TOUS in Action

By looking at all the four clusters of multiple symptoms in Figure 3a, imagine that the three arrows are a continuum, so that pain causes lack of sleep, lack of sleep causes low mood, leading to unproductive work, reduced activity, leads to distress but resilience, comorbidity, family support, spirituality, and religiosity could buffer the worst scenario in certain individual.

From this study’s perspective, the three concepts are in concordance with Lenz and colleagues. Firstly, experiencing factors primarily pain symptoms, co-occurring symptoms, insomnia, and fatigue. Secondly, consequences or outcome, women with breast cancer tend to lean towards resilience or distress. Thirdly, the distress level and resilience level are influenced by comorbidities as the physiological variable, spiritual belief and religious concerns, psychological variables, and family support as the situational variable.

37%

31% 25%

7%

The role of spiritual/religious concerns, family support, and comorbidities are significant. Spirituality and religiosity is a resource to cope with confronting issues associated with chronic diseases such as cancer (Büssing et al., 2010). The Malays in Malaysia are synonymously Muslims. Muslims believe in God as a fundamental

concept. All events such as cancer or chronic diseases are fated and determined by God, therefore the individual needs to accept that fact and move on (Nabipour et al., 2016). The Malaysian Chinese believe in spirituality and religiosity for healing psychological ailments rather than believing in bio-medical means of treatment. Apart from

stigmatisation, by adopting a religious-spiritual approach, individuals retain autonomy throughout the healing process (Ting & Ng, 2012). Another study found that prayer, spirituality, and religiosity played important roles, perceived as comforting and

supportive in cancer patients during chemotherapy. Notably, spirituality and religiosity are part of complementary and alternative medicine (CAM) practice in Malaysia (Gan, Leong, Bee, Chin, & Teh, 2015). Possibly, religiosity and the spiritual world isolated survivors from their existing pain. Researching this issue would provide concrete and rational findings because currently this issue is considered vague and abstract. Possibly in the future, the role of distraction and imagery might benefit women with cancer who do not believe in spirituality or religiosity.

It is known that the level of social support affects the level of anxiety and depression in women with breast cancer in Malaysia (Ng et al., 2015). Perhaps family support and social support were able to reduce the pain experienced in this population. This is an aspect requiring further research. However, other studies have found that Malaysians in general are family orientated, providing support, relationship, and family cohesiveness, which extends to village level and social group level. The relationship is reciprocal and accompanied by a sense of obligation (Sharan & Mohamad, 2000). A

family and there was collaborative decision-making among the family. The support extended to emotional support, managing health, life style, and dietary practice. Based on these studies, which show that breast cancer survivors experience strong family support, it is therefore not unexpected that family support was not a predictor of persistent pain in this research.

Although this study had been restructured to minimise bias in term of comorbidities (for instance, limiting the age to a maximum of 80 years old and restricting participants to those who had had surgery 3 months to 5 years ago), the researcher acknowledges that comorbidities in the current study in fact worked to the advantage of these participants. The chances were that the comorbidities they

experienced had given them means to make adjustments to their lives. Studies have found that people with pain comorbidities experience some form of adjustment (Bendayan, Esteve, & Blanca, 2012; G. Ruiz-Párraga, T., López-Martínez, Esteve, Ramírez-Maestre, & Wagnild, 2015). Therefore, comorbidities did not appear as a predictor of persistent pain.

Resilience is a set of adaptive responses to pain and pain related to life’s adversities. The interaction involves social support, such as from family, relationships, and any interpersonal factors that contribute to pain adaptation. The adaptation does not necessarily mean getting back to a premorbid status; rather it is an adjustment to new plans in life, learning and growing, improving social support, and understanding one’s own ability to withstand pain (Yeung, Arewasikporn, & Zautra, 2012).

From a provider’s clinical view, cancer is associated with distress. From a survivor’s perspective, it has been shown that 45% of survivors do not report distress, because they do not consider themselves in distress either physically or emotionally. They have learned to cope, and moreover, in the presence of resilience, the level of distress declined (Min et al., 2013). Similarly, distress and pain coexist. An increasing

number of studies on Cognitive Behavioural Therapy have informed researchers that it works to deescalate distress symptoms (Okifuji & Turk, 2015; Syrjala et al., 2014; Tatrow & Montgomery, 2006). Based on this evidence, a psychological construct can be modulated by intervention, which is a good thing.

The phenomena found by other studies, spontaneously explained the findings of this study, the negative linear association of distress and pain was not extraordinary after all. Although the negative linear association of resilience fits the normal norm, perhaps due to pain the women had adjusted their responses to pain and pain related to life adversity. Probably the support from family, and community that is exclusive culture to Malaysian contributed to the positive adjustment, and the role of religiosity and spirituality believes could not be underestimated. To appraise the women under pinning this study is to look at all the above in a holistic view.