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Volume 17, Issue 3 (2025)
Iran J War Public Health 2025, 17(3): 229-235 |
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Received: 2025/05/16 | Accepted: 2025/06/27 | Published: 2025/07/23
Received: 2025/05/16 | Accepted: 2025/06/27 | Published: 2025/07/23
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Jasim D, Mohammed W. Social Support as a Mediator between Resilience and Quality of Life in Gastrointestinal Cancer Patients Receiving Chemotherapy. Iran J War Public Health 2025; 17 (3) :229-235
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Authors
D.H. Jasim *1, W.K. Mohammed2
1- Ministry of Health, Missan Health Directorate, Missan, Iraq
2- Department of Adult Nursing, Faculty of Nursing, University of Baghdad, Baghdad, Iraq
2- Department of Adult Nursing, Faculty of Nursing, University of Baghdad, Baghdad, Iraq
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Introduction
Gastrointestinal (GI) cancers are some of the most frequently occurring types of malignancies worldwide [1]. These cancers often present significant challenges in terms of diagnosis and treatment, as symptoms can be vague and easily attributed to other conditions. GI cancer encompasses a variety of cancers that can affect any part of the GI tract, including the esophagus, stomach, colon, rectum, anus, gallbladder, pancreas, or liver [2]. The incidence of GI cancers is influenced by various factors, including diet, lifestyle, genetics, and environmental exposures, making prevention and early detection critical. Effective management of GI cancers requires a multidisciplinary approach that includes surgery, chemotherapy, radiation therapy, and supportive care to improve patient outcomes and quality of life.
Chemotherapy is one of the most common types of treatment for many kinds of cancer [3]. This treatment involves the use of powerful drugs that target rapidly dividing cancer cells, but it can also affect healthy cells, leading to a range of side effects such as nausea, fatigue, and hair loss. The effectiveness of chemotherapy can vary depending on the type of cancer, the stage of the disease, and individual patient factors, making personalized treatment plans essential. Furthermore, advancements in chemotherapy, including targeted therapies and combination regimens, continue to improve outcomes and enhance the quality of life for patients undergoing treatment. It is used to treat cancer or palliate the condition by shrinking tumors to reduce symptoms associated with cancer [4, 5]. However, it often results in debilitating side effects, such as fatigue, pain, and emotional distress [6]. The administration of chemotherapy on multiple occasions has deleterious implications for the physical and social functions of individuals afflicted with cancer [7]. In addition to the physical toll, these side effects can significantly impact a patient’s quality of life, leading to isolation and a decreased ability to engage in daily activities. Many patients also experience anxiety and depression as they navigate the challenges of treatment, which can further exacerbate feelings of helplessness. Consequently, it is essential for healthcare providers to offer comprehensive support services, including psychological counseling and symptom management, to help patients cope with the multifaceted effects of chemotherapy. The need for comprehensive care that addresses both the physical and psychological aspects of cancer treatment is increasingly recognized in the literature [8]. Maintaining a high quality of life (QOL) is particularly important for cancer patients undergoing chemotherapy, as the treatment can be both physically and emotionally taxing [9].
In recent years, positive psychology has evolved significantly, with resilience emerging as a pivotal focus in mental health research both domestically and internationally [10, 11]. Seiler and Jenewein discovered that the physiological foundation of psychological resilience in cancer patients lies in the adaptability of the “reward and fear circuit” [12]. Cancer patients with higher psychological resilience generally experience better mental and physical well-being. Therefore, it is essential for cancer patients to explore strategies for building psychological resilience, as it can significantly improve their mental health [13].
Social support has been shown to help cancer patients cope better with their illness and adapt quickly to changes, serving as a psychological intervention that contributes to successful disease management [14]. This support can come from various sources, including family, friends, support groups, and healthcare providers, all of which play a crucial role in providing emotional reassurance and practical assistance. Furthermore, the presence of a strong support network can reduce feelings of isolation and anxiety, ultimately leading to improved treatment adherence and better overall health outcomes. Additionally, it has been found that the greater the social support, the lower the depression rates in patients, and that social support has a positive impact on resilience [15, 16]. Emotional and informational support from family, friends, and healthcare providers can alleviate stress and improve coping mechanisms [17]. Furthermore, social support serves as a preventive factor for QOL and is a crucial predictor of well-being in cancer patients [18, 19].
