lower depression scores.
Remission status was significant in all of the QOL models, with the exception of social/
family QOL, but it was not predictive in any of the mental health models. Overall, the
results of the study indicate that emotional social support seeking is an important coping
strategy for women currently experiencing treatment for ovarian cancer as well as for those
who are in remission.
In comparing the two forms of social support seeking, emotional social support seeking
was predictive of QOL and decreased mental health symptoms, while instrumental social
support seeking was not a significant predictor in any of the models. Similarly, in early
research, Smith, Redman, Burns, and Sagert (1986) found that, among breast, endometrial
and ovarian cancer patients, the most beneficial type of support was socioemotional. It is
possible that emotional social support seeking is particularly helpful because it facilitates
opportunities for emotional disclosure. The seeking and, in turn, receiving of emotional
558 E. M. Hill

social support could also help in facilitating health-promoting behaviors like healthcare
seeking (Jackson et al., 2007) or self-care behaviors (e.g. eating well, physical activity; Park et
al., 2008) that can help contribute to QOL. Further research on the potential behavioral and
psychological mediators involved in the link between social support seeking and well-being
is needed to expand this area of study.
It is notable that while emotional social support seeking was predictive of overall QOL,
social/family QOL, functional QOL and decreased depression, it was not predictive of the
other outcomes examined. Given the predictive power of remission status across the mod-
els, it is possible that the physical experience of the disease and/or treatment is so closely
linked to certain domains of QOL (e.g. physical, ovarian cancer-specific concerns) that
social support seeking was not able to explain any additional variance in those models.
Indeed, research indicates that QOL fluctuates in accordance with the disease status or
disease trajectory (Arriba, Fader, Frasure, & von Gruenigen, 2010; Price et al., 2013), and
therefore the physical state of the ovarian cancer patient remains a salient factor in QOL.
In light of the mixed influence of emotional social support seeking in the models of the
present study, cognitive coping strategies and their role in the QOL and mental health of
ovarian cancer patients should be considered in this area of study. In a recent study, Price
et al. (2013) found that cognitive-oriented coping including optimism, helplessness/hope-
lessness and minimization measured at the beginning of the last year of life predicted QOL
closer to death. Therefore, while social support seeking appears to be important in facili-
tating well-being among women with ovarian cancer, the role of cognitive reframing and
other cognitive strategies must also be noted. The present study’s findings also highlight that
QOL among ovarian cancer patients is, indeed, multidimensional, and that certain coping
strategies may have an impact on certain QOL domains, while other coping strategies may
help to improve other QOL domains.
The strengths and limitations of the present study must be acknowledged. First, a strength
of the study was that the participants were recruited from the PCR, a population-based reg-
istry. Although the use of a population-based registry allows women in both rural and urban
settings the opportunity to be represented in research, it must be noted that some groups
were underrepresented or not represented in the present study. African-American women,
despite accounting for 7.2% of ovarian cancer cases in Pennsylvania in 2011 (Pennsylvania
Department of Health, 2014), were not represented. Younger women (<50 years of age) were
also underrepresented, which is important limitation given that younger ovarian cancer
patients report different psychosocial needs and concerns than older ovarian cancer patients
(Roland et al., 2013). The underrepresentation of certain groups relates generally to the
relatively low response rate in the present study, which may impact the generalizability of
the results. The time of data collection relative to time of diagnosis (2014 vs. 2011) is an
important consideration; the women who took part may be healthier and therefore this
potential bias in the data must be considered.
It is also noteworthy that the present study examined social support-related coping
mechanisms rather than objective social support (e.g. marital status, number of individ-
uals that currently live with the participant) or perceived social support, which are also
important considerations in this area of study. Nonetheless, given the relationship between
emotional social support seeking and both QOL and decreased depression, it is pertinent
that patients, loved ones and healthcare professionals acknowledge and consider promoting
 Psychology, Health & Medicine  559

emotional social support seeking as a potentially effective coping mechanism both during
active treatment and when in remission.
Finally, it must be emphasized that the current study was cross- sectional in nature. It is
possible that the coping strategies, mental health and QOL of the participants fluctuated
since time of diagnosis. In a related thread, the study was correlational and therefore the
direction of the associations cannot be determined from the results. Helgeson and Cohen
(1996) noted that it is possible that social support facilitates adjustment, but it could also be
that positive adjustment to cancer leads to increased supportive interpersonal relationships
and perhaps increased social support seeking. Future longitudinal studies that examine
social support-related coping mechanisms and changes in QOL and health over time would
help in clarifying the direction of the relationships observed in the present study.

Conclusion
Overall, the results of this study identify emotional social support seeking as an impor-
tant coping strategy for QOL and decreased depression among ovarian cancer patients
both in remission and not in remission. Future research should consider looking at the
relationship between social support seeking and the social support received, and how this
interaction impacts the QOL and mental health of women with ovarian cancer. Due to the
high symptom burden, invasive treatments and lengthy disease trajectories, understanding
the psychosocial needs, QOL and mental health of women with ovarian cancer remains an
important research endeavor.

Acknowledgments
I would like to acknowledge the assistance of Kaitlin Watkins, Molly Weyant, and Erin Ziegelmeyer
with this research.

Disclosure statement
No potential conflict of interest was reported by the author.

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