Relationship between social support and self-hardiness among breast cancer women in Nasiriyah, Iraq

Objective: To assess the role of social support in predicting self-hardiness among women having breast cancer. Method: The descriptive correlational study was conducted at the Oncology Centre, Nasiriyah, Iraq, from August 3 to September 22, 2022, and comprised women receiving treatment for breast cancer. Data was collected using a questionnaire designed in the light of the Multidimensional Scale of Perceived Social Support, which was found reliable on the basis of a pilot study. Data was analysed using SPSS 20. Results: There were 150 women with mean age 50.4±11.18 years. Of them, 135(90%) were married, 113(75.3%) were unemployed, 90(60%) were living in rural areas, and 89(59.3%) had low socioeconomic status. Overall, 108(72%) patients reported they received little social support. Self-hardiness significantly diﬀered in relation to marital status ( p =0.021), place of residence ( p =0.003) and income level ( p =0.005). Social support positively correlated with self-hardiness ( p =0 .000). Conclusion: Social support was found to be a predictor of increased self-hardiness that enhances resilience and enables patients to deal with one of the most devastating illnesses of modern times.


Introduction
With 23% of the 1.1 million new cases identified each year, breast cancer (BC) is the most common type of cancer among women globally 1 .Additionally, it is the leading cause of cancer-related deaths globally, with low-resource countries recording the highest mortality rates 2 .About 4.4 million women diagnosed with BC in the past 5 years are still alive. 3A BC woman suffers from psychological instability, which causes anxiety and discomfort 4 .Psychosocial responses to somatic disorders vary widely from person to person, and is a manifestation of the close relationship between the body and the soul, and how each impact gets influenced by the other 5 .A wide range of emotions and stress are likely to be felt by cancer patients and their families.Every cancer patient worries about dying, failing to achieve their goals in life, losing their creativity and confidence, changing their social roles and way of life, and running into financial trouble.Every cancer patient feels the impact of situations like this immediately 6 .Social ties can help people cope with the disease.The process gets hindered if social reactions are unfavourable and anti-disease, but social support facilitates cognitive and stressful events in addition to helping patients adjust to their environments 7 .Social support entails someone offering assistance and encouragement, particularly to a specific person.Some studies suggest that social support may have a moderating effect in how the coping style is affected.Social support would undoubtedly help cancer patients if it helped them cope with major life stresses and prevent the development of mood disorders.Social support is required to meet the demand for psychosocial security, to lessen the amount of psychological anguish produced by the intensity of disease-related events, and to effectively eliminate symptoms of psychosocial difficulties 8 .The current study was planned to assess the role of social support in predicting self-hardiness among BC women.

Patients and Methods
The descriptive correlational study was conducted at the Oncology Centre, Nasiriyah, Iraq, from August 3to September 22 , 2022.Approval was obtained from the ethics review committees of Middle Technical University, Iraq, and Dhi Qar University, Iraq.The sample was raised randomly by purposive sampling technique.The sample size was based on approximately 10% of the total monthly reviews, and according to a previous published study. 9The inclusion criteria were women diagnosed with BC for last 6 months or longer with different levels of education and those who agreed to participate in the study.Women who did not agree to be a part of the study were excluded.All the study participants were explained the objectives and of the study.The consent of the study participants was obtained, after explaining the objectives which were for promoting science.All the participants were assured of confidentiality of the data acquired.Data was collected using a questionnaire in the Arabic language (Annexure) and the participants also answered in Arabic.These answers were translated into English by a language expert.The questionnaire included sociodemographic data.Another questionnaire was designed based on the Multidimensional Scale of Perceived Social Support (MSPSS). 10The self-report tool subjectively assessed social support through MSPSS-12 items measured on a 4point Likert scale, ranging from never to always. 9Cronbach's alpha was 0.83.Besides, a self-hardiness questionnaire was developed by the researchers and was validated by a panel of experts, with Cronbach's alpha value 0.89.Data was analysed using SPSS 20.Frequencies and percentages as well as mean and standard deviation values were used, as appropriate, to express data.Analysis of variance (ANOVA) test was used to compare the continuous variables.Statistical significance was defined as two-tailed p≤0.05.
Self-hardiness significantly differed in relation to marital status (p=0.021),place of residence (p=0.003) and income level (p=0.005),but was not significantly related to age or gender (Table 4).Social support positively correlated with self-hardiness (p=0.001)(Table 5).Liner regression also showed significant association between social support and self-hardiness (