GI cancer patients experience psychological distress, which affects their QOL over time [20, 21]. This distress can manifest in various forms, including anxiety, depression, and fear of recurrence, significantly impacting their emotional well-being and daily functioning. Furthermore, the psychological burden can lead to decreased treatment adherence and hinder the patients’ ability to engage in social activities, compounding feelings of isolation and helplessness. Resilience acts as a buffer against the psychological distress associated with cancer, mediating the relationship between hope and spiritual well-being [22]. This psychological trait helps patients adapt to the challenges of cancer treatment [8]. Low resilience has been associated with a greater degree of psychological suffering, including depression and anxiety, which can negatively impact treatment adherence and outcomes [23, 24]. When individuals lack the coping mechanisms necessary to navigate the challenges of their illness, they may become overwhelmed by stressors, leading to a cycle of despair that further diminishes their motivation to follow through with prescribed treatments. Additionally, the interplay between low resilience and psychological distress can create barriers to effective communication with healthcare providers, as patients may struggle to express their needs or concerns, ultimately compromising their overall care. Recognizing and addressing low resilience in cancer patients is crucial, as enhancing their coping strategies can foster a more positive outlook and improve both adherence to treatment and health outcomes.
Screening for poor resilience could enhance QOL by addressing negative emotions and boosting resilience through appropriate interventions [25, 26]. Understanding how social support influences this relationship is crucial, as it can inform targeted interventions that not only improve resilience but also enhance the overall well-being of patients. Additionally, this study addresses a significant gap in the literature by exploring the complex interplay between psychological factors and social dynamics, which is often overlooked in cancer care. Ultimately, the findings could lead to the development of comprehensive support programs that empower individuals with cancer, fostering both emotional and social resources that contribute to better health outcomes. The aim of this study was to investigate the mediating role of social support in the relationship between resilience and QOL.
Instrument and Methods
Study design and Sample
This quantitative, descriptive cross-sectional study was conducted on 275 patients with GI cancer receiving chemotherapy from October 27, 2024, to April 30, 2025. The study was undertaken in three Iraqi governorates, including the Al-Shifa Oncology Center in the Missan Health Directorate, the Specialized Oncology Center in the Basra Health Directorate, and the Oncology Center at Al-Haboubi Hospital in the Dhi Qar Health Directorate. These settings were chosen because they care for many cancer patients receiving chemotherapy, making them ideal for recruiting participants. The study sample was selected using a non-probability (purposive) sampling method.
The inclusion criteria for the study required participants to be adults diagnosed with stage III or IV GI cancer who were receiving chemotherapy, at least 18 years old of both sexes, able to read and write, have undergone at least two sessions of chemotherapy, and voluntarily agreed to participate in the study. Patients were excluded if they had cognitive impairments that would affect their ability to complete questionnaires, were unable to read or write, were undergoing their first chemotherapy session, or refused to participate.
The total population size of GI cancer patients undergoing chemotherapy at the selected oncology centers was 1,135. Considering a confidence level of 95% and a margin of error set at 5%, the sample size was calculated using standard formulas for sample size estimation to be 287. However, the final sample size included 275 participants, as 12 invalid or incomplete questionnaires were eliminated.
Research tools
The demographic and clinical data form
This form collected demographic information, including age, sex, marital status, education level, occupation, and monthly income. Clinical information included the type of cancer, the stage of cancer, and the duration of treatment.
Connor-Davidson Resilience Scale (CD-RISC10)
Developed by Dr. Kathryn Connor and Dr. Jonathan Davidson between 2001 and 2013 [27], the Arabic version was translated by Hamed et al. [28]. This scale consists of 10 items designed to assess the respondent’s resilience. The items are evaluated using a five-point Likert scale (range 0-4). The overall score (range 0-40) is calculated, with higher scores indicating enhanced resilience. Each item score is summed to compute the overall score.
European Organization for Research and Treatment of Cancer Quality of Life (EORTC QLQ-F17)
The EORTC QLQ-F17 is a QOL instrument developed by the EORTC QOL group [29]. It is designed to assess QOL in cancer patients. The questionnaire comprises functional domains and global health status/QOL, with a total of 17 items. Responses are recorded using a Likert scale, typically ranging from 1 to 4 or 1 to 7. Scores for each domain are calculated by averaging the scores of the items within that domain. The scores can be converted to a scale of 0-100, where higher values indicate better functioning or an improved QOL.
