Ⅰ. Introduction

Childhood cancer survivors deal with the stressors of their specific cancer diagnoses and treatments while they also manage regular daily life stressors when they return to normal life after treatment is completed (Hobbie et al., 2000; Kazak, Alderfer, Rourke, Simms, Streisand, & Grossman, 2004; Lee & Santacroce, 2007). After cancer treatments, survivors may feel uncertainty about treatment, follow-up, and symptoms (Lauver, Connolly-Nelson, & Vang, 2007). Some survivors develop posttraumatic symptoms after the traumatic experience of cancer. They might experience bad dreams and difficult memories, avoid reminders of the traumatic experiences, be startled by sudden sounds, or be overly sensitive to their surroundings (Foa, Cashman, Jaycox, & Perry, 1997). They also might be stressed with daily events that are affected by their cancer experience. Consider the young adult cancer survivor who may struggle with how to communicate with her new romantic partner about her cancer history and potential associated fertility issues (Zebrack, 2011). A large body of empirical studies has found a significant proportion of childhood cancer survivors report severe symptoms of distress (e.g., Wiener et al., 2006; Michel, Rebholz, von der Weid, Bergstraesser, & Kuehni, 2010; Gianinazzi et al., 2013).

Cancer patients and survivors respond to these stressors with diverse coping strategies. Coping is defined as cognitive and behavioral efforts to manage external and/or internal demands that are perceived as threats (Larzarus & Folkman, 1984). Coping with life stress is important for survivors of pediatric cancer because it is positively associated with their risky health behaviors (Tercyak, Donze, Prahlad, Mosher, & Shad, 2006). How survivors respond to and deal with stress, therefore, serves as useful information for understanding these young adults’ health behaviors and quality of life.

The numerous studies in this field have not reached consensus on the types of coping strategies used, constructs of the different strategies, relationships between coping strategies, and the quality of life of childhood cancer survivors. Attempts to understand these topics in a cultural context have been inadequate. Situational knowledge, which is specific to a particular situation (Haraway, 1988), is important to understand illness experiences; thus examining these topics among cancer survivors from different cultural backgrounds will help determine distinct meanings of illness, as well as different responses to diagnosis and treatment (Li et al., 2011).

The present study explores Korean childhood cancer survivors’ coping strategies with life stressors and the associations of the types of coping strategies with health-related quality of life. An examination of the characteristics of the coping strategies in this group will help psychosocial oncology service providers develop programs for cancer survivors that enable them to better adjust to stressful experiences and will contribute to the knowledge of coping in cancer survivorship.

Ⅱ. Literature Review

Ⅲ. Methods

Ⅳ. Results

Ⅴ. Discussion

Our exploratory study found that Korean childhood cancer survivors used diverse coping strategies, which were conceptually categorized as approach coping, social coping, and avoidant coping. In our sample, the findings that approach coping (i.e., problem-solving activities directed at the source of the stress) was related to better physical and mental health, whereas social coping (i.e., behaviors directed toward relationships with others) and avoidant coping (i.e., behaviors that orient the focus away from the problem) were related to poorer mental health in this population, have several clinical and research implications.

Our findings are consistent with previous research that found cancer patients and survivors who used approach coping were more likely to experience positive psychological well-being, and those who used avoidant coping were more likely to experience negative psychological adjustment and physical health (see Roesch et al., 2005 for review). Cancer survivors who used fewer avoidant coping strategies, such as denial, behavioral disengagement, and substance abuse, were more likely to face their challenges directly, feel less burdened and distressed, and in turn, experience greater psychological well-being (Turner-Sack, Menna, & Setchell, 2012). Furthermore, avoidant coping contributed to pediatric cancer patients’ depression (Frank, Blount, & Brown, 1997) as well as cancer survivors’ negative health behavior change concerning diet, exercise, and sleep (Park, Edmondson, Fenster, & Blank, 2008).

Avoidant coping strategies may reduce stress and prevent anxiety from becoming crippling, whereas approach coping strategies allow for appropriate action and the possibility for taking advantage of opportunities to make situations more controllable (Roth & Cohen, 1986). Avoidant strategies might be valuable during the initial period of diagnosis and treatment when emotional resources are limited, as they can reduce stress and anxiety and allow for a gradual recognition of threat as well as the time needed to collect resources to change the environment (Lazarus, 1983). However, if the avoidant strategies prevent an assimilation and resolution of the trauma, they may ultimately be counterproductive (Roth & Cohen, 1986). In the long run, the effectiveness of avoidant strategies depends on how well they facilitate approach coping (Roth & Cohen, 1986). Therefore, partial, tentative, or minimal use of avoidant coping strategies can often lead to a more positive emotional outlook, particularly over a long period of time. For example, humor can be a positive way of dealing with life’s challenges, by lightening up a situation, and was therefore operationalized as emotion-focused coping (Coolidge, Segal, Hook, & Stewart, 2000). In our study, however, humor seemed to be used as a way of avoiding a stressful situation by only joking about it but not approaching its core issues. This kind of humor, which avoids the important issues, is different from the positive reframing approach of creating pleasant and/or humorous meaning out of one’s situation. Kimemia, Asner-Self, and Daire (2011) found that humor was inversely related to positive reframing. Future research might look into the ways humor either positively or negatively relates to stress in multicultural settings.

