The Effects of Perceived Social Support, Psychological Resilience and Coping Strategies on Life Satisfaction in Men Diagnosed with Testicular Cancer

Testicular cancer is one of the most common cancers among young men. The patients diagnosed with testicular cancer may experience psychological disturbances during its diagnosis and treatment process. The present study was examined the effects of perceived social support, psychological resilience and coping strategies on life satisfaction in men diagnosed with testicular cancer. This cross-sectional data was obtained from the participants through different scales. The statistical analysis was included descriptive analysis and multiple logistic regression model for the variables. A total of 174 patients, mean 36, range=20-60 years, were included in the study. Results showed that the variables of HADS depression, HADS anxiety, perceived social support, psychological resilience and coping strategies included in the multiple logistic regression analysis explained the change in life satisfaction variance by 42% (R 2 =6.351; R 2 =0.423) determined by p <0.005. The statistical signicance was found for HADS depression score (t=-0.31; p=0.000), HADS anxiety (t=-1.07, p=0.002) and psychological resilience (t=-0.23, p=0.001) in terms of life satisfaction levels of patients treated with testicular cancer. There was no statistical signicance found among other variables and life satisfaction levels of patients (p>0.005). Testicular cancer, which is common among men, causes negative consequences on the life of individuals. Social support of the patients both during the diagnosis period and during the treatment, it causes changes in life satisfaction and psychological resilience. Therefore, psychological problems such as a decrease in the coping strategies of the patients, depression or anxiety are beginning to be observed.


Introduction
Testicular cancer is the most common cancer seen in young men. This cancer, which is seen in early ages, affects the family life, career and especially sexual functions of men. With an adequate oncological care, it is most curable cancer with a more than 95% of survival rate [1]. In the studies conducted, psychological disturbances caused by sexual dysfunction and the thought of experiencing infertility problems in the future were found in patients diagnosed with testicular cancer [2]. While high levels of anxiety and depression symptoms were detected in the patients, it was argued that these could have a negative effect on the quality of life of the patients [3]. Testicular cancer and its diagnosis cause some psychological problems in patients. Patients who need psychological support both after the diagnosis and during the treatment process, not knowing the strategies to cope with the problems may cause some negative reactions [4]. The study result demonstrated that erection, ejaculation disorders, fear of infertility and body image problems occur frequently [5]. Testicular cancer is a condition that creates problems with a major life crisis and psychological chronic stress in the diagnosis and medical treatment process among couples. Also, testicular cancer, which is a life crisis for individuals; it reduces the psychological resilience of individuals and partners, forces coping strategies, consumes their energy both physically and psychologically [6]. However, the diagnosis and treatment of testicular cancer also negatively affects the life satisfaction of individuals. For this reason, the diagnosis and treatment process of cancer is a process in which individuals need more social support and want to perceive this support at a high level. Since the life expectancy of cured testicular patients is long, minimizing the effects on long-term health and quality of life are important goals [7]. Although it is predicted that patients' psychological resilience and life satisfaction and often psychological symptoms may be observed during the treatment process of testicular cancer, there is no study conducted on this subject.
This study aimed to investigate the effects of perceived social support, psychological resilience and coping strategies on the life satisfaction variable of patients diagnosed with testicular cancer. In addition, it was aimed to reveal the effects of depression, somatization and anxiety that patients have on life satisfaction.

Study Design
The study was a descriptive and cross-sectional study using survey questionnaires to measure the outcome variables. A total of 174 men diagnosed with a testicular cancer at the age of 20-60 were included in the study. The survey method was used to collect data from the participants.

Instruments
Participants' socio-demographic characteristics such as age, marital status, educational level, income and other clinical characteristics were collected and evaluated.

Hospital Anxiety and Depression Scale (HADS)
The Hospital Anxiety and Depression Scale is a commonly use for the participants to measure anxiety and depression levels. Consisting of 14 items, HADS measures both anxiety (HADS-A) and depression (HADS-D) levels with an equal number of questions. Patients rank the question on a Likert scale ranging from 0 to 3 and the subscale from 0 to 21. A total score of 8 or above was de ned as an optimal cut-off score for comfort for both anxiety and depression.
The Multidimensional Scale of Perceived Social Support (MSPSS) Multidimensional Perceived Social Support Scale was developed to determine the social support elements perceived by individuals. It consists of 12 items in total. It is a 7-point (1-7 points), likert-type scale ranging from "absolutely no" to absolutely yes. The source of perceived social support can be measured in three sub-dimensions: family, friends, and signi cant others. The lowest score that can be obtained from the subscales is 4 and the highest score is 28. The lowest score to be obtained from the whole scale is 12, and the highest score is 84.

The Coping Attitudes Scale (CAS)
The scale consists of 60 questions and 15 subscales. Each of these scales provides information about a separate coping attitude. As a result, the higher the scores to be obtained from the subscales give the possibility to comment on which coping attitude is used more by the person. Five of these coping attitudes (active coping, planning, suppressing other occupations, holding back, use of useful social support) are classi ed as problem-focused. The other ve coping attitudes (use of emotional social support, positive reinterpretation and development, acceptance, joking, and religious coping) are classi ed as emotion-oriented. The other ve coping attitudes (focusing on the problem and revealing emotions, behavioral disengagement, substance use, denial and mental disengagement) are classi ed as the least useful non-functional coping attitude. means that his/her life satisfaction is low and that he/she gets a high score means that his / her life satisfaction is high.