Multidimensional Scale of Perceived Social Support (MSPSS-12)
This scale assesses perceived social support from family, friends, and significant others [30]. It consists of 12 items evaluated on a five-point Likert scale (range 1-5). Scores range from 12 to 60, with higher average scores representing greater social support.
Data analysis
SPSS 26 was utilized for coding and analyzing the data. Statistical methods were applied, and the Hayes Macro Test was employed to test the moderating role [31].
Findings
Patients in the age group of 50-59 years constituted the largest proportion at 26.2%, followed by the age groups of 30-39 years (22.2%) and 40-49 years (18.9%). The mean age was 45.05±13.53 years, ranging from 20 to 70 years, with an average of 45.05 years. In terms of sex, 58.9% of patients were male and 41.1% were female. Married patients constituted the largest proportion at 75.6%. Regarding education, the largest proportion of patients completed their education at the university level (31.3%) or at an institute (27.6%). As for employment, 43.6% of patients were unemployed, while 35.3% were employed in the government sector. In terms of monthly income, 44% of patients earned less than 300,000 Iraqi dinars (Table 1).
Table 1. Frequency of socio-demographic characteristics of patients with gastrointestinal cancer (n=275)
As for the type of cancer, colon cancer constituted the largest percentage at 62.9%, followed by stomach cancer at 12.0%, and both rectal and pancreatic cancers at 8.7% each, while liver cancer represented 7.6%. Regarding the cancer stage, 70.2% of patients were in stage III, and 29.8% were in stage IV. In terms of the duration of chemotherapy, 37.1% of patients received treatment for a period of 3 to 8 months, while 28.4% received treatment for a period of 9 to 14 months. The mean duration of chemotherapy was 13.11±8.26 months (Table 2).
Table 2. Frequency of clinical characteristics of patients with gastrointestinal cancer (n=275)
The mean resilience score was 22.84, reflecting a generally low level of psychological resilience. The table indicates that the mean perceived social support score was 44.62, suggesting that most participants had a high level of perceived social support.
Additionally, the mean physical performance score was 50.87, indicating a good level of physical ability. The mean functional performance score was 26.69, reflecting significant limitations in performing daily roles. Cognitive performance recorded a mean score of 64.62, indicating a good level of cognitive ability, while emotional performance recorded a mean score of 40.15, indicating significant emotional challenges. Social performance achieved a mean score of 54.18, reflecting relatively good social interactions. Global Health Status/QOL achieved a mean score of 48.08, indicating a poor level with a significant impact on health status. Finally, the mean overall QOL score was 47.43, reflecting a relatively poor ability to adapt to health conditions (Table 3).
Table 3. Mean scores of resilience, quality of life, and social support in the studied patients (n=275)
The total effect of resilience on QOL was 0.7227, indicating that increased resilience is associated with increased QOL (p<0.001), and this relationship was not random. When examining the direct effect only, it remained positive but was less strong, at 0.4031, indicating that part of the effect of resilience on QOL occurred directly without reliance on social support. The indirect effect via social support was 0.3196 and was statistically significant (Table 4).
Table 4. Mediation analysis of resilience and quality of life (n=275)
Discussion
This study aimed to investigate the mediating role of social support in the relationship between resilience and QOL. The mediating role of social support in the relationship between resilience and QOL is an important area of study that has significant implications for individual well-being and mental health. The mediating role of social support in this relationship is a critical issue that underscores the interconnectedness of social factors and mental health. By addressing this relationship, we can better understand how to support individuals in their journeys toward resilience and improved well-being.
The average age was 45.05 years; half of the patients were male, and three-quarters of the sample were married. These findings are consistent with some of the preceding local studies conducted in Iraq [32-35]. In the study by Fowler et al. on the association between social vulnerability and geriatric assessment impairments among older adults with gastrointestinal cancers, the sample aged 60 years and older 60.5% were married [34].
Most patients completed their education at a university or an institute, and nearly half of the patients were unemployed and earned less than 300,000 Iraqi dinars monthly. These findings demonstrate similarities to prior studies conducted in Iraq [36-38].