Discussion
The age of the subjects in the current study ranged between 50-59 years.The rate of chemotherapy treatment is generally higher in women than in men 11,12 , which is indicative of the fact that women are more prone than men to get BC.Data indicated that the majority of the subjects were married, had low socioeconomic status, resided in rural areas, and generally bemoaned the lack of resources.These findings were largely consistent with those of earlier studies 13,14 .
Social support aids cancer patients in managing their psychological symptoms, and as long as they value it, they view it as crucial to their wellbeing.The two causes of their sorrow are pessimism as they show poor response to treatment and have limited hope of finding a remedy for the illness 15 .
The absence of various types of social support 16 activates the negative consequences of unpleasant events and conditions to which a person is exposed, which impairs the patient's health.This is due to the fact that patients recognise how important it is for their network of social interactions, including family, friends, doctors and nurses, to support them in getting treatment, and to hasten the stages of their recovery.
The findings of a study in Pakistan were comparable to those of the current one, recommending that individuals with cancer should undergo rehabilitation, and both the public and medical professionals should be concerned about their mental health 17 .
The current results showed that self-hardiness differed according to the patients' marital status, place of residence, and income, but not according to their age and occupation.Even though they have a substantial impact on patient care and health monitoring, the nurse and the doctor are frequently mentioned in discussions and are associated in the minds of cancer patients.This can be described in terms of the kinds of psychological reasons produced by the patient's own social support system.The patient frequently has health-related anxiety, and frequently experiences hopelessness.
Social support can help people overcome their ailments, give them hope and optimism, and even briefly make them forget about their illnesses.Social support boosts optimism for the future, and this hope in turn serves to strengthen the patients' ability to deal with their diseases.This helps to improve the patients' ability to deal with their conditions psychologically, biologically and clinically.A study 18  established that social support can improve adaptation to the disease, and that social support is adversely related to the earliest symptoms of cancer, like pain, exhaustion, cough, stress and depression 19 .The presence of the spouse's dimension of social support, along with other dimensions or sources of social support, like the patient's family and physician is crucial to the patient having an equal chance of recovery since both married and unmarried cancer patients have an equal chance of recovering.One of the most significant examples of this phenomenon is family solidarity, which means members of the patient's family at all levels can forge a solid social connection that makes up for the absence of a spouse or partner, much like how married and single people coexist in the same society and culture, and are consequently subject to the same influences 20,21.According to the current study, social support has a considerable impact on the self-hardiness of BC patients, and there is a positive relationship between social support and toughness.These results suggest that low self-hardiness and low social support are correlated.This demonstrates that the level of social support BC patients receive has a positive correlation with their level of selfseriousness.This was corroborated by earlier studies 22 .
The current results were also in line with a study 23 , which found a connection between social support and outlook on life.Another study 24 discovered a significant link between the overall scores of social support and psychological toughness among BC patients.
To the best of our knowledge, the current study is the first to observe how people in Iraq support those with cancer.Moreover, a large sample size including almost all the BC patients attending a single cancer centre is a strength of the current study.

Conclusion
Social support was found to be a predictor of increased self-hardiness, which enhanced resilience among BC patients and enabled them to deal with one of the most devastating illnesses of modern times.The development of educational counselling, care and social support programmes for BC patients are necessary to rehabilitate the affected community.

12 J
found that individuals with an active social network have stronger immunity than those without a network of close relationships.It has been Iraq Supp.: 2nd ISCOHMS 2022 S-Pak Med Assoc (Suppl.8)

Table - 2
: Level of social support reported by women with breast cancer (n=150).