This study examined the hypothesized SEM of PTG based on FH and the mediating roles of PCER and SOC. The findings of this study provide information that could help develop a new approach for conducting targeted interventions to develop PTG in patients with lung cancer undergoing chemotherapy.
This study found a significant and positive correlation between FH and PTG in patients with lung cancer undergoing chemotherapy, which was consistent with Hypothesis 1 and the family systems theory [48]. According to the family systems theory, stronger family systems and better family support help enhance the intimate relationship between individuals and family members [49]. Cognitive, affective, and behavioral influences among family members in the family system are reciprocal [50]. This is manifested in seeking help from family members when experiencing financial difficulties in the course of treatment, sharing painful feelings with family members when experiencing the side effects of chemotherapy, and discussing and reflecting on ways to alleviate the toxic side effects. These methods can enhance the relationship between patients with lung cancer undergoing chemotherapy and their family members [51], which facilitates their growth by reflecting on the positive effects of trauma. In addition, family members actively organize family activities and increase the frequency of communication among family members, providing family support and care for patients with lung cancer undergoing chemotherapy. This mobilizes FH within the family system. FH can alleviate negative emotions, such as fear, anger, and frustration, in patients with lung cancer undergoing chemotherapy [52], helping them accept the current situation and actively participate in the management of family affairs. FH facilitates the exploration of new possibilities for oneself, overturning the idea that they will be abandoned by the world if they are sick, reconnecting with their personal values, and resisting trauma with a positive and optimistic mindset to obtain PTG [53]. In addition, FH in the family support system allows patients with lung cancer undergoing chemotherapy to actively plan and seek solutions to the trauma of their current treatment and disease, rather than focusing on determining why the disease occurred and complaining that modern medical technology cannot cure the disease [54]. This problem-oriented approach helps patients with lung cancer undergoing chemotherapy utilize available medical and family resources, reduce trauma, develop their ability to resist illness, solve problems, and thrive [55]. Therefore, we recommend building positive family social networks, enriching the family social structure, strengthening communication between patients with lung cancer undergoing chemotherapy and family members, and enhancing FH to promote PTG.
The results of this study showed that PTG, PCER, and FH levels in patients with lung cancer undergoing chemotherapy were significantly and positively correlated. Moreover, PCER partially mediated the relationship between PTG and FH, which was consistent with Hypothesis 2 and the family systems theory. According to this theory, FH is a family resource that can help individuals develop PCER and obtain PTG [44]. Lung cancer has a 27% incidence and mortality rate, which are higher than other cancers [52]. Patients undergoing chemotherapy often experience side effects, such as nausea and vomiting, which trigger a disturbance in the secretion of antidiuretic hormones [53], leading to delayed excitation of the excitatory central nervous system and, ultimately, negative emotions, such as anger, frustration, and distress. All of these factors cause family concerns [54]. FH provides material, conditional, and emotional resources for patients with lung cancer undergoing chemotherapy and helps them construct the belief of changing life events through their own actions to alleviate negative emotions and re-establish PCER. Furthermore, FH helps patients with lung cancer undergoing chemotherapy actively cooperate with medical personnel during treatment, become physically active, and accept the diagnosis of lung cancer [59]. In addition, FH helps patients with lung cancer undergoing chemotherapy break down the physical and psychological problems encountered during chemotherapy and reflect on why the trauma occurred and what was done to alleviate it. This provides experiences in preventing and controlling trauma [60], such as actively cooperating with treatment and establishing healthy lifestyles and behaviors. Moreover, this study found that PTG increased in patients with lung cancer undergoing chemotherapy after using PCER. This may be because 49.8% of the participants in this study had stage IV cancer. Death is the greatest threat during this period. This threat reduces their appreciation of life and increases their fear of the disease. Fear of illness was much higher among patients with lung cancer (71%) than those with other cancers (4–41%) [60]. In contrast, PCER not only alleviates fear but also helps people seek meaning in their lives after the trauma, enhance their understanding of the nature and effects of trauma, and complete the process of meaning construction and benefit finding [22]. FH should be used in the future to provide patients with lung cancer undergoing chemotherapy with as many family resources as possible and actively organize family activities to enrich their daily lives [61]. In addition, care for patients with lung cancer undergoing chemotherapy should include psychological training to develop PCER and ability to find benefits and express and manage emotions [62].
The results of this study showed that PTG, SOC, and FH in patients with lung cancer undergoing chemotherapy were significantly and positively correlated, and SOC partially mediated the relationship between PTG and FH, which was consistent with Hypothesis 3 and the resilience theory. According to the resilience theory, a good survival environment can reduce the negative effects of risk on individuals and help them find opportunities in adversity [63]. Some studies have shown that patients with advanced lung cancer undergoing chemotherapy have a higher symptom burden and an interrelated physical and psychological symptom cluster, leading to psychological problems [64, 65]. Tolerance and support from family members help patients rebuild their belief systems, enabling them to correctly understand the onset and progression of the disease and utilize their own psychological resources to resist and overcome trauma. Furthermore, family support helps them to alleviate the shame and guilt caused by the belief that smoking leads to lung cancer [66]. Moreover, family support promotes the development of SOC [52]. Similar results were observed among Chinese patients with breast cancer and thyroid cancer [67, 68]. This may be related to the Chinese Confucian culture, in which the family is the basic unit of individual social activity. Maintaining the psychological health of patients with cancer is important. High levels of SOC help patients express their emotions, accept adversity, and seek opportunities for individual growth from trauma [69]. Comprehensibility, manageability, and meaningfulness are important components of SOC [38]. Manageability has the largest effect on SOC, suggesting that it plays an important role in strengthening FH for PTG. Patients with lung cancer undergoing chemotherapy with strong manageability use electronic devices to find out more about the current state of their lung cancer treatment and read hospital health pamphlets to learn more about the adverse symptoms of chemotherapy [70]. All these pathways alleviate the uncertainty of the disease in patients with lung cancer undergoing chemotherapy and help them develop positive qualities, such as optimism, hope, and bravery. Furthermore, these pathways enhance their personal strength, allow them to correctly assess their personal abilities, and support the development of PTG [71]. Therefore, enhancing the SOC of patients with lung cancer undergoing chemotherapy is important to strengthen the impact of FH on PTG. The results of this study showed that SOC and PCER mediated the relationship between FH and PTG, which was consistent with Hypothesis 4. The mediating effect of SOC was stronger than that of PCER. Therefore, this study suggests that healthcare professionals should implement mental health interventions from a family perspective to help patients with lung cancer undergoing chemotherapy establish belief systems, enhance self-confidence, and confront the disease and treatment [72, 73] to enhance their PTG with a focus on SOC.
This study had several limitations. First, this study used non-probability convenience sampling; therefore, there may have been selection bias in the selection of participants. Moreover, this study investigated only patients receiving lung cancer chemotherapy in the oncology departments of two tertiary care hospitals in Shandong Province, China. Therefore, these findings may not be applicable to other regions. Follow-up studies should be conducted with larger samples. Third, this was a cross-sectional study, and the causal relationship of the hypothetical model could not be determined. Therefore, longitudinal or randomized controlled trials should be conducted to validate the findings of this study. Fourth, this study had a confounding bias. This study only explored the relationship between PCER, SOC, PTG, and FH and did not consider the effects of underlying demographic factors on the four variables. Further investigations should analyze the differences in the demographic information of the four variables and investigate the relationship between the four variables among demographic subgroups. Despite the aforementioned shortcomings, this study incorporated the family systems and resilience theories to enrich the study of the mechanisms between FH and PTG.