Regarding the type of cancer and duration of chemotherapy, colon cancer constituted the largest percentage, followed by stomach cancer. In terms of the duration of chemotherapy, more than one-third of patients received treatment for three to eight months. These results align with the study by Li et al. [39]. Concerning the cancer stage, nearly three-quarters of patients were in stage III. These findings are similar to those of a study conducted in South Korea, which showed that nearly three-quarters of patients had stage III cancer [40].
Model four of the PROCESS macro procedure was used to examine the mediating effect of perceived social support (PSS) on the resilience and QOL of patients with GI cancer, after controlling for various parameters. The total effect of resilience on QOL was 0.7227, the direct effect value was 0.4031, and the indirect effect via social support was 0.3196. This research indicates that social support may act as a link between resilience and QOL.
This result aligns with previous research indicating that social support partially mediates the correlation between resilience and QOL among individuals diagnosed with breast cancer [41, 42]. Zhang et al. explored the mediator role of social support in patients with breast cancer. They reported that participants with stronger social support have higher resilience and better quality of life, and social support plays a partial mediator role in the relationship between resilience and quality of life. They conceded that social support is essential for the development of resilience and the improvement of QOL in Chinese patients having breast cancer [41]. Çakir et al. assessed the correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery. They used the Connor-Davidson Resilience Scale and the Multidimensional Scale of Perceived Social Support to interview 103 patients undergoing colorectal cancer surgery. Family support and significant other support were positively correlated with subscale and total scores of the Resilience Scale They reported that family support and significant other support are positively correlated with subscale and total scores of the Resilience Scale. They also conceded that social support provided to patients by family and healthcare professionals plays an essential role in increasing resilience [42].
Moreover, research indicates that individuals with low psychological resilience, older age, and reduced social support are at an increased risk of experiencing a decline in QOL [43, 44]. Dai et al. assessed the actuality of resilience, social support, and QOL among patients with inflammatory bowel disease (IBD) in China. They found that enhancing the resilience levels of patients with IBD is essential, particularly for those living in rural areas who may benefit from increased social support. They suggest that a higher level of social support is associated with greater resilience, which is crucial for maintaining the psychosomatic health of IBD patients. Therefore, interventions aimed at improving emotional regulation, coping strategies, and social support should be implemented to boost resilience, manage the condition effectively, and ultimately promote a better QOL [43]. Kuang et al. assessed the effect of psychological resilience on self-efficacy and QOL in patients with diabetic foot ulcers. They declare that individuals with high psychological resilience have significantly higher self-efficacy, general health, vitality, social functioning, role emotional, and mental health compared to those with low psychological resilience. They report that low psychological resilience and older age are risk factors for self-efficacy. Furthermore, they note that low psychological resilience, older age, lower perceived social support, and higher levels of glycated hemoglobin are risk factors for QoL. Additionally, they indicate that males exhibit lower psychological resilience than females, while those receiving more social support demonstrate higher psychological resilience than participants receiving less social support [44].
Receiving higher levels of social support may help improve psychological resilience [10, 42, 45]. This suggests that individuals who experience elevated levels of social support encounter a diminished incidence of adverse health outcomes following stressful events compared to those with minimal social support [46].
It is recommended to establish structured programs to enhance psychological resilience, stress management, and coping skills for GI cancer patients. These programs should incorporate evidence-based therapeutic approaches, such as cognitive-behavioral therapy and mindfulness practices, to equip patients with effective tools for managing their emotional and psychological challenges. They should be part of routine care in hospitals and cancer centers. It is also suggested to strengthen social support networks. It is essential to encourage family involvement and community support to enhance the perceived social support for cancer patients. This could include support groups, counseling sessions, and family education programs. It is also recommended to integrate psychological resilience training into routine care. Psychological resilience training should be a fundamental part of the treatment pathway for GI cancer patients. This can include counseling sessions, resilience workshops, and educational materials that help patients develop stronger coping mechanisms.
Conclusion
Social support mediates the relationship between psychological resilience and quality of life.
Acknowledgments: The authors sincerely thank the patients who participated in this study, as well as all those who provided scientific support and assistance in completing this research.
Ethical Permissions: The authors obtained permission from the scientific committee at the College of Nursing at the University of Baghdad (Code: 27/10/2024) in Baghdad.
Conflicts of Interests: There are no conflicts of interests.
Authors' Contribution: Jasim DH (First Author), Methodologist/Main Researcher/Discussion Writer/Statistical Analyst (70%); Mohammed WK (Second Author), Introduction Writer/Assistant Researcher/Discussion Writer (30%)
Funding/Support: No funding was received.
Gastrointestinal (GI) cancers are some of the most frequently occurring types of malignancies worldwide [1]. These cancers often present significant challenges in terms of diagnosis and treatment, as symptoms can be vague and easily attributed to other conditions. GI cancer encompasses a variety of cancers that can affect any part of the GI tract, including the esophagus, stomach, colon, rectum, anus, gallbladder, pancreas, or liver [2]. The incidence of GI cancers is influenced by various factors, including diet, lifestyle, genetics, and environmental exposures, making prevention and early detection critical. Effective management of GI cancers requires a multidisciplinary approach that includes surgery, chemotherapy, radiation therapy, and supportive care to improve patient outcomes and quality of life.
Chemotherapy is one of the most common types of treatment for many kinds of cancer [3]. This treatment involves the use of powerful drugs that target rapidly dividing cancer cells, but it can also affect healthy cells, leading to a range of side effects such as nausea, fatigue, and hair loss. The effectiveness of chemotherapy can vary depending on the type of cancer, the stage of the disease, and individual patient factors, making personalized treatment plans essential. Furthermore, advancements in chemotherapy, including targeted therapies and combination regimens, continue to improve outcomes and enhance the quality of life for patients undergoing treatment. It is used to treat cancer or palliate the condition by shrinking tumors to reduce symptoms associated with cancer [4, 5]. However, it often results in debilitating side effects, such as fatigue, pain, and emotional distress [6]. The administration of chemotherapy on multiple occasions has deleterious implications for the physical and social functions of individuals afflicted with cancer [7]. In addition to the physical toll, these side effects can significantly impact a patient’s quality of life, leading to isolation and a decreased ability to engage in daily activities. Many patients also experience anxiety and depression as they navigate the challenges of treatment, which can further exacerbate feelings of helplessness. Consequently, it is essential for healthcare providers to offer comprehensive support services, including psychological counseling and symptom management, to help patients cope with the multifaceted effects of chemotherapy. The need for comprehensive care that addresses both the physical and psychological aspects of cancer treatment is increasingly recognized in the literature [8]. Maintaining a high quality of life (QOL) is particularly important for cancer patients undergoing chemotherapy, as the treatment can be both physically and emotionally taxing [9].
In recent years, positive psychology has evolved significantly, with resilience emerging as a pivotal focus in mental health research both domestically and internationally [10, 11]. Seiler and Jenewein discovered that the physiological foundation of psychological resilience in cancer patients lies in the adaptability of the “reward and fear circuit” [12]. Cancer patients with higher psychological resilience generally experience better mental and physical well-being. Therefore, it is essential for cancer patients to explore strategies for building psychological resilience, as it can significantly improve their mental health [13].
Social support has been shown to help cancer patients cope better with their illness and adapt quickly to changes, serving as a psychological intervention that contributes to successful disease management [14]. This support can come from various sources, including family, friends, support groups, and healthcare providers, all of which play a crucial role in providing emotional reassurance and practical assistance. Furthermore, the presence of a strong support network can reduce feelings of isolation and anxiety, ultimately leading to improved treatment adherence and better overall health outcomes. Additionally, it has been found that the greater the social support, the lower the depression rates in patients, and that social support has a positive impact on resilience [15, 16]. Emotional and informational support from family, friends, and healthcare providers can alleviate stress and improve coping mechanisms [17]. Furthermore, social support serves as a preventive factor for QOL and is a crucial predictor of well-being in cancer patients [18, 19].