The Resilience Scale for Adults (RSA)
It is a 5-point Likert-type scale that includes a total of 33 items, in order to avoid biased evaluations in choosing the items, in which positive and negative features are on different sides. The dimensions in the scale are named as 'self-perception', 'future perception', 'structural style', 'social competence', 'family adaptation' and 'social resources'. In the assessment, the scoring method was allowed to measure psychological resilience high or low, and it was suggested that existing inverse questions should be evaluated according to this scheme. Friborg et al. (2003) were developed the scale.

Statistical Analyses
The obtain data was analyzed using the SPSS 23 package program. The descriptive analysis including mean, standard deviation, percentage and frequency were calculated. Logistic regression and multiple linear regression analysis were used to examine whether the study has a signi cant predictive effect on dependent variables. The statistical signi cance was taken as p <0.05.

Results
A total of 173 testicular cancer patients were included in this study with a mean age of 36 (SD 12.76). The majority of them (81.1%) were married, had tertiary education (41.9%) and low income (67.8%). The most of them were smoked cigarettes (62.6%) and used alcohol (72.9%). In addition, the majority of them had surgery (64.3%) and had no comorbidities (79.3%). In Table 2, mean scores, standard deviation and ranges of domains of HADS, MSPSS, CAS, SWL and RSA were presented. The mean HADS-anxiety score was 1.9 (SD = 2.9) while the mean score of HADSdepression was 1.   Table 3 presents multiple logistic regression to determine whether the independent variables had an effect on the result. Analyzes were performed using the enter model in multiple linear regression analysis.
The signi cance and explanation percentage of the model with all variables were calculated. In the regression analysis, the model was created with the stepwise variable selection method. The modeling process was performed with the independent variables of HADS anxiety, HADS depression, MSPSS, CAS, SWL and RSA. These independent variables were scored with the calculations speci ed in the scales. Accordingly, the model was found to be signi cant as a result of the variance analysis of the regression equation obtained as a result of the analysis (F = 6.138; p < 0.05). Accordingly, the variables of HADS depression, HADS anxiety, perceived social support, psychological resilience and coping strategies included in the multiple linear regression analysis explained the change in life satisfaction variance by 42% (R 2 = 6.351; R 2 = 0.423) determined (p < 0.005). The statistical signi cance was analyzed of the independent variables and the result showed that HADS depression score (t =-0.31; p = 0.000), HADS anxiety (t =-1.07, p = 0.002) and psychological resilience (t=-0.23, p = 0.001) were found to be signi cant in terms of life satisfaction levels of patients treated with testicular cancer. There was no statistical signi cance found among other variables and life satisfaction levels of patients (p > 0.005). Discussion Testicular cancer is the most common type of cancer in almost 1% of men between the ages of 20 and 40 [8]. The most common problems faced by patients diagnosed with testicular cancer are sexual function problems. However, the most common mental problems among patients were stated as anxiety and depression. Factors such as the diagnosis of cancer, age, family history, smoking, alcohol use and psychological endurance were among the important factors affecting the treatment process of the disease [9]. The ages of the participants in the study ranged from 20 to 60 and the mean age was 36. The education level of patients diagnosed with testicular cancer is very important in terms of treatment process, reproductive and health behaviors. This variable affects the perception of cancer and the level of cancer-related problems [10]. For this reason, those with a high level of education may be more conscious during the treatment process. When the educational status of the participants was evaluated, it was found that most of the participants were tertiary (41.9%). The low education level of individuals; it is thought to lead to a decrease in their quality of life, less awareness of health risks, not knowing about health protective measures, not being able to use coping strategies when they experience health problems, and a decrease in their psychological resilience. The results from this study show that the majority of men diagnosed with testicular cancer patients report high level of anxiety and depression symptoms. Also, the results of the study indicate an increased occurrence of psychological resilience after a diagnosis of testicular cancer [11]. There was a signi cant different between the patients who had diagnosed with testicular cancer, levels of depression, anxiety and psychological resilience. Although, there is a gap in the literature regarding this subject and testicular cancer patients, previous studies reported that psychological problems such as high level of anxiety and depression symptoms are related to testicular cancer patients during diagnosis and treatment process [12]. The study results have shown that psychosocial factors such as emotional disorders, spouse problems, lack of social support or social exclusion accompanying patients' increased stress can lead to a decrease in life satisfaction [13]. In addition, other studies reported that the social support perceived by cancer patients from their spouses has positive effects on life satisfaction. Social support directly affects life satisfaction in cancer patients' coping with the disease during the treatment process [14]. It has been reported that the level of psychological resilience due to stress and anxiety decreases in patients diagnosed with testicular cancer and treated [15]. Thus, this has a negative effect on the quality of life. The psychological resilience of the patients is related to different variables in the treatment process and the importance of supporting psychological resilience in coping with the negativities experienced by the individuals and increasing their life satisfaction. In this study, it was found that resilience has a positive effect on life satisfaction.
Although there are no studies on the low relationship between testicular cancer, which is one of the traumatic and negative life events, and life satisfaction, it has been reported in other cancer studies that individuals with more coping strategies have more positive life satisfaction. It has been reported that coping strategies directly contribute to changes in life satisfaction and are likely to change the level of life satisfaction.

Conclusion
Testicular cancer, which is common among men, causes negative consequences on the life of individuals. Social support of the patients both during the diagnosis period and during the treatment, it causes changes in life satisfaction and psychological resilience.
Therefore, psychological problems such as a decrease in the coping strategies of the patients, depression or anxiety are beginning to be observed. Testicular cancer is not only an oncological disorder, but also psychologically, and patients should be given support to cope with psychological disturbances and increase their psychological resilience.