The relationships between social coping and poorer mental health that we found are counterintuitive, because the behavior of seeking social support in stressful situations seems both active and positive. Yet, contrary to this common belief, seeking social support does not necessarily contribute to better health-related quality of life for cancer survivors (Castellano et al., 2013). Several studies have also indicated that emotional support and venting are related to psychological distress and depression (Blank & Bellizzi, 2006; Turner-Sack et al., 2012). The relationship between social support and psychosocial outcomes of cancer survivors may also depend on individual factors. It has been found that for cancer survivors with high alexithymia, higher depression and negative affect are related to a high level of emotional sharing and high perceived negative support (Boinon et al., 2012). More social support has also been found to be related to higher anxiety among cancer survivors with low optimism (Applebaum et al., 2014). It is clear that the relationship between social coping and quality of life is complex.

We propose three possible explanations for the negative associations of social coping with mental health in our sample. First, although this cross-sectional study finding does not infer causal directions, perhaps the survivors with poorer mental health use more social coping, and not the other way around –more social coping leads to poorer mental health.

Second, social coping may be stressful in the collectivist Korean culture, where individuals are expected to avoid placing a burden on others (Yeh, Arora, & Wu, 2006). Those who seek external help when facing stress might encounter inadequate social support, which could aggravate their stress. Although social support is generally considered to be an important positive factor in coping with stress (Lazarus & Folkman, 1984), negative social interactions, such as those that cause the individual to experience an unfavorable psychological reaction and have reservations about the relationship, may have a detrimental impact (Lincoln, 2000). Research on social support and illness reveals two specific types of such “supportive” interactions: (a) when the patient perceives the wrong person provided a specific type of support, and (b) when the patient feels that although the correct person has offered the support, he or she has not done so in a helpful manner (Neuling & Winefield, 1988; Rose, 1990). Both sources of supportive interactions may play a critical role in the positive and negative effects on psychological well-being. In Korea, cancer survivors often experience social stigma (Cho et al., 2013a; Kim, Yi, & Kim, 2014). In this cultural setting, where talking about cancer and sharing stories about cancer experiences are not socially accepted (Cho et al., 2013b), cancer survivors who use social coping and want to be comforted through social relationships might face enormous challenges.

Our third explanation for the negative association of social coping and mental health is that social coping might be used as a way of trying to distract the survivors from their stress. In our sample, self-distraction was a major component of social coping that seemed to be used as a way of directing coping energy outward in social relationships. According to David and Suls (1999), those with a lower perception of control over stressful events tend to choose distraction strategies. Individuals may use distracting stimuli, entertainment, or activity to avoid thinking about the stressors (Ayers, Sandler, West, & Roosa, 1996), thereby controlling psychological stress (Lazarus, 1993). Self-distraction can be a healthy way of coping with stress in certain circumstances. It is particularly helpful when one has to deal with strong and disturbing emotions (Baumeister, Heatherton, & Tice, 1994). For example, adult and pediatric patients undergoing chemotherapy experienced reduced levels of distress and unpleasant treatment side effects by playing video games (Vasterling, Jenkins, Tope, & Burish, 1993) or with a developmentally appropriate electronic toy (Dahlquist, Pendley, Landthrip, Jones, & Steuber, 2002). However, if this strategy is used without properly addressing the underlying problems, it can aggravate the stress and worsen the situation (Zillmann, Hezel, & Medoff, 1980).

A few limitations should be considered in interpreting the study findings. First, the survivors in this study voluntarily participated, which is likely to affect the types of coping strategies that they use. The participants’ coping strategies might be different depending on whether their stress is general or cancer-specific. Future studies could examine different types of stressors and their impact on quality of life. Second, our participants had gone through cancer diagnosis and treatment in the past. Particularly, the participants had been diagnosed with cancer at 9.86 years of age on average, and it is possible that their memories of their cancer experience might have faded. Thus, the impact of their stressor and how they cope with stress might be different from other survivors or patients who are currently undergoing cancer treatment. In addition, particular stressors and coping strategies might function at different phases of survivorship. Thus, the time since treatment should be considered in explaining the association between coping strategies and quality of life. Third, coping strategies should be considered together with other factors to understand the survivors’ quality of life. For example, situational factors (e.g., nature, degree, and chronicity of the stressor) and personal factors (e.g., personality and beliefs about coping resources and their effectiveness) should be assessed to decide whether particular coping strategies are adaptive. Thus, future studies are needed to determine how specific coping strategies are used in adaptive or maladaptive ways by persons facing stressful situations and to examine the mechanisms by which coping approaches affect their well-being. Also, their social support, such as family, should be considered because it may buffer or worsen their coping with stress. Finally, our exploratory study did not examine causal relationships between coping and health-related quality of life. Future studies should examine the unique variance of coping strategies accounting for health-related quality of life, controlling for other important sociodemographic variables.

Ⅵ. Conclusion

This study explored the correlations between coping strategies and health-related quality of life among adolescent and young adult Korean cancer survivors. Three coping factors－approach (active coping, positive reframing, religion, acceptance, and planning), social (emotional support, instrumental support, self-distraction, and venting), and avoidant (behavioral disengagement, self-blame, and humor)－were found. Approach coping was associated with better physical and mental health, whereas both social and avoidant coping were associated with poorer mental health. Our study provides insight into the childhood cancer survivors’ coping with stress and possible associations with health-related quality of life. Psychosocial oncology service providers should assess survivors’ coping strategies, develop ways to understand their impact on quality of life, and use the information in developing relevant programs. Specifically, our study may help psychosocial oncology service providers develop educational programs to assist childhood cancer survivors build approach coping strategies at different phases of their cancer experience. Further research is warranted to understand the mechanisms behind social and avoidant coping behaviors among Korean childhood cancer survivors, and psychosocial support should be available for survivors if such strategies are used in maladaptive ways. Also, providing education to psychosocial service providers is important to help them recognize coping strategies that may improve the cancer survivors’ quality of life.