GI cancer patients experience psychological distress, which affects their QOL over time [20, 21]. This distress can manifest in various forms, including anxiety, depression, and fear of recurrence, significantly impacting their emotional well-being and daily functioning. Furthermore, the psychological burden can lead to decreased treatment adherence and hinder the patients’ ability to engage in social activities, compounding feelings of isolation and helplessness. Resilience acts as a buffer against the psychological distress associated with cancer, mediating the relationship between hope and spiritual well-being [22]. This psychological trait helps patients adapt to the challenges of cancer treatment [8]. Low resilience has been associated with a greater degree of psychological suffering, including depression and anxiety, which can negatively impact treatment adherence and outcomes [23, 24]. When individuals lack the coping mechanisms necessary to navigate the challenges of their illness, they may become overwhelmed by stressors, leading to a cycle of despair that further diminishes their motivation to follow through with prescribed treatments. Additionally, the interplay between low resilience and psychological distress can create barriers to effective communication with healthcare providers, as patients may struggle to express their needs or concerns, ultimately compromising their overall care. Recognizing and addressing low resilience in cancer patients is crucial, as enhancing their coping strategies can foster a more positive outlook and improve both adherence to treatment and health outcomes.
Screening for poor resilience could enhance QOL by addressing negative emotions and boosting resilience through appropriate interventions [25, 26]. Understanding how social support influences this relationship is crucial, as it can inform targeted interventions that not only improve resilience but also enhance the overall well-being of patients. Additionally, this study addresses a significant gap in the literature by exploring the complex interplay between psychological factors and social dynamics, which is often overlooked in cancer care. Ultimately, the findings could lead to the development of comprehensive support programs that empower individuals with cancer, fostering both emotional and social resources that contribute to better health outcomes. The aim of this study was to investigate the mediating role of social support in the relationship between resilience and QOL.
Instrument and Methods
Study design and Sample
This quantitative, descriptive cross-sectional study was conducted on 275 patients with GI cancer receiving chemotherapy from October 27, 2024, to April 30, 2025. The study was undertaken in three Iraqi governorates, including the Al-Shifa Oncology Center in the Missan Health Directorate, the Specialized Oncology Center in the Basra Health Directorate, and the Oncology Center at Al-Haboubi Hospital in the Dhi Qar Health Directorate. These settings were chosen because they care for many cancer patients receiving chemotherapy, making them ideal for recruiting participants. The study sample was selected using a non-probability (purposive) sampling method.
The inclusion criteria for the study required participants to be adults diagnosed with stage III or IV GI cancer who were receiving chemotherapy, at least 18 years old of both sexes, able to read and write, have undergone at least two sessions of chemotherapy, and voluntarily agreed to participate in the study. Patients were excluded if they had cognitive impairments that would affect their ability to complete questionnaires, were unable to read or write, were undergoing their first chemotherapy session, or refused to participate.
The total population size of GI cancer patients undergoing chemotherapy at the selected oncology centers was 1,135. Considering a confidence level of 95% and a margin of error set at 5%, the sample size was calculated using standard formulas for sample size estimation to be 287. However, the final sample size included 275 participants, as 12 invalid or incomplete questionnaires were eliminated.
Research tools
The demographic and clinical data form
This form collected demographic information, including age, sex, marital status, education level, occupation, and monthly income. Clinical information included the type of cancer, the stage of cancer, and the duration of treatment.
Connor-Davidson Resilience Scale (CD-RISC10)
Developed by Dr. Kathryn Connor and Dr. Jonathan Davidson between 2001 and 2013 [27], the Arabic version was translated by Hamed et al. [28]. This scale consists of 10 items designed to assess the respondent’s resilience. The items are evaluated using a five-point Likert scale (range 0-4). The overall score (range 0-40) is calculated, with higher scores indicating enhanced resilience. Each item score is summed to compute the overall score.
European Organization for Research and Treatment of Cancer Quality of Life (EORTC QLQ-F17)
The EORTC QLQ-F17 is a QOL instrument developed by the EORTC QOL group [29]. It is designed to assess QOL in cancer patients. The questionnaire comprises functional domains and global health status/QOL, with a total of 17 items. Responses are recorded using a Likert scale, typically ranging from 1 to 4 or 1 to 7. Scores for each domain are calculated by averaging the scores of the items within that domain. The scores can be converted to a scale of 0-100, where higher values indicate better functioning or an improved QOL.
Multidimensional Scale of Perceived Social Support (MSPSS-12)
This scale assesses perceived social support from family, friends, and significant others [30]. It consists of 12 items evaluated on a five-point Likert scale (range 1-5). Scores range from 12 to 60, with higher average scores representing greater social support.
Data analysis
SPSS 26 was utilized for coding and analyzing the data. Statistical methods were applied, and the Hayes Macro Test was employed to test the moderating role [31].
Findings
Patients in the age group of 50-59 years constituted the largest proportion at 26.2%, followed by the age groups of 30-39 years (22.2%) and 40-49 years (18.9%). The mean age was 45.05±13.53 years, ranging from 20 to 70 years, with an average of 45.05 years. In terms of sex, 58.9% of patients were male and 41.1% were female. Married patients constituted the largest proportion at 75.6%. Regarding education, the largest proportion of patients completed their education at the university level (31.3%) or at an institute (27.6%). As for employment, 43.6% of patients were unemployed, while 35.3% were employed in the government sector. In terms of monthly income, 44% of patients earned less than 300,000 Iraqi dinars (Table 1).
Table 1. Frequency of socio-demographic characteristics of patients with gastrointestinal cancer (n=275)
As for the type of cancer, colon cancer constituted the largest percentage at 62.9%, followed by stomach cancer at 12.0%, and both rectal and pancreatic cancers at 8.7% each, while liver cancer represented 7.6%. Regarding the cancer stage, 70.2% of patients were in stage III, and 29.8% were in stage IV. In terms of the duration of chemotherapy, 37.1% of patients received treatment for a period of 3 to 8 months, while 28.4% received treatment for a period of 9 to 14 months. The mean duration of chemotherapy was 13.11±8.26 months (Table 2).
Table 2. Frequency of clinical characteristics of patients with gastrointestinal cancer (n=275)
The mean resilience score was 22.84, reflecting a generally low level of psychological resilience. The table indicates that the mean perceived social support score was 44.62, suggesting that most participants had a high level of perceived social support.
Additionally, the mean physical performance score was 50.87, indicating a good level of physical ability. The mean functional performance score was 26.69, reflecting significant limitations in performing daily roles. Cognitive performance recorded a mean score of 64.62, indicating a good level of cognitive ability, while emotional performance recorded a mean score of 40.15, indicating significant emotional challenges. Social performance achieved a mean score of 54.18, reflecting relatively good social interactions. Global Health Status/QOL achieved a mean score of 48.08, indicating a poor level with a significant impact on health status. Finally, the mean overall QOL score was 47.43, reflecting a relatively poor ability to adapt to health conditions (Table 3).
Table 3. Mean scores of resilience, quality of life, and social support in the studied patients (n=275)
The total effect of resilience on QOL was 0.7227, indicating that increased resilience is associated with increased QOL (p<0.001), and this relationship was not random. When examining the direct effect only, it remained positive but was less strong, at 0.4031, indicating that part of the effect of resilience on QOL occurred directly without reliance on social support. The indirect effect via social support was 0.3196 and was statistically significant (Table 4).
Table 4. Mediation analysis of resilience and quality of life (n=275)
Discussion
This study aimed to investigate the mediating role of social support in the relationship between resilience and QOL. The mediating role of social support in the relationship between resilience and QOL is an important area of study that has significant implications for individual well-being and mental health. The mediating role of social support in this relationship is a critical issue that underscores the interconnectedness of social factors and mental health. By addressing this relationship, we can better understand how to support individuals in their journeys toward resilience and improved well-being.
The average age was 45.05 years; half of the patients were male, and three-quarters of the sample were married. These findings are consistent with some of the preceding local studies conducted in Iraq [32-35]. In the study by Fowler et al. on the association between social vulnerability and geriatric assessment impairments among older adults with gastrointestinal cancers, the sample aged 60 years and older 60.5% were married [34].
Most patients completed their education at a university or an institute, and nearly half of the patients were unemployed and earned less than 300,000 Iraqi dinars monthly. These findings demonstrate similarities to prior studies conducted in Iraq [36-38].
Regarding the type of cancer and duration of chemotherapy, colon cancer constituted the largest percentage, followed by stomach cancer. In terms of the duration of chemotherapy, more than one-third of patients received treatment for three to eight months. These results align with the study by Li et al. [39]. Concerning the cancer stage, nearly three-quarters of patients were in stage III. These findings are similar to those of a study conducted in South Korea, which showed that nearly three-quarters of patients had stage III cancer [40].
Model four of the PROCESS macro procedure was used to examine the mediating effect of perceived social support (PSS) on the resilience and QOL of patients with GI cancer, after controlling for various parameters. The total effect of resilience on QOL was 0.7227, the direct effect value was 0.4031, and the indirect effect via social support was 0.3196. This research indicates that social support may act as a link between resilience and QOL.
This result aligns with previous research indicating that social support partially mediates the correlation between resilience and QOL among individuals diagnosed with breast cancer [41, 42]. Zhang et al. explored the mediator role of social support in patients with breast cancer. They reported that participants with stronger social support have higher resilience and better quality of life, and social support plays a partial mediator role in the relationship between resilience and quality of life. They conceded that social support is essential for the development of resilience and the improvement of QOL in Chinese patients having breast cancer [41]. Çakir et al. assessed the correlation between social support and psychological resilience levels in patients undergoing colorectal cancer surgery. They used the Connor-Davidson Resilience Scale and the Multidimensional Scale of Perceived Social Support to interview 103 patients undergoing colorectal cancer surgery. Family support and significant other support were positively correlated with subscale and total scores of the Resilience Scale They reported that family support and significant other support are positively correlated with subscale and total scores of the Resilience Scale. They also conceded that social support provided to patients by family and healthcare professionals plays an essential role in increasing resilience [42].
Moreover, research indicates that individuals with low psychological resilience, older age, and reduced social support are at an increased risk of experiencing a decline in QOL [43, 44]. Dai et al. assessed the actuality of resilience, social support, and QOL among patients with inflammatory bowel disease (IBD) in China. They found that enhancing the resilience levels of patients with IBD is essential, particularly for those living in rural areas who may benefit from increased social support. They suggest that a higher level of social support is associated with greater resilience, which is crucial for maintaining the psychosomatic health of IBD patients. Therefore, interventions aimed at improving emotional regulation, coping strategies, and social support should be implemented to boost resilience, manage the condition effectively, and ultimately promote a better QOL [43]. Kuang et al. assessed the effect of psychological resilience on self-efficacy and QOL in patients with diabetic foot ulcers. They declare that individuals with high psychological resilience have significantly higher self-efficacy, general health, vitality, social functioning, role emotional, and mental health compared to those with low psychological resilience. They report that low psychological resilience and older age are risk factors for self-efficacy. Furthermore, they note that low psychological resilience, older age, lower perceived social support, and higher levels of glycated hemoglobin are risk factors for QoL. Additionally, they indicate that males exhibit lower psychological resilience than females, while those receiving more social support demonstrate higher psychological resilience than participants receiving less social support [44].
Receiving higher levels of social support may help improve psychological resilience [10, 42, 45]. This suggests that individuals who experience elevated levels of social support encounter a diminished incidence of adverse health outcomes following stressful events compared to those with minimal social support [46].
It is recommended to establish structured programs to enhance psychological resilience, stress management, and coping skills for GI cancer patients. These programs should incorporate evidence-based therapeutic approaches, such as cognitive-behavioral therapy and mindfulness practices, to equip patients with effective tools for managing their emotional and psychological challenges. They should be part of routine care in hospitals and cancer centers. It is also suggested to strengthen social support networks. It is essential to encourage family involvement and community support to enhance the perceived social support for cancer patients. This could include support groups, counseling sessions, and family education programs. It is also recommended to integrate psychological resilience training into routine care. Psychological resilience training should be a fundamental part of the treatment pathway for GI cancer patients. This can include counseling sessions, resilience workshops, and educational materials that help patients develop stronger coping mechanisms.
Conclusion
Social support mediates the relationship between psychological resilience and quality of life.
Acknowledgments: The authors sincerely thank the patients who participated in this study, as well as all those who provided scientific support and assistance in completing this research.
Ethical Permissions: The authors obtained permission from the scientific committee at the College of Nursing at the University of Baghdad (Code: 27/10/2024) in Baghdad.
Conflicts of Interests: There are no conflicts of interests.
Authors' Contribution: Jasim DH (First Author), Methodologist/Main Researcher/Discussion Writer/Statistical Analyst (70%); Mohammed WK (Second Author), Introduction Writer/Assistant Researcher/Discussion Writer (30%)
Funding/Support: No funding was received.
Keywords